Since the late 1990s, Botswana (population of 1.7 million) has had one of the highest HIV prevalences in the world. The rate in pregnant women peaked in 2003, with an adjusted prevalence rate of 37.4%.1 The 2005 sentinel surveillance study showed an adjusted prevalence rate of 33.4%, indicating a possible decrease,2 although interpretation of prevalence figures may be confounded by the widespread availability of highly active antiretroviral therapy (HAART) in the public sector since 2002, which has substantially reduced the mortality of HIV/AIDS.
A nationwide prevention of mother-to-child transmission of HIV (PMTCT) program was launched in 1999 and provided in all districts by 2001. Antiretroviral treatment (ART) was offered in selected health facilities in 2002 and has been rolled out nationwide thereafter. By the end of June 2006, more than 70,000 Batswana were on ART. It is estimated that up to 110,000 might be eligible for treatment, provided that everybody is tested for HIV.
HIV TESTING AND COUNSELING IN BOTSWANA
HIV testing has been offered through public health facilities since the late 1980s. In addition, a network of voluntary counseling and testing centers (VCTs), known as Tebelopele in Setswana, was started in 2000, and there are currently Tebelopele centers in all 24 health districts.
Only 39% of pregnant women were tested for HIV in 2002, and 52% were tested in 2003. Attendance at Tebelopele testing centers was lower than expected, with approximately 37,000 first-time attendees from 2000 through 2002. Although the demand for ART was high from the start, with long waiting lists in many facilities, a large proportion of patients were diagnosed with advanced disease and many potential beneficiaries of treatment continued to delay HIV testing until they were seriously ill. By 2003, the pretest/posttest counseling model had been challenged3 and was discussed internationally and at the national level. The same year, a study among pregnant women in Francistown showed that 94% were in favor of routine HIV testing (RHT) for pregnant women.4 Focus group discussions with communities and health workers also showed a high level of support for RHT. Based on recommendations from a national consultative meeting, RHT was endorsed by President Festus Mogae through the National AIDS Council (NAC) in October 2003. The President then formally announced to the public the introduction of RHT from January 1, 2004.5,6 The most important goals of the new approach were to make everybody aware of his or her status so as to increase the uptake of interventions like ART and PMTCT at the most appropriate stage of the process and to reduce the stigma.
After the government's decision was announced by the President, the Ministry of Health (MOH) issued guidelines for RHT. Indications were symptoms of HIV infection, including tuberculosis (TB); pregnancy; sexually transmitted infection; any patient aged 16 years or older visiting a health facility; any individual going for a general medical examination; and a patient's own wish.7 Rape and needle-prick injury were added soon afterward.
The approach chosen is an “opt-out policy,” meaning that the patient is informed that an HIV test is going to be done but that he or she has a right to refuse. There is no written consent. If the patient opts out and the health worker thinks there is a strong reason for HIV testing (eg, pregnancy, AIDS-defining illness), the patient may be referred to a trained counselor for ordinary pretest counseling. No patient may be tested against his or her wish, however.
The introduction of RHT was widely publicized through verbal and written media, and the MOH has produced materials like posters and folders for patients in English and Setswana. Group education through flip charts is also widely used before individual testing.
The aim of this article is to report on Botswana's experience with 2.5 years of routine HIV testing.
MATERIALS AND METHODS
When RHT was introduced, HIV testing was done by enzyme-linked immunosorbent assay (ELISA) methods and blood had to be sent to hospitals for testing. In mid-1994, however, rapid HIV tests were introduced for use in hospitals and primary health care facilities. Before the introduction of RHT, the PMTCT program had started to recruit so-called “lay counselors.” They were secondary school graduates, who trained for a month and were then sent to the facilities, mainly primary care facilities like clinics and health posts. When the rapid tests were introduced, the lay counselors were given additional training to conduct the testing. The flow chart being used for routine HIV testing is shown in Figure 1. Testing is by parallel rapid tests or parallel ELISAs: in the first case, Uni-Gold Recombigen HIV (Trinity Biotech, Bray, Ireland) and Determine HIV 1/2 (Abbott Diagnostics, Abbott Park, IL) tests are used. If discordant, parallel tests are repeated. If rapid tests are still discordant, the OraQuick (OraSure Technologies, Bethlehem, PA) test is used as a tie-breaker.8 A polymerase chain reaction (PCR) assay is used for infant testing, particularly for follow-up of children born to HIV-positive mothers, but only a single specialized laboratory does this test.
