Botswana appears to have achieved very high rates of HIV diagnosis, treatment, and viral suppression – much better than most Western nations, including the US according to a new study from Harvard TH Chan School of Public Health and colleagues in Botswana. The findings suggest that even in countries with limited resources where a large percentage of the population is infected with HIV, strong treatment programs can help make significant headway against the HIV/Aids epidemic.
“By now, we hoped to have an HIV vaccine. That hasn’t happened. Ironically, treatment of HIV-infected persons may be our most effective, efficient way to prevent new infections. These results show that Botswana has made great progress in reducing the number of people who are infectious to others,” said Dr Max Essex, Mary Woodard Lasker professor of health sciences, chair of the Harvard TH Chan School of Public Health Aids Initiative and chair of the Botswana Harvard Aids Institute Partnership.
Global HIV programmes have continued to face challenges in achieving the high rates of testing and treatment needed to optimize health and reduce new infections. Mounting evidence suggests that providing antiretroviral treatment (ART) to all people living with HIV, regardless of the stage of their disease, can help. In 2014, the Joint United Nations Programme on HIV/AIDS (UNAIDS) proposed new testing and treatment targets: that 90% of all people living with HIV know their HIV status; that 90% diagnosed with HIV be given ART; and that 90% who receive treatment have virologic suppression – very low blood levels of HIV – by the year 2020.
The researchers looked at the achievability of the UNAIDS targets in Botswana – a middle-income African nation where 25% of the population aged 15-49 is HIV positive but which also has a mature public ART programme – by directly measuring HIV status, treatment, and viral suppression among 12,610 people from 30 communities across the country between October 2013 and November 2015. Study participants were drawn from a large, ongoing HIV prevention study in Botswana. The participants responded to a questionnaire, had their blood tested for HIV if their status wasn’t known, and, if they were infected with HIV, their viral load was checked.
Out of the 12,610 participants, 3,596 (29%) were HIV infected and 2,995 (83.3%) of these individuals already knew their HIV status. Among those who knew their status, 2,617 (87.4%) were receiving ART.
Significantly, the study authors called it “remarkable” that of the 2,609 people receiving ART who had their viral load checked, 2,517 (96.5%) had viral suppression.
Until now, there has been considerable uncertainty as to whether the ambitious targets proposed by UNAIDS can be achieved, especially in countries with limited resources where the HIV burden is highest, according to the study authors. But the new findings suggest that Botswana could meet and even exceed the targets well before 2020, especially if ART eligibility is expanded – and that other countries could do the same.
“This is significant work as it provides further evidence that the UNAIDS 90-90-90 treatment target is both realistic and achievable,” said UNAIDS executive director Michel Sidibé, who was not involved in the study.
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).
A population-based sample of individuals was recruited 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. A random sample of about 20% of households in each community was selected. 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. We used modified Poisson generalised estimating equations 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.
81% of enumerated eligible household members took part in the survey (10% refused and 9% were absent). Among 12 610 participants surveyed, 3596 (29%) were infected with HIV, and 2995 (83•3%, 95% CI 81•4–85•2) of these individuals already knew their HIV status. Among those who knew their HIV status, 2617 (87•4%, 95% CI 85•8–89•0) were receiving ART (95% of those eligible by national guidelines, and 73% of all infected people). Of the 2609 individuals receiving ART with a viral load measurement, 2517 (96•5%, 95% CI 96•0–97•0) had viral load of 400 copies per mL or less. Overall, 70•2% (95% CI 67•5–73•0) of HIV-infected people had virological suppression, close to the UNAIDS target of 73%.