Search

In Botswana, HIV prevalence is 20.3% among those between 15 and 49 years old, and in sub-Saharan Africa, higher income has been associated with increased HIV risk. We qualitatively explored barriers to HIV testing and acceptability of HIV self-testing (HIVST) among higher socio-economic status (SES) men in Botswana. Twenty higher SES men (10 tested, 10 not tested recently) participated in semi-structured interviews and 10 men participated in asynchronous online focus groups (FGs) about HIV testing barriers and HIVST acceptability. Results indicated that stigma, inconvenience and perceived lack of confidentiality were barriers to HIV testing, as were masculinity-related concerns (e.g. fear of losing status if they accessed testing or were found to be HIV positive). Men said that HIVST reduced barriers to testing and that test kits could be placed in public spaces for pick-up and used in private. Overall, HIVST was seen as acceptable and feasible among higher SES men in Botswana.

BACKGROUND: Social support reciprocity (the extent to which people exchange mutual support) is associated with long-term health. METHODS: We examined whether overall social support and reciprocity of support between people living with HIV and their treatment partners (informal caregivers selected from patients’ social networks to support adherence) is associated with HIV viral suppression. A total of 130 patients living with HIV and their treatment partners were recruited from a clinic in Gaborone, Botswana from May 2016 to April 2017. Participants completed surveys assessing socio-demographic and social network characteristics. Patients and treatment partners rated their emotional closeness to each other (not at all close=0, somewhat close=1, very close=2). RESULTS: Multivariable logistic regressions indicated a significantly higher likelihood of viral suppression among patients who reported greater average emotional closeness to social network members. The likelihood of viral suppression was lower in asymmetric relationships in which patients felt closer to treatment partners than treatment partners felt to them (compared to when treatment partners felt closer to patients); this negative effect was strongest in dyads with female treatment partners and male patients. Follow-up analyses additionally indicated that asymmetric relationships in which treatment partners felt closer to patients were as protective as symmetric relationships, in which patients and treatment partners felt equally close. CONCLUSIONS: Perceptions around reciprocity may matter as much as overall relationship closeness in patients’ health outcomes. Interventions to improve the support of informal caregivers could help to improve relationship quality and health outcomes among people with HIV.

Most of the adolescents living with HIV and AIDS were born prior to the introduction of the Antiretroviral Therapy in Botswana. This cohort had just reached adolescence and it was imperative to understand their sexuality and 26 ALWHA aged 15 to 19 years, their parents/guardians and health care providers participated in the study. An elicitation survey was conducted among this group followed by Focus Group Discussions. In-depth interviews were conducted among 8 and 25 parents/guardians and health care providers respectively. Thematic content analysis was adopted to analyze the data. The following themes were derived: difficulty to disclose one’s HIV-infected status, parents/guardians failure to discuss sexuality issues with adolescents, mode of HIV transmission, sexual activity and inactivity, sex education, sexual violations, conscripted intimacy, and the right to sexual relations. The same issues were expressed by parents/guardians and health care providers. Sexuality education needs to be incorporated and strengthened at both nursing curricula and at policy level. Programes that reinforce parent- child communication should be instituted and strengthened at community, institutional and national levels.

Background Behavioral intentions (motivational factors), attitudes, subjective norm (social pressures), and perceived behavioral control promote or discourage smoking behavior among adolescents. Objective To assess students’ behavioral intentions, attitudes, subjective norms and perceived behavioral control on smoking using the Theory of Planned Behavior. The prevalence of smoking among the adolescents is also calculated. Methods In this cross-sectional study, structured self-administered questionnaires were used to collect data from adolescents in primary and secondary schools. Data on demographics, behavioral intentions, attitudes, subjective norms, and perceived behavioral control towards smoking were collected. Pearson product moment correlations and logistic regression models were used to determine factors associated with current smoking. Results A total sample of 2554 (mean age = 15; Range = 12–18 years) students participated in the study. Twenty-nine percent (n = 728) of the students had tried smoking at least once. Smoking was predicted by attitudes, subjective norms, perceived behavioral control and intention.There was a strong association between having a parent or guardian, caregiver or close friend who smoked (p < 0.001) and being a smoker. The majority of students (57%) conveyed that adults talked to them about the harmful effects of cigarette smoking and 50% had discussed smoking concerns with their friends. Students who had positive attitudes towards smoking like “smoking makes you confident” were more likely to be current smokers (OR: 1.63, 95% CI: 1.03–2.59). The feeling or conviction that they could refuse a cigarette if offered was an impediment from smoking (OR: 0.18, 95% CI: 0.13–0.26). Conclusions Attitudes, subjective norms, and perceived behavioral control contributed significantly to the students' smoking. Right attitudes must be cultivated and behavioral control must be strengthened for early effective interventions to curtail smoking among adolescents.

