How Botswana nearly eliminated mother-to- child transmission of HIV and saved thousands of lives

Botswana, which once had the highest HIV infection rate in the world at nearly 40 percent of all adults, has nearly eliminated mother-to-child transmission by being an early adopter of best practices in controlling the spread of the virus.

Routine testing of all pregnant women became a national policy in 2005. The next year, the policy was expanded to include newborn testing, to allow for early infant diagnosis of HIV. In 2013, Botswana began offering all pregnant and breastfeeding women who tested positive for HIV free antiretroviral therapy (ARV) to reduce the risk of transmission of the virus from mother to child. In 2016, the country adopted a “treat all” strategy, providing all HIV-positive citizens with free ARV to reduce the spread of the virus within the adult population.

In 2019, Botswana expanded access to free ARV to HIV-positive migrants living in the country. An estimated 30,000 of the 150,000 migrants in Botswana are HIV positive. And recently, the government began offering women who are currently negative, but at high-risk of contracting HIV, pre-exposure prophylaxis.

The impact has been dramatic. Botswana has cut perinatal transmission from 40% in 1999 to under 2% in 2020. Here’s what that means in terms of lives impacted: in 1999, 4,600 children were infected by their mothers. In 2021, the last year for which data is available fewer than 500 children were infected by their mothers.

By integrating prevention of mother-to-child transmission, testing, and protocols into standard sexual, and reproductive health services, uptake of testing and treatment for pregnant women climbed from 49% in 2002 to 98% by 2010 and has stayed at that level. Currently, 98% of pregnant women agree to be tested for HIV and of those who test positive, 98% agree to take ARV.

“This is a huge accomplishment for a country that has one of the most severe HIV epidemics in the world – Botswana demonstrates that an AIDS-free generation is possible,” said Dr. Matshidiso Moeti, WHO Regional Director for Africa, in a statement. “This groundbreaking milestone is a big step forward in ending AIDS on the continent and shows how visionary political leadership aligned with public health priorities can save lives. I look forward to other African countries also reaching this goal.”

Alankar Malviya, the country director for UNAIDS Botswana, noted a few key drivers of Botswana’s success. “Botswana’s leadership embraced a data-driven strategy; they invested in expanding the number of healthcare providers and health facilities offering testing and treatment; they worked to ensure that civil society and international donors were aligned with government priorities; they truly treated all, including migrants; they have moved to deliver all HIV related services under one roof to improve access to care; and Botswana’s health systems collects good quality data to support implementation.”

Good data is a high priority, said Mpho Mmelesi, who served for nearly six years as a manager of research, monitoring, and evaluation in Botswana’s national AIDS coordinating agency and today works for UNAIDS. To improve data quality, the government is currently working to digitize its health data. Electronic data systems are being used in about 60 percent of health facilities. Each health facility has a staff member who is responsible for managing and collating data related to the testing and treatment of pregnant women and their children. And each of the country’s 27 health districts has a dedicated monitoring and evaluation officer and a program coordinator to manage the mother-to-child transmission program and related data. Routine and robust data quality audits are performed regularly, said Mmelesi.

“When the AIDS epidemic started,” recalled Mmelesi. “We couldn’t see the light at the end of the tunnel. Everyone around you was sick and every weekend there were funerals to attend, including funerals for children. That was heartbreaking.”

She added: “But by making HIV testing and treatment available to all, and now providing pre-exposure prophylaxis to women at high risk of contracting HIV while pregnant or breast feeding, will further reduce transmission during pregnancy and breastfeeding to less than 2%."

Botswana currently tests all pregnant women for HIV, repeatedly, throughout their pregnancies and after they give birth. If they test positive, they are encouraged to take and are provided with ARV to prevent mother-to-child transmission and their babies are tested and given ARV within six weeks of birth. Women who initially test negative, are re-tested during pregnancy and while breastfeeding, said Mmelesi.

“The high PMTCT testing and treatment uptake is because of the good health seeking behaviors of women,” said Mmelesi. “They trust the health system as more than 90% deliver in a health facility and agree to HIV testing and treatment because they know all of this is in the best interest of their child.

Research shows that mothers who are HIV positive but do not receive ARV have a 15% to 45% chance of transmitting the virus to their children during pregnancy, labor, delivery or breastfeeding. The risk of transmission drops to less than 5% if mothers and children receive ARV from initiation of pregnancy through the end of breastfeeding.

Globally, 15 countries have been certified for eliminating mother-to-child HIV transmission, but none of them had an epidemic as large as Botswana.

Mohamed Fall, UNICEF Regional Director for Eastern and Southern Africa, said in a statement that the country’s progress could serve as an example for others. “We applaud Botswana for this remarkable achievement, which serves as inspiration to other countries in Eastern and Southern Africa,” said Fall. “The progress on prevention of mother to child transmission of HIV in this region is truly a public health success, with more than 1.7 million new infections in children averted since 2010.”

Today, Botswana’s HIV prevalence rate among adults is 20.3%, ranking in the top four countries impacted by HIV and AIDS.

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