Botswana: HIV incidence ‘likely to increase’ in next 10 years

In 2018, Botswana met the 2020 UNAIDS Fast Track '90-90-90' targets, with 91% of people living with HIV diagnosed, 92% of people diagnosed on treatment, and more than 95% on treatment virally suppressed. But new findings reveal that the rate of new infections is not declining quickly enough to sufficiently slow the pace of the epidemic.

The new study set out to assess whether the country’s current policy of preventing migrants from accessing free HIV treatment and care is hindering efforts to reduce incidence.

Botswana has one of the world’s largest HIV epidemics, with a prevalence estimated at 22.8% nationally. Among migrants, who make up around 7% of the population and mostly come from Zimbabwe, prevalence is thought to be 20%.

Researchers used a population-based predictive tool to examine the impact three different funding scenarios would have on new HIV infections and AIDS-related deaths in Botswana between 2020 and 2030, using 2010 as a data starting point.

The first scenario made predictions based on the current funding situation for HIV treatment and care. The second investigated a scenario where HIV funding was increased to ensure 95% of people living with HIV had been diagnosed, put on treatment and virally suppressed – but for citizens only. The third examined a scenario where the budget was scaled up to meet the 95% targets, but for both citizens and migrants.

Under the first scenario, 172,000 people were predicted to become HIV-positive and 8,400 people were predicted to die from an AIDS-related illness between 2020 and 2030.

Scaling up to achieve the 95% targets among citizens only was predicted to avert 48,000 of these infections and 1,700 deaths. Achieving targets for both citizens and migrants was predicted to avert a further 16,000 infections and around 440 more deaths.

This indicates that including migrants would reduce HIV incidence at almost double the rate of the current funding scenario, and would clearly benefit the population overall.

However, even with scaled-up treatment for migrants and citizens, the model predicted that 108,000 people would become HIV positive over the next ten years. This infection rate is still too high to end the country’s HIV epidemic, pointing to the central role of HIV prevention in reducing HIV incidence.

The findings contradict a 2018 study, which projected similar results for diagnosis, treatment and viral suppression but indicated that Botswana was likely to reduce HIV incidence to target-level by 2030. Authors of the current study suggest this is because the 2018 study failed to take into account the impact of migration on Botswana’s HIV epidemic and only included data up to 2016 in its modelling. The current study used HIV incidence data from 2017, when Botswana reported a rise in new infections.

The cost of including migrants in scaled-up treatment services between 2020 and 2030 was estimated to be USD $74 million. This would be cost-effective in the long run due to the reduction in new infections it would help to bring.