The amount of biomedical research being conducted around the world has greatly expanded over the past 15 years, with particularly large growth occurring in low- and middle-income countries (LMICs). This increased focus on understanding and responding to disease burdens around the world has brought forth a desire to help LMIC institutions enhance their own capacity to conduct scientifically and ethically sound research. In support of these goals the Johns Hopkins-Fogarty African Bioethics Training Program (FABTP) has, for the past six years, partnered with three research institutions in Africa (University of Botswana, Makerere University in Uganda, and the University of Zambia) to support research ethics capacity. Each partnership began with a baseline evaluation of institutional research ethics environments in order to properly tailor capacity strengthening activities and help direct limited institutional resources. Through the course of these partnerships we have learned several lessons regarding the evaluation process and the framework used to complete the assessments (the Octagon Model). We believe that these lessons are generalizable and will be useful for groups conducting such assessments in the future.

IntroductionThe global burden of cancer continues to increase in low- and middle-income countries, particularly in sub-Saharan Africa (SSA). Botswana, a middle-income country in SSA, has the second highest prevalence of HIV worldwide and has seen an increase in human papillomavirus (HPV)-associated cervical cancer over the last decade in the setting of improved survival of HIV-infected women. There is an urgent need to understand more clearly the causes and consequences of HPV-associated cervical cancer in the setting of HIV infection. We initiated the Ipabalele (‘take care of yourself’ in Setswana) programme to address this need for new knowledge and to initiate long-term research programme capacity building in the region. In this manuscript, we describe the components of the programme, including three main research projects as well as a number of essential cores to support the activities of the programme.Methods and proceduresOur multidisciplinary approach aims to further current understanding of the problem by implementing three complementary studies aimed at identifying its molecular, behavioural and clinical determinants. Three participant cohorts were designed to represent the early, intermediate and late stages of the natural history of cervical cancer.The functional structure of the programme is coordinated through programmatic cores. These allow for integration of each of the studies within the cohorts while providing support for pilot studies led by local junior investigators. Each project of the Ipabalele programme includes a built-in capacity building component, promoting the establishment of long-lasting infrastructure for future research activities.Ethics and disseminationInstitutional review board approvals were granted by the University of Pennsylvania, University of Botswana and Ministry of Health and wellness of Botswana. Results will be disseminated via the participating institutions and with the help of the Community Advisory Committee, the project’s Botswana advisory group.

Objective Many national HIV guidelines recommend that health care providers encourage patients to identify a treatment partner from their social network to support antiretroviral therapy adherence. This study examined associations of patient and treatment partner characteristics with patient viral suppression in Botswana. Design One hundred thirty-one patients [67 (51.1%) virally suppressed and 64 (48.9%) not suppressed] and their treatment partners were recruited for cross-sectional interviews from one HIV clinic. Methods Participants completed surveys assessing social network, sociodemographic, and psychosocial characteristics. Open-ended questions explored treatment partner relationship quality. Results Multivariate logistic regressions indicated a higher likelihood of viral suppression among patients who reported greater average emotional closeness to their network members [odds ratio (95% confidence interval) = 3.8 (1.3 to 11.5), P = 0.02] and whose treatment partners were spouses/partners [odds ratio (95% confidence interval) = 2.6 (1.0 to 6.7), P = 0.04]. Qualitative analyses indicated that treatment partners of suppressed patients provided both medical and nonmedical support, whereas treatment partners of unsuppressed patients focused mainly on adherence reminders and appointment accompaniment. Treatment partners, especially of unsuppressed patients, requested ongoing training and counseling skills. Conclusions Additional research is needed to further explore effective characteristics of treatment partners to inform HIV treatment guidelines. Standard training for treatment partners could include medical-related information and counseling education.

The study assesses correlates of abstinence intention among HIV positive adolescents aged 15-19 years to identify salient behavioural, normative and control beliefs relevant to sexual risky behaviour using the theory of reasoned action and planned behaviour. A cross sectional survey of 98 HIV positive adolescents aged 15-19 years was conducted at a Children’s center and from the infectious disease care clinics in Mochudi. Among 98 respondents, 56% were females (mean age 15.80, SE=0.21) and 44% were males (mean age 15.73, SE = 0.187). Abstinence behavioural beliefs (p

