Back in December last year, Botswana received a silver tier status from the World Health Organisation (WHO) in recognition of the country's efforts working ever closer to ending mother-to-child transmission of the human immunodeficiency virus (HIV).

The WHO awards this honour to countries that have been able to keep their mother-to-child transmission below 5%, provide care to expectant mothers, administer antiretroviral (ARV) treatment to more than 90% of pregnant women living with HIV, and see fewer than 500 per 100,000 HIV-transmitted births.

Children are actually deeply impacted by the spread of HIV globally, with some 1,400 children becoming HIV positive and 1,000 children dying of HIV-related causes every day; while an estimated 2.5 million children worldwide under the age of 15 are living with HIV/AIDS — 1.9 million of whom are in sub-Saharan Africa. 

So we're going to take a look at what Botswana has been doing to reduce mother-to-child transmission of HIV, what other countries can learn from its efforts, and what we can all do to help. 

3 Key Things You Should Know About Botswana’s HIV Eradication Efforts

  1. Botswana is the first high-burden country (defined as more than 2% of women living with HIV) to be certified for achieving this "silver tier" milestone in the journey to eliminating mother-to-child transmission.
  2. Without any health interventions for women living with HIV, mother-to-child transmission can be between 15% and 45% during pregnancy, delivery, and breastfeeding.
  3. 90% of babies who acquired HIV from infected mothers are in sub-Saharan Africa.

Why Are Botswana's Efforts Being Praised?

Botswana joins 15 other countries in the world — including Bermuda, Cuba, Sri Lanka, and Thailand — that have received the "silver tier" certfication for their efforts towards ending this form of transmission of the disease. However, the southern African nation should be particularly hailed for its work, as no other country on the list (put together and monitored by the WHO) was facing an epidemic as severe as Botswana's. 

Following Botswana’s accolade, UNICEF Regional Director for Eastern and Southern Africa, Mohammed Fall, said: “We applaud Botswana for this remarkable achievement, which serves as inspiration to other countries in Eastern and Southern Africa.”

Fall added that the efforts to achieve the notable milestone saw more than 1.7 million new infections in Botswana’s children prevented since 2010. This is an extraordinary accomplishment, especially considering that in 1999, Botswana had a prevalence rate of up to 30%.

But how has Botswana been doing it? Mainly by implementing an aggressive national response programme that spanned over 20 years, that has included actions like: testing and retesting women and infants for HIV throughout pregnancy and while breastfeeding; and encouraging and supporting breastfeeding among HIV-positive mothers with a suppressed viral load of less than 400, and providing infant formula for those who can't breastfeed.

After starting antiretroviral therapy (ART) treatment for all children under five in 2014, Botswana then, a year later, became one of the first countries to implement what's known as "Option B+" — a strategy that treats all pregnant and breastfeeding women diagnosed with HIV with a lifelong triple antiretroviral treatment regimen. Countries that have since adopted this strategy include Rwanda and Zambia.

Continuing the work, Botswana then started a "treat all" programme for the general population, then going on to, in 2019, provide free ART for non-citizens too. 

What Does This Mean for the Most Vulnerable?

Since there is no cure yet for HIV, prevention is a critical step in ending HIV and AIDS on the continent.

WHO Regional Director for Africa, Dr. Matshidiso Moeti, said “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.”

“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," Dr. Moeti continued. "I look forward to other African countries also reaching this goal." 

With the world so focused on COVID-19, many other diseases that compromise public health have been neglected. Despite significant progress in the efforts to eradicate HIV, it remains a public health threat globally, and has a particularly high prevalence in Africa.

An analysis by the WHO found that the added burden of the coronavirus to already fragile health systems and the immune systems of people living with HIV poses a threat to the UN Global Goal 3 (which calls for access to good health care and well-being) across the continent.

In 2020, there were 37.7 million people living with HIV globally. The sub-Saharan Africa region accounts for 67% (24.7 million) of all people living with HIV, while Africa as a whole also accounts for two-thirds of the newly affected population.

