Many countries have experienced challenges with achieving high rates of HIV testing and treatment. Botswana may serve as a useful “demonstration case” in assessing the feasibility of approaching the new UNAIDS 2020 targets for 90% of HIV-infected persons knowing their status, 90% of these individuals receiving sustained ART, and 90% of those starting ART having undetectable HIV-1 RNA.
A population-based random sample of individuals was recruited and interviewed in 24 communities in Botswana from October 2013 to July 2015 as part of a large, ongoing PEPFAR funded pair-matched community-randomized trial designed to evaluate the impact of a combination prevention package on HIV incidence (the “BCPP” study). A random sample of 20% of households in each of these 24 communities was selected from a list of all households created using Google Maps. Consenting household residents age 16-64 years who were Botswana citizens were asked to participate in an individual questionnaire, and to have blood drawn for HIV testing in absence of written documentation of positive HIV status (and for HIV-RNA testing if HIV-infected, regardless of ART status).
Seventy-nine percent of enumerated eligible household members took part in the survey (11% refused participation and 10% were absent). Among 9,780 participants, 2,727 (28%) were HIV-infected; 2,226 (82%) of the HIV-infected residents already knew their HIV status. Among those who knew their HIV status, 1,915 (86%) were receiving ART (this represented 95% of those eligible for ART by national guidelines). Overall, 70% of all HIV-infected persons were on ART. We obtained an HIV-1 RNA result in greater than 99% of HIV-infected. Of the 1,932 individuals who had already started ART (including 17 defaulters), 1,837 (95%) had HIV-1 RNA <400 copies/mL and 1,764 (91%) had HIV-1 RNA <40 copies/mL.
Botswana, a resource-constrained setting with high HIV prevalence, has achieved very high rates of HIV testing and treatment coverage. Rates of knowledge of HIV status, ART initiation, and virologic suppression are close to the UNADS 90-90-90 targets, at 82%, 86%, and 95%, respectively. Overall, 67% of HIV-infected persons had HIV-1 RNA<400 copies/mL, approaching the UNAIDS target of 73%.