Background : Supportive supervision is a way to foster performance, productivity, motivation, and retention of health workforce. Nevertheless there is a dearth of evidence of the impact and acceptability of supportive supervision in low- and middle-income countries. This article describes a participatory process of transforming the supervisory practice of district health managers to create a supportive environment for primary healthcare workers. Objective : The objective of the study was to explore how district health managers can change their practice to create a more supportive environment for primary healthcare providers. Design : A facilitated co-operative inquiry group (CIG) was formed with Ngamiland health district managers. CIG belongs to the participatory action research paradigm and is characterised by a cyclic process of observation, reflection, planning, and action. The CIG went through three cycles between March 2013 and March 2014. Results : Twelve district health managers participated in the inquiry group. The major insights and learning that emerged from the inquiry process included inadequate supervisory practice, perceptions of healthcare workers’ experiences, change in the managers’ supervision paradigm, recognition of the supervisors’ inadequate supervisory skills, and barriers to supportive supervision. Finally, the group developed a 10-point consensus on what they had learnt regarding supportive supervision. Conclusion : Ngamiland health district managers have come to appreciate the value of supportive supervision and changed their management style to be more supportive of their subordinates. They also developed a consensus on supportive supervision that could be adapted for use nationally. Supportive supervision should be prioritised at all levels of the health system, and it should be adequately resourced. Keywords: supportive supervision; district health managers; healthcare workers; primary healthcare; co-operative inquiry group (Published: 24 June 2016) Citation: Glob Health Action 2016, 9 : 31263 - http://dx.doi.org/10.3402/gha.v9.31263

Objectives. We sought to identify correlates of forced sex perpetration among men and victimization among women in Botswana and Swaziland. Methods. We surveyed a 2-stage probability sample of 2074 adults from the 5 districts of Botswana with the highest HIV prevalence rates and all 4 regions of Swaziland. We used multivariable logistic regression to identify correlates of forced sex victimization and perpetration. Results. Lifetime prevalence rates of forced sex victimization of women were 10.3% in Botswana and 11.4% in Swaziland; among men, rates of perpetration were 3.9% in Botswana and 5.0% in Swaziland. Lifetime history of forced sex victimization was the strongest predictor of forced sex perpetration by men in Botswana (adjusted odds ratio [OR] = 13.70; 95% confidence interval [CI] = 4.55, 41.50) and Swaziland (adjusted OR = 5.98; 95% CI = 1.08, 33.10). Problem or heavy drinking was the strongest predictor of forced sex victimization among women in Botswana (adjusted OR = 2.55; 95% CI = 1.19, 5.49) and Swaziland (OR = 14.70; 95% CI = 4.53, 47.60). Conclusions. Sexual violence in Botswana and Swaziland is a major public health and human rights problem. Ending codified gender discrimination can contribute to fundamentally changing gender norms and may be an important lever for gender-based violence prevention in these countries.

Objectives. We sought to examine the impact of treatment access on HIV stigma in Botswana 3 years after the introduction of a national program of universal access to antiretroviral therapy. Methods. We studied the prevalence and correlates of HIV stigma in a population-based study of 1268 adults in Botswana in 2004. We used multivariate logistic regression to assess correlates of stigmatizing attitudes and a new measure, anticipated HIV stigma. Results. Overall, 38% of participants had at least 1 stigmatizing attitude: 23% would not buy food from a shopkeeper with HIV; 5% would not care for a relative with HIV. Seventy percent reported at least 1 measure of anticipated stigma: 54% anticipated ostracism after testing positive for HIV, and 31% anticipated mistreatment at work. Perceived access to antiretroviral therapy was strongly and independently associated with decreased odds of holding stigmatizing attitudes (adjusted odds ratio [AOR] = 0.42; 95% confidence interval [CI] = 0.24, 0.74) and of anticipated stigma (AOR = 0.09; 95% CI = 0.03, 0.30). Conclusions. Our findings suggest that antiretroviral therapy access may be a factor in reducing HIV stigma. Nevertheless, the persistence of stigmatizing attitudes and significant anticipated stigma suggest that HIV stigma must be a target for ongoing intervention.

Partnering in research across disciplines and across countries can be challenging due to differing contexts of practice and culture. This study sought to demonstrate how central constructs that have application across disciplines and countries can be studied while concurrently considering context. Groups of nurses from Botswana, Ireland, Israel, New Zealand, and Spain partnered to identify how to measure the constructs of caring for self, burnout, and compassion fatigue, replicating a study by Johnson (2012), who found that caring for self had a moderately strong negative relationship with both compassion fatigue and burnout. While these constructs were of interest to all five groups, the conversation of contextual influences varied. All five groups used the same instruments to measure the central constructs. Levels of burnout and compassion fatigue varied by country but were moderated by caring for self. Partnering across countries made it possible to understand that caring for self moderates the negative impact of burnout and compassion fatigue in all five countries. This study gives insight into methods for partnering across disciplines and contexts.

