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Objectives: Chlamydia trachomatis and Neisseria gonorrhoeae are common sexually transmitted infections (STIs). Untreated infection in pregnancy can result in adverse neonatal outcomes, including vertical transmission. Screening for these infections is not routine in low- and middle-income countries (LMICs)., Methods: The Maduo Study was a non-randomised cluster crossover trial in Botswana to provide preliminary data on the effect of antenatal C. trachomatis and N. gonorrhoeae screening and treatment on postdelivery prevalence and vertical transmission to infants. Pregnant women asymptomatic for STIs were enrolled at four clinics (seven clusters). The intervention arm received C. trachomatis and N. gonorrhoeae screening at first antenatal care, third trimester and postdelivery. The standard-of-care arm received postdelivery screening only. Infants of women with a positive test postdelivery in both arms were screened. A cluster-level analysis was performed to compare the risk of postdelivery infection between intervention and standard-of-care arms., Results: The study enrolled 500 women; 206 (82.1%) and 187 (75.1%) were retained in the intervention and standard-of-care arms, respectively and screened ≤12 weeks postdelivery. C. trachomatis prevalence in the intervention arm reduced from 22.7% at first antenatal care to 1.0% postdelivery. N. gonorrhoeae prevalence reduced from 1.2% at first antenatal care to 0% postdelivery. The risk of C. trachomatis and/or N. gonorrhoeae was lower in the intervention arm postdelivery (0.6%) compared with the standard-of-care arm (15.7%); adjusted risk difference: -14.7% (95% CI -23.0%, -6.4%). Among 26 infants born to women with either infection postdelivery, 10 (38.5%) tested positive ( C. trachomatis : 9; N. gonorrhoeae : 1)., Conclusions: Postdelivery prevalence of C. trachomatis was significantly lower among pregnant women in Botswana who received diagnostic antenatal screening. Among women with C. trachomatis and/or N. gonorrhoeae postdelivery, more than one-third transmitted the infection to their infants. This exploratory study suggests antenatal STI screening has the potential to reduce infection in newborns in similar LMIC settings., Trial Registration Number: NCT04955717., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

HIV-associated cryptococcal meningitis remains a key driver of AIDS-related mortality. Mortality is twice as high in those who present later to care and with severe symptoms such as confusion. We embedded a qualitative methods study within a randomised controlled trial in Gaborone, Botswana and Kampala, Uganda with the aim of understanding pathways to care. We conducted in-depth interviews with trial participants and surrogate decision makers and analysed data thematically. Between January 2020 and June 2021 we interviewed 58 individuals. Pathways to care were prolonged because headaches were disregarded by participants and healthcare workers as a common occurrence with a broad differential diagnosis of predