HIV programmes face challenges achieving high rates of HIV testing and treatment needed to optimise health and to reduce transmission. We used data from the Botswana Combination Prevention Project study survey to assess Botswana's progress toward achieving UNAIDS targets for 2020: 90% of all people living with HIV knowing their status, 90% of these receiving sustained antiretroviral therapy (ART), and 90% of those having virological suppression (90-90-90).
Botswana is a middle-income country with a stable democracy, high HIV prevalence (25·2% of people aged 15–49 years). In Botswana, HIV-infected citizens receive free three-drug ART from decentralised health clinics if they have a CD4 count ≤ 350 cells per μL, WHO stage III or IV illness (including recent tuberculosis diagnosis), or a history of cancer or if they are pregnant or breastfeeding (irrespective of CD4 count).
A population-based sample of individuals was recruited from a 20% simple random sample of all households in the communities and interviewed in 30 rural and periurban communities from Oct 30, 2013, to Nov 24, 2015, as part of a large, ongoing community-randomised trial designed to assess the effect of a combination prevention package on HIV incidence. Consenting household residents aged 16–64 years who were Botswana citizens or spouses of citizens responded to a questionnaire and had blood drawn for HIV testing in the absence of documentation of positive HIV status. Viral load testing was done in all HIV-infected participants, irrespective of treatment status. Modified Poisson generalised estimating equations were used to obtain prevalence ratios, corresponding Huber robust SEs, and 95% Wald CIs to examine associations between individual sociodemographic factors and a binary outcome indicating achievement of the three individual and combined overall 90-90-90 targets. The study is registered at ClinicalTrials.gov, number NCT01965470.
81% of enumerated eligible household members took part in the survey (10% refused and 9% were absent). Among 12,610 participants surveyed, 3,596 (29%) were infected with HIV, and 2,995 (83·3%, 95% CI 81·4–85·2) of these individuals already knew their HIV status. 73% of HIV-infected participants were women, and median age was 40 years. Among those who knew their HIV status, 2,617 (87·4%, 95% CI 85·8–89·0) were receiving ART (95% of those eligible by national guidelines, and 73% of all infected people); an additional 26 participants reported taking ART previously, but were not on ART. Of the 2,609 individuals receiving ART with a viral load measurement, 2,517 (96·5%, 95% CI 96·0–97·0) had viral load ≤ 400 copies per mL (2,428 (93·1%, 92·1–94·0) had HIV-1 RNA ≤ 40 copies per m). Overall, 70·2% (95% CI 67·5–73·0) of HIV-infected people had virological suppression, close to the UNAIDS target of 73%.
In conclusion, we found one of the highest overall coverage levels of the UNAIDS 90-90-90 targets (HIV testing, ART, and virological suppression) that has been described to date worldwide—a level that nearly achieves the UNAIDS target.
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