Background An adequate health workforce force is central to universal health coverage and positive public health outcomes. However many African countries have critical shortages of healthcare workers, which are worse in primary healthcare. The aim of this study was to explore the perceptions of healthcare workers, policy makers and the community on the shortage of healthcare workers in Botswana. Method Fifteen focus group discussions were conducted with three groups of policy makers, six groups of healthcare workers and six groups of community members in rural, urban and remote rural health districts of Botswana. All the participants were 18 years and older. Recruitment was purposive and the framework method was used to inductively analyse the data. Results There was a perceived shortage of healthcare workers in primary healthcare, which was believed to result from an increased need for health services, inequitable distribution of healthcare workers, migration and too few such workers being trained. Migration was mainly the result of unfavourable personal and family factors, weak and ineffective healthcare and human resources management, low salaries and inadequate incentives for rural and remote area service. Conclusions Botswana has a perceived shortage of healthcare workers, which is worse in primary healthcare and rural areas, as a result of multiple complex factors. To address the scarcity the country should train adequate numbers of healthcare workers and distribute them equitably to sufficiently resourced healthcare facilities. They should be competently managed and adequately remunerated and the living conditions and rural infrastructure should also be improved.

This article discusses the response of Botswana to the HIV/AIDS epidemic. In recognition of the fact that HIV/AIDS is more than just a health issue, Botswana has instigated a multi-sectoral response to the epidemic, which sets Botswana apart as an example of a country following ‘best practice’ in HIV/AIDS prevention and control. Yet the battle is not over. AIDS is the leading cause of death in Botswana for young adult women aged between 15 and 19 years old. This article makes suggestions for future improvement, to respond to the challenges facing Batswana women living with, and affected by, HIV/AIDS.

This study seeks to determine the prevalence and risk factors for smoking among students aged 12-18 years in two cities in Botswana. Using a sample of 2554 students we adapted the Global Youth Tobacco Survey (GYTS) methodology to assess students' smoking practices, knowledge, beliefs and attitudes. Logistic regression models were used to evaluate factors associated with smoking. The results revealed that 10% of students were current tobacco smokers with 29% reporting having tried smoking. Self-image and acceptance by peers were the strongest predictors of smoking overall (adjusted Odds Ratio [aOR]: 3.13, 95%, Confidence Interval [CI]: 2.67-3.66). Intention to smoke or to continue to smoke and perceived norms in conformity with smoking were also independently associated with smoking (aOR: 1.81, 95% CI: 167-2.11 and aOR: 1.31, 95% CI: 1.10-1.57, respectively). Perceived prevalence and exposure to smoking by peers and family and access to tobacco products was stronger among females (aOR: 1.69, 95% CI: 1.52-1.91) compared to males (aOR: 0.93, 95% CI: 0.70-1.24). Our results indicate that anti-tobacco interventions in Botswana should prioritize intra-personal factors associated with smoking. Our findings also suggest that different interventions targeting male and female students should be explored.

Background: Botswana is a large middle-income country in Southern Africa with a population of just over two million. Shortage of human resources for health is blamed for the inability to provide high quality accessible health services. There is however a lack of integrated, comprehensive and readily-accessible data on the health workforce. Aim: The aim of this study was to analyse the existing databases on health workforce in Botswana in order to quantify the human resources for health. Method: The Department of Policy, Planning, Monitoring and Evaluation at the Ministry of Health, Ministry of Education and Skills Development, the Botswana Health Professions Council, the Nursing and Midwifery Council of Botswana and the in-country World Health Organization offie provided raw data on human resources for health in Botswana. Results: The densities of doctors and nurses per 10 000 population were four and 42, respectively; three and 26 for rural districts; and nine and 77 for urban districts. The average vacancy rate in 2007 and 2008 was 5 % and 13 % in primary and hospital care, respectively, but this is projected to increase to 53 % and 43 % , respectively, in 2016. Only 21 % of the doctors registered with the Botswana Health Professions Council were from Botswana, the rest being mainly from other African countries. Botswana trained 77 % of its health workforce locally. Conclusion: Although the density of health workers is relatively high compared to the region, they are concentrated in urban areas, insuffiient to meet the projected requirements and reliant on migrant professionals.

BackgroundDepression is a leading contributor to the burden of disease worldwide, a critical barrier to HIV prevention and a common serious HIV co-morbidity. However, depression screening and treatment are limited in sub-Saharan Africa, and there are few population-level studies examining the prevalence and gender-specific factors associated with depression.MethodsWe conducted a cross-sectional population-based study of 18-49 year-old adults from five districts in Botswana with the highest prevalence of HIV-infection. We examined the prevalence of depressive symptoms, using a Hopkins Symptom Checklist for Depression (HSCL-D) score of ≥ 1.75 to define depression, and correlates of depression using multivariate logistic regression stratified by sex.ResultsOf 1,268 participants surveyed, 25.3% of women and 31.4% of men had depression. Among women, lower education (adjusted odds ratio [AOR] 2.07, 95% confidence interval [1.30-3.32]), higher income (1.77 [1.09-2.86]), and lack of control in sexual decision-making (2.35 [1.46-3.81]) were positively associated with depression. Among men, being single (1.95 [1.02-3.74]), living in a rural area (1.63 [1.02-2.65]), having frequent visits to a health provider (3.29 [1.88-5.74]), anticipated HIV stigma (fearing discrimination if HIV status was revealed) (2.04 [1.27-3.29]), and intergenerational sex (2.28 [1.17-4.41]) were independently associated with depression.DiscussionDepression is highly prevalent in Botswana, and its correlates are gender-specific. Our findings suggest multiple targets for screening and prevention of depression and highlight the need to integrate mental health counseling and treatment into primary health care to decrease morbidity and improve HIV management efforts.

