Reflecting on Botswana eliminating Mother-to-Child HIV transmission
On an annual basis, UNAIDS releases a global AIDS update report, which contains reflections on the reporting period, builds up to what can be expected, and makes recommendations on how countries need to respond to HIV at the national level, as well as collaboratively at regional and international levels. On July 27, the most recent update titled “In Danger: Global AIDS Update 2022” was published. In it, new data are presented, which reveal the ways in which COVID-19 and other global crises shifted attention and resources away from HIV over the last two years, resulting in the heightened risks which will invariably impact many lives.
UNAIDS calls for an increase in domestic funding for Health and HIV funding given the shift in major donor approaches and competing priorities with pandemics and the global economic crisis due to the impact of the Russia-Ukraine war. A sustained AIDS response in Botswana will require tapping into efficiency gains and doing more with less. Botswana has brilliant achievements under its belt in reversing the tide of HIV, with excellent government – CSO – Development Partners’ collaboration, and must do everything to ring-fence the gains and sustain the response by keeping communities at the centre of the programme cycle.
Amidst all these challenges, as presented in the report, the story of how Botswana became the first high-burden country to be honoured with certification on the Path to Eliminate Vertical HIV Transmission, stands out, like a diamond. In 2014, WHO with UN partners – UNAIDS, UNICEF, and UNFPA – including networks of women living with HIV, initiated a global process for reviewing and validating countries that have reached key impact and process indicators to eliminate mother-to-child transmission (EMTCT) of HIV and syphilis. In other words, to reduce transmission and new infections to a very low level, where it is no longer considered a major public health threat. Since 2015, more than 15 countries from four WHO regions have been validated for the elimination of HIV and/ or syphilis. In recognition of progress towards reaching EMTCT of HIV, Botswana applied to be validated on the Path to Elimination (PTE). The application was based on the successful preliminary review of process and impact indicators for the years 2017–2019. The products of the process included the Botswana EMTCT National Validation Report (NVR) and the Afro Regional Validation Report (RVR) which provided the WHO Global Validation Advisory Committee (GVAC) with a strong recommendation to certify Botswana as having met the impact and process indicators for the Silver Tier of PTE during the two-year review period 2018–2019. The GVAC also provided recommendations for further strengthening the programme. It should be noted that Botswana’s validation report was the first global submission from the African region and the first submission for the category of PTE, which was created specifically for high-burden countries which have made strong progress along the continuum of EMTCT.
The ‘Silver Tier’ that Botswana has attained requires an HIV case rate of fewer than 500 per 100,000 live births, mother-to-child HIV transmission rate under five percent and provision of antenatal care and antiretroviral treatment to more than 90% of pregnant women.
Botswana utilised the recommended WHO EMTCT tools and followed the criteria and processes for validation of EMTCT for HIV and syphilis. It focused on four key areas programme implementation, data systems, laboratory systems, human rights, community engagement, and gender equality – HR, GE, and CE.
In October 2021, the GVAC certified Botswana for the ‘Path to Elimination’ for HIV at the Silver Tier level. The GVAC certification came with recommendations that the country is expected to address and to be reported on in the maintenance report in October 2024. In addition, the GVAC requested that a national plan to address the recommendations on Human Rights/ Gender Equality, and Community Engagement (HR, GE, and CE) be developed and submitted as an update to the GVAC in October 2022.
This certification is an important milestone for Botswana, as well as for other high-burden countries. It tells the important story, that an AIDSfree generation is possible. It is also illustrative of what can be achieved through a collaborative effort between visionary political leadership and a society committed to the advancement of public health priorities.
Botswana’s leadership continues to be exemplary in the ongoing Constitutional review process, where meaningful public participation has been ensured and promoted through the Constitutional Review Committee’s continued engagements with all sections of society in Botswana, seeking out their input at all points of the decision-making process, and specific engagements with different civil society organisations which work on specific thematic areas, including marginalised communities. It is heartening to see civil society organisations mobilising the voices of the most marginalised sections of society and making maximum use of this window of opportunity. The process in turn will be enriched by contributions from Key Populations, Youth and Women groups including young mothers, claiming their Sexual and Reproductive Human Rights. The report indicates that globally the number of new infections dropped only 3.6 percent between 2020 and 2021, the smallest annual decline in new HIV infections since 2016. Within and between countries are stalling progress in the HIV response and HIV is further widening those inequalities. New infections occurred disproportionately amongst young women and adolescent girls, with a new infection every two minutes in this population in 2021. The gendered HIV impact, particularly for young African women and girls, occurred amidst disruption of key HIV treatment and prevention services, millions of girls out of school due to pandemics, and spikes in teenage pregnancies and gender-based violence. In sub-Saharan Africa, adolescent girls and young women are three times as likely to acquire HIV as adolescent boys and young men.
It is important to note that although Botswana has done well in reaching this notable milestone, it is not exempted from the challenges faced by the global community, as reflected by the global update report. Urgent action and international solidarity including a focus on building systems resilience for such shocks in future and a focus on sustainability of the response are most needed.
*Alankar Malviya, is the UNAIDS Botswana country director and representative. He is a graduate of the London School of Economics and has over 25 years of diverse development sector experience, with government, private sector, and the UN. He started his career with Civil Services in his home country, India and has worked with the UN since 2005. Before coming to Botswana in April 2022, he was Senior Regional Advisor Fast Track for Eastern and Southern Africa, for UNAIDS regional office based in Johannesburg, South Africa