Those who test negative should be offered retesting once a year. A repeat test can be done at any time at the patient's own request, however.
The 31 public hospitals submit aggregated data on RHT to the MOH on a monthly basis. Primary care facilities (608 clinics and health posts) submit aggregated data to their district health teams, which, in turn, report monthly to the MOH. These reports provide data on numbers offered testing, numbers accepting, and test results by age group and gender. Reasons for testing and testing methods are also reported. The private health sector, which consists of 4 private hospitals and approximately 200-300 private practitioners, does not report, however.
In 2004, 60,846 persons were reported tested through RHT, increasing to 157,894 in 2005 and 88,218 in the first half of 2006. The reported rate of RHT in the population in 2004 was 36 of 1000 persons versus 93 of 1000 persons in 2005 and 104 of 1000 persons for the first 6 months of 2006. A smaller proportion of those offered testing opted out in the first part of 2006 compared with 2005 (6.8% vs. 11.2%). Testing uptake in 2005 was lowest in the age group from 15 to 19 years of age (87.0% of those offered testing), and uptake for girls and women aged 15 to 19 years was 89.4% versus 75.6% for boys and men. During 2004, 41.9% tested positive as compared to 31.5% in 2005 and 28.1% in first part of 2006. More details are shown in Table 1 and Figure 2.
Annual attendance at the VCTs has increased every year since they were started and has continued increasing parallel to the introduction of routine testing. Table 2 shows new attenders at Tebelopele centers from 2000 through 2006. Of new Tebelopele attenders, 33% of female attendees and 26.2% of male attendees tested positive in 2005.
Reported reasons for routine testing in 2005 were patient's wish (50.1%), pregnancy (24.7%), medical examination (6.5%), clinical suspicion (5.7%), sexually transmitted infection (2.3%), rape (1.0%), TB (0.4%), needlestick injury (0.2%), and other (9.1%). Rapid methods were used for 85% of routine tests in 2005, ELISA tests were used for 13.5%, and PCR assays were used for 1.5%.
Data from the National Antiretroviral Program, Mahalapye test site, show that the proportion of patients being assessed for HAART and who had a CD4 count ≤100 cells/μL was reduced from 48.7% in 2003 to 33.8% in the first part of 2006 (Fig. 3). The reduction from 2003 to 2006 was highly significant (χ2 test for trend = 40.56 with 3 degrees of freedom [df]; P < 0.00001).
Because Botswana was the first African country to introduce the RHT strategy and international guidelines9 were lacking at the time, the country was prompted to be innovative and to develop its own system. Guidelines for standardization, training materials for health care workers and public education, and a reporting system had to be established parallel to the implementation of RHT. Because of these factors, and amid the skepticism of legal and ethical concerns, progress on implementation is monitored at the NAC on a quarterly basis. Particularly during the first year, there were some problems with incomplete reporting, and a rough estimate is that the total number tested through RHT in the public sector in 2004 through 2005 may be 5% to 10% higher than reported previously because of missing reports. In addition, the private health care sector is not yet included in the reporting system but does offer RHT. It does, however, report on ART, and 8500 of the 70,685 patients who were on ART in Botswana by mid-2006 were initiated on treatment in the private sector. We do not know how much overlap there is between the private and public sectors with regard to testing or VCTs. A conservative estimate is that at least 14% to 15% of the population was tested through RHT in the public and private health sectors or at the VCTs in 2005.
The introduction of rapid tests clearly increased patients' and health workers' acceptance of RHT, as shown by the test statistics. The delay in obtaining results from ELISA testing, with consequent loss of patients to the system, is also largely avoided with rapid tests.
It is not surprising that girls and women older than 15 years of age are overrepresented among those offered testing, because pregnancy is one of the main criteria. A higher proportion of men than women tested HIV-positive in routine testing, however, although more women tested positive at the VCTs. Population-based studies in Botswana and elsewhere in Africa10,11 have shown that women generally have higher HIV prevalences than men, reflecting a higher vulnerability to infection. Our data do not permit an analysis of reasons for testing by gender, but we believe that the higher infection rates in routinely tested men may reflect differences in health-seeking behavior. Men opt out more frequently than women. Fear of learning one's status, lack of perceived HIV risk, and fear of having to change sexual practices with a positive HIV test result were given as the key barriers to testing in a nationwide study in 2004.12 Reasons for opting out of testing are not reported, but perhaps more men than women postpone testing until they have symptomatic HIV disease.
With regard to reasons for testing, we believe that the reporting system might not give a fully accurate picture. For example, national TB program data indicate that at least 4000 patients with TB were tested for HIV in 2005, whereas only 602 were ticked as having TB in the reporting forms (the rest have probably been ticked as “patient's wish” or “other”). We think the main problem is that HIV testing usually is initiated by doctors or nurses. The staff who conduct the testing and are responsible for submitting the reports (lay counselors or laboratory personnel) might not know the exact reason for testing, however, and are likely to use the option “patient's wish” as a generic reason. We need to find a better way to capture these data without compromising confidentiality.
We also face challenges in quality assurance of rapid testing and counseling. There is a quality control policy for testing,8 and quality assurance is in place in hospital laboratories, but it is not yet operationalized for clinics and health posts. Likewise, we do not know enough about the quality of counseling. Refresher courses are held annually for the lay counselors, however, and counseling supervision is being developed.
A nationwide population-based study in mid-2004 showed that 25% of the population between 10 and 64 years of age and 42% of those between 20 and 24 years of age had been tested for HIV, with more women than men having been tested.10 Another study conducted toward the end of 2004 showed that 48% of adults between 18 and 49 years of age reported that they had ever been tested.12 We assume that the proportion of Batswana who have been tested has increased considerably since then. The MOH has made it a target that at least 70% of the sexually active population should know its status by 2008.13
The numbers offered testing may seem high, but public health facilities in Botswana have more than 2 million adult outpatient attendances per year.14 In addition, a considerable proportion of routine tests are self-initiated. Thus, it seems that the guidelines are not being fully implemented. We suspect that the main reason is capacity problems in the facilities, with testing primarily being offered to high-priority groups such as symptomatic patients and pregnant women as well as to those patients who ask for it themselves.
An argument against RHT is that it could keep patients away from health facilities or that patients might be coerced into testing against their wish.15,16 Attendance at antenatal clinics remains high at more than 95%, however, and a study in pregnant women in 2004 showed that RHT increased their acceptance of testing.17 Similarly, a pilot study on intrapartum RHT in Uganda found that testing uptake increased.18 It is also worth mentioning that the MOH has not received any information or complaint about patients being tested against their wish, and there have been no reports of discrimination or stigmatization as a result of routine HIV testing. In view of the concern expressed by human rights organizations in Botswana on the principle of routine testing and the presence of unfettered private media, it is highly unlikely that abuses or adverse outcomes would go unreported. A recent survey found that 81% of Batswana adults were extremely or very much in favor of RHT, 8.4% were somewhat in favor of it, and only 10.6% were opposed to it. Sixty percent believed that it would reduce the HIV-related stigma.12 We believe that the increasing numbers of people who are tested through RHT or VCTs in Botswana and the decreasing proportion of patients who opt out when offered RHT are the best indications that RHT is well accepted and that the HIV-related stigma is decreasing.
There is a need for improvements in the reporting system, and we have also described challenges in quality assurance of rapid testing and counseling. Nevertheless, we are convinced that RHT has been of great benefit. It has provided access to preventive services and early access to ART for a substantial number of Batswana, and increasing numbers know their HIV status. Some eastern and southern African countries like Kenya and Lesotho have introduced RHT, Zimbabwe has implemented it in the antenatal care setting, and other countries are piloting it.19 In a country like Botswana, with good access to ART and PMTCT, we believe that the benefits of RHT fundamentally outweigh the risks.
Thanks to John P. A. Puvimanasinghe for providing CD4 cell counts from the Mahalapye test site and to Reggie Moatshi for the Tebelopele data.
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