Background Both food insufficiency and HIV infection are major public health problems in sub-Saharan Africa, yet the impact of food insufficiency on HIV risk behavior has not been systematically investigated. We tested the hypothesis that food insufficiency is associated with HIV transmission behavior. Methods and Findings We studied the association between food insufficiency (not having enough food to eat over the previous 12 months) and inconsistent condom use, sex exchange, and other measures of risky sex in a cross-sectional population-based study of 1,255 adults in Botswana and 796 adults in Swaziland using a stratified two-stage probability design. Associations were examined using multivariable logistic regression analyses, clustered by country and stratified by gender. Food insufficiency was reported by 32% of women and 22% of men over the previous 12 months. Among 1,050 women in both countries, after controlling for respondent characteristics including income and education, HIV knowledge, and alcohol use, food insufficiency was associated with inconsistent condom use with a nonprimary partner (adjusted odds ratio [AOR] 1.73, 95% confidence interval [CI] 1.27–2.36), sex exchange (AOR 1.84, 95% CI 1.74–1.93), intergenerational sexual relationships (AOR 1.46, 95% CI 1.03–2.08), and lack of control in sexual relationships (AOR 1.68, 95% CI 1.24–2.28). Associations between food insufficiency and risky sex were much attenuated among men. Conclusions Food insufficiency is an important risk factor for increased sexual risk-taking among women in Botswana and Swaziland. Targeted food assistance and income generation programs in conjunction with efforts to enhance women's legal and social rights may play an important role in decreasing HIV transmission risk for women., In a cross-sectional study, Sheri Weiser and colleagues found that food insufficiency was an important risk factor for increased sexual risk-taking in women in Botswana and Swaziland., Editors' Summary Background. For people in sub-Saharan Africa, insufficient food for their daily needs and infection with the human immunodeficiency virus (HIV; the cause of acquired immunodeficiency syndrome or AIDS) are inextricably linked and major causes of illness and death. By reducing the number of healthy adults in the region, HIV/AIDS has decreased food production so fewer people have secure access to sufficient food for a healthy life—many are subject to “food insecurity.” Because good nutrition is essential for a strong immune system, food insecurity increases the likelihood that people exposed to HIV become infected with the virus and reduces their ability to remain healthy after infection. Consequently, more people succumb to HIV/AIDS and food insecurity increases. To break this vicious cycle, UNAIDS (the Joint United Nations Programme on HIV/AIDS) and other international bodies have suggested a move towards integrated food security programs and HIV/AIDS prevention and treatment programs wherever possible. Why Was This Study Done? Integrated food and HIV/AIDS programs might also be beneficial for another reason. HIV is usually spread through unprotected sex with an infected partner and it is thought that a lack of food increases sexual risk taking, particularly among poor women. These women have little control over food supplies but are expected to feed their children and other members of the household (such as elders). To do this, they may sell sex or become sexually involved with men of a different generation, both of which put them at risk of HIV. In addition, they are rarely able to demand that their partners use condoms or to control when they have sex. In this study, the researchers have examined how food insufficiency affects sexual risk taking among men and women in Swaziland and Botswana. These two countries have the highest HIV infection rates in the world—one in three adults in Swaziland and one in four in Botswana are infected—and in both countries many people are extremely poor. What Did the Researchers Do and Find? The researchers interviewed more than 2,000 randomly selected adults from Botswana and Swaziland using a standard questionnaire. This included general questions about the participants (for example, age and marital status) and questions about food insufficiency (defined as not having had enough food to eat over the previous 12 months) and risky sexual behaviors—for example, sex exchange (selling or paying for sex) and inconsistent condom use—over the same period. Nearly one in three women and one in four men reported food insufficiency. After allowing for variables such as education and income, women in both countries who reported food insufficiency were nearly twice as likely to have used condoms inconsistently with a non-regular partner or to have sold sex as women who had had sufficient food. They were also more likely to have had intergenerational sexual relationships and to report a lack of control in sexual relationships. Among men, food insufficiency was weakly associated with inconsistent condom use but not with other risky sexual behaviors. What Do These Findings Mean? Food insufficiency is associated with multiple (often interdependent) risky sexual practices among women in Botswana and Swaziland. These results may not hold for other countries and may be limited by the definition of food insufficiency used in the study and by participants failing to remember or report all instances of risky behavior or food insufficiency that occurred during the previous year. Nevertheless, the findings strongly suggest that protecting and promoting access to food may decrease vulnerability of women in sub-Saharan Africa to HIV infection. Improved food security might be achieved through targeted food assistance and by supporting women's subsistence farming and other means of food production. Such programs would also need to enhance women's legal and social rights so that they have more control over food supplies as well as their sexual lives. Additional Information. Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0040260. The Food and Agriculture Organization of the United Nations Special Programme for Food Security (in several languages) HIV InSite, comprehensive and up-to-date information on all aspects of HIV/AIDS from the University of California San Francisco UNAIDS (Joint United Nations Programme on HIV/AIDS) fact sheet on nutrition, food security, and HIV/AIDS HIV and AIDS in Swaziland and Botswana, information provided by Avert, an international AIDS charity The IMAGE Study, an example of a research initiative that is investigating the potential role of poverty alleviation and women's empowerment in reducing HIV incidence in South Africa

Background In Botswana, an estimated 24% of adults ages 15–49 years are infected with HIV. While alcohol use is strongly associated with HIV infection in Africa, few population-based studies have characterized the association of alcohol use with specific high-risk sexual behaviors. Methods and Findings We conducted a cross-sectional, population-based study of 1,268 adults from five districts in Botswana using a stratified two-stage probability sample design. Multivariate logistic regression was used to assess correlates of heavy alcohol consumption (>14 drinks/week for women, and >21 drinks/week for men) as a dependent variable. We also assessed gender-specific associations between alcohol use as a primary independent variable (categorized as none, moderate, problem and heavy drinking) and several risky sex outcomes including: (a) having unprotected sex with a nonmonogamous partner; (b) having multiple sexual partners; and (c) paying for or selling sex in exchange for money or other resources. Criteria for heavy drinking were met by 31% of men and 17% of women. Adjusted correlates of heavy alcohol use included male gender, intergenerational relationships (age gap ≥10 y), higher education, and living with a sexual partner. Among men, heavy alcohol use was associated with higher odds of all risky sex outcomes examined, including unprotected sex (AOR = 3.48; 95% confidence interval [CI], 1.65 to 7.32), multiple partners (AOR = 3.08; 95% CI, 1.95 to 4.87), and paying for sex (AOR = 3.65; 95% CI, 2.58 to 12.37). Similarly, among women, heavy alcohol consumption was associated with higher odds of unprotected sex (AOR = 3.28; 95% CI, 1.71 to 6.28), multiple partners (AOR = 3.05; 95% CI, 1.83 to 5.07), and selling sex (AOR = 8.50; 95% CI, 3.41 to 21.18). A dose-response relationship was seen between alcohol use and risky sexual behaviors, with moderate drinkers at lower risk than both problem and heavy drinkers. Conclusions Alcohol use is associated with multiple risks for HIV transmission among both men and women. The findings of this study underscore the need to integrate alcohol abuse and HIV prevention efforts in Botswana and elsewhere., Alcohol use is associated with multiple risks for HIV transmission in men and women. The findings underscore the need to integrate alcohol abuse and HIV prevention efforts in Botswana and elsewhere., Editors' Summary Background. Human immunodeficiency virus (HIV), the cause of acquired immunodeficiency syndrome (AIDS), is most commonly spread through unprotected sex with an infected partner. HIV enters the body through the lining of the sex organs, rectum, or mouth, and destroys immune system cells, leaving the infected person susceptible to other viruses and bacteria. Although HIV education and prevention campaigns emphasize the importance of safe sex in reducing HIV transmission, people continue to become infected by having unprotected sex (that is, not using a condom) with either a nonmonogamous partner or multiple sexual partners, or in situations where they are paying for or selling sex. Research in different populations suggested that heavy alcohol use is associated with risky sexual behaviors. This is because alcohol relaxes the brain and body, reduces inhibitions, and diminishes risk perception. Drinking alcohol may further increase the risk of becoming infected with HIV through its suppressive effects on the immune system. Why Was This Study Done? Alcohol abuse is widespread in sub-Saharan Africa where most HIV infections occur and has been associated with risky sexual behaviors. It may therefore be one of the most common, potentially modifiable HIV risk factors in this region. However, research to date has concentrated on the association between alcohol consumption and risky sex in people attending HIV-treatment clinics or recruited at beer halls, and these populations may not be representative of the general population of sub-Saharan Africa. In this study, the researchers have investigated the potential role of alcohol in perpetuating the HIV epidemic by undertaking a population-based study on alcohol use and high-risk sexual behaviors in Botswana. Nearly a quarter of adults are infected with HIV here, and alcohol abuse is also common, particularly in the townships. What Did the Researchers Do and Find? The researchers recruited a random cross-section of people from the five districts of Botswana with the highest number of HIV-infected individuals and interviewed all 1,268 participants using a questionnaire. This included general questions about the participants (for example, their age and marital status) and questions about alcohol use, sexual behavior, and knowledge of HIV. Overall, 31% of the men in the study and 17% of the women were heavy drinkers—more than 21 drinks/week for men, 14 for women; a drink is half a pint of beer or a glass of wine. Heavy alcohol use was associated with being male, being in an intergenerational relationship (at least 10 years age difference between partners; intergenerational sex facilitates the continued spread of HIV in sub-Saharan Africa), having had more education, and living with a sexual partner. Among men, those who drank heavily were three to four times more likely to have unprotected sex or multiple partners or to pay for sex than nondrinkers. Among women, there was a similar association between heavy drinking and having unprotected sex or multiple partners, and heavy drinkers were eight times as likely to sell sex as nondrinkers. For both men and women, the more they drank, the more likely they were to have risky sex. The study did not address behavior among same-sex partnerships. What Do These Findings Mean? This study indicates that heavy alcohol consumption is strongly and consistently associated with sexual risk behaviors in both men and women in Botswana. Because of the study design, it does not prove that heavy alcohol use is the cause of such behaviors but provides strong circumstantial evidence that this is the case. It is possible that these results may not apply to neighboring African countries—Botswana is unique in being relatively wealthy and in its government being strongly committed to tackling HIV. Nevertheless, taken together with the results of other studies, this research strongly argues for the need to deal with alcohol abuse within HIV prevention programs in sub-Saharan Africa. Strategies to do this could include education campaigns that target both alcohol use and HIV in schools and in social venues, including beer halls. But, stress the researchers, any strategy that is used must consider the cultural and social significance of alcohol use (in Botswana, alcohol use is a symbol of masculinity and high socioeconomic status) and must simultaneously tackle not only the overlap between alcohol use and risky sexual behavior but also the overlap between alcohol and other risk behaviors such as intergenerational sex. Additional Information Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0030392. US National Institute of Allergy and Infectious Diseases factsheet on HIV infection and AIDS US Department of Health and Human Services information on AIDS US Centers for Disease Control and Prevention information on HIV/AIDS US National Institute on Alcohol Abuse and Alcoholism patient information on alcohol and HIV/AIDS] Aidsmap, information on HIV and AIDS provided by the charity NAM,which includes some information on HIV infections and alcohol AVERT information on HIV and AIDS in Botswana

This paper reports an evaluation of the implementation of the School Health Policy (SHP) in Botswana schools. Historically, school health originated with a concern for the number of children being excluded from school owing to communicable diseases. In 1999, the three ministries, Ministry of Health, Ministry of Education and Ministry of Local Government, developed the Botswana School Health Policy and Procedures Manual. The school health services are organized at national, district and local levels. The purpose of the evaluation was to explore how school health services were delivered in schools in Botswana. Data on current practices on school health were collected using observations, field notes and interviews of various school personnel in 27 schools located in the Gaborone district, and surrounding villages using the assessment guide in the SHP. Content analysis was used to analyse the data. Several challenges to implementing the school health policy were identified, for example, lack of human resources, lack of equipment supplies, lack of health knowledge among teachers, as well as organizational problems. This has budgetary implications for Botswana at both central and district levels. Commitment of all stakeholders in all ministries concerned would also improve the implementation of school health services.

Background The Botswana government recently implemented a policy of routine or “opt-out” HIV testing in response to the high prevalence of HIV infection, estimated at 37% of adults. Methods and Findings We conducted a cross-sectional, population-based study of 1,268 adults from five districts in Botswana to assess knowledge of and attitudes toward routine testing, correlates of HIV testing, and barriers and facilitators to testing, 11 months after the introduction of this policy. Most participants (81%) reported being extremely or very much in favor of routine testing. The majority believed that this policy would decrease barriers to testing (89%), HIV-related stigma (60%), and violence toward women (55%), and would increase access to antiretroviral treatment (93%). At the same time, 43% of participants believed that routine testing would lead people to avoid going to the doctor for fear of testing, and 14% believed that this policy could increase gender-based violence related to testing. The prevalence of self-reported HIV testing was 48%. Adjusted correlates of testing included female gender (AOR = 1.5, 95% CI = 1.1–1.9), higher education (AOR = 2.0, 95% CI = 1.5–2.7), more frequent healthcare visits (AOR = 1.9, 95% CI = 1.3–2.7), perceived access to HIV testing (AOR = 1.6, 95% CI = 1.1–2.5), and inconsistent condom use (AOR = 1.6, 95% CI = 1.2–2.1). Individuals with stigmatizing attitudes toward people living with HIV and AIDS were less likely to have been tested for HIV/AIDS (AOR = 0.7, 95% CI = 0.5–0.9) or to have heard of routine testing (AOR = 0.59, 95% CI = 0.45–0.76). While experiences with voluntary and routine testing overall were positive, 68% felt that they could not refuse the HIV test. Key barriers to testing included fear of learning one's status (49%), lack of perceived HIV risk (43%), and fear of having to change sexual practices with a positive HIV test (33%). Conclusions Routine testing appears to be widely supported and may reduce barriers to testing in Botswana. As routine testing is adopted elsewhere, measures should be implemented to assure true informed consent and human rights safeguards, including protection from HIV-related discrimination and protection of women against partner violence related to testing., Editors' Summary Background. In 2005, there were 5 million new infections with the human immunodeficiency virus (HIV), and the disease it causes—acquired immunodeficiency syndrome (AIDS)—killed three million people. Despite the increased availability of drugs that can fight HIV (antiretrovirals), the AIDS epidemic continues to grow, particularly in sub-Saharan Africa. To halt it, more needs to be done to prevent the spread of HIV. Education about safe sex can help—HIV is most commonly spread through unprotected sex with an infected partner—but increasing HIV testing is of paramount importance. Unfortunately, the uptake of voluntary counseling and testing in sub-Saharan Africa is