Children are arguably among the most vulnerable to the spread of HIV, which is why it's so imperative that this is being directly addressed in Botswana. Executive Director of the Joint United Nations Programme on HIV/AIDS (UNAIDS), Dr. Winnie Byanyima, said, “Children are among the groups left furthest behind in the HIV response. Addressing this inequality and preventing new HIV infections in children is critical if we are to end AIDS.”

Africa’s Notable Progress in Eradicating HIV

While Botswana may be leading the pack in terms of tackling HIV mother-to-child transmission, many other African countries are also making tremendous strides in their HIV eradication efforts.  Africa as a whole has made notable progress in ending the HIV epidemic over the last decade — new infections have been reduced by 43% and AIDS-related deaths have almost halved.

In December 2020, UNAIDS implemented a 95-95-95 five-year plan in an effort to eradicate AIDS by 2030. The strategy sets out three targets that must be achieved by 2025 in order to end AIDS as a public health threat by 2030: Target 1 is to ensure that 95% of all those living with HIV know their status; the second target is to have 95% of those who are aware of their status to be on treatment; and target 3 aims to have 95% of all those on treatment to have their viral load suppressed.

As of December 2021, according to the WHO, African countries reported 87% of people living with HIV knowing their status; of those 77% are on treatment; and 68% have a low viral load.

But despite many countries falling behind on milestones, and COVID-19 having caused further disruption, there are nine African countries that are well on track to reaching these targets by 2025 — which are Botswana, Cabo Verde, Kenya, Lesotho, Malawi, Nigeria, Rwanda, Uganda, and Zimbabwe. 

Dr. Moeti highlighted that governments need to make a fresh push towards reaching these goals, by increasing resources and commiting to strengthening Africa’s fragile health care systems.

How Does This Relate to Ending Poverty and Achieving the Global Goals?

The continued existence of HIV and AIDS is a threat to public health and the livelihoods of everyday people — but those living in low- and middle-income countries are disproportionately affected. Poverty can only be perpetuated in the low-income countries where the virus and disease have higher prevalence, and where access to health care is more limited than in high-income nations. This holds back progress towards Global Goal 3, for good health and well-being.

“We cannot have poor countries at the back of the queue. It should not depend on the money in your pocket or the colour of your skin to be protected against these deadly viruses,” said Dr. Byanyima in a statement.

It’s also important to note that women and girls in the sub-Saharan region bear the brunt of the disease, with 80% of all women living with HIV being in this region; while women and girls also accounted for 59% of all new HIV infections in the region in 2019. The disproportionate burden of the virus on women and girls is also holding back progress towards Global Goal 5, for gender equality.

What Action Can We All Take?

As part of Global Citizen's year-long "End Extreme Poverty NOW — Our Future Can't Wait" campaign, we're focusing on three key areas: empowering girls, taking climate action, and breaking the systemic barriers that keep people trapped in poverty. 

With the COVID-19 pandemic having exposed and exacerbated vast inequities between rich and poor countries, we're focusing our "systemic barriers" work on building sustainable access to health care and achieving financial equity — helping lower-income countries recover from the pandemic, and strengthening their health care systems both in responding to COVID-19 and other health threats, like HIV/AIDS. You can read more about how we're advocating to break systemic barriers — and what this means — here

You can join us by taking action to call on governments, pharmaceutical companies, and the private sector to step up their support to breaking systemic barriers, firstly by prioritising an end to the COVID-19 pandemic and mitigating other, and future, health threats; and secondly to significantly step up funding to finance global health care and support health systems in low- and middle-income nations so essential health care supplies can reach people in need. 

Get started by signing up as a Global Citizen (either here, or by downloading the Global Citizen app), and head to our "Break Systemic Barriers NOW" campaign page to start taking action! 

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Defeat Poverty

Botswana Is Making Extraordinary Strides in Tackling HIV. Here's What to Know.

By Tshiamo Mobe