worryingly low. Fear of being stigmatized—socially disgraced—and discriminated against, fears about the positive result itself, and worries about access to antiretroviral drugs are all putting people off being tested. Why Was This Study Done? In Botswana, one in three adults is infected with HIV. Since 2002, antiretroviral drugs have been freely available but enrollment in the Botswana National Treatment Program during its first two years was slow, in part due to inadequate uptake of voluntary HIV testing. Consequently, in early 2004, the government introduced a policy of routine HIV testing in which all patients are tested for HIV when they visit their doctor unless they opt out. A major aim of this approach to HIV testing, which was formally recommended in June 2004 by UNAIDS and the World Health Organization, is to increase uptake of HIV testing and treatment, and to reduce HIV-related stigma by treating the HIV test like any other routine medical procedure. However, there are fears that the policy could back-fire—people might not visit their doctors, for example, because they are afraid of being tested and think that they will not be able to refuse the test. In this study, the researchers investigated knowledge of and attitudes to routine testing in Botswana to understand better the consequences of a routine testing policy. What Did the Researchers Do and Find? The researchers interviewed adults throughout Botswana about their knowledge of and attitudes to routine HIV testing 11 months after introduction of the policy. Only half of the participants had heard of routine testing before being interviewed but nearly all were in favor of routine testing. More than half thought it would reduce HIV-related stigma and the violence toward women that is associated with an HIV-positive status. However, almost half believed that routine testing might prevent people from going to the doctor because of fear of testing and a few thought the policy would increase violence against women. Nearly half of the interviewees had had an HIV test and the researchers found, for example, that women were more likely to have been tested than men and that people with stigmatizing attitudes toward people living with HIV and AIDS were less likely to be tested. Fear of learning one's HIV status, lack of perceived risk, and fear of having to change sexual practices if positive all stopped people taking the test. Finally, although experiences with testing were generally positive, approximately two-thirds of interviewees who had been tested felt that it would have been difficult to refuse the test. What Do These Findings Mean? These results show that there is widespread support for routine HIV testing in Botswana, a finding supported by recent increases in treatment uptake. Routine testing, write the researchers, holds significant promise for the prevention and treatment of HIV/AIDS in Botswana and elsewhere. In particular, increasing the number of people tested for HIV may reduce HIV-related stigma, which should further increase testing and hopefully slow the spread of HIV. But the results of this study also highlight some areas of concern. Whenever HIV testing policies are implemented, human rights must be protected by ensuring that patients have all the information necessary to make an informed and free decision about being tested, by providing protection for women against violence related to HIV status, and by ensuring total confidentiality. Careful monitoring of Botswana's program and similar programs will be needed to ensure that these human rights are fully met, conclude the researchers. Additional Information. Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0030261 • US National Institute of Allergy and Infectious Diseases factsheet on HIV infection and AIDS • US Department of Health and Human Services information on AIDS • US Centers for Disease Control and Prevention information on HIV/AIDS • UNAIDS and World Health Organization 2004 policy statement on HIV testing • AVERT, a UK-based charity, provides information about HIV and AIDS in Botswana, A cross-sectional, population-based study of 1,268 adults from five districts in Botswana showed that routine HIV testing appears to be widely supported and may reduce barriers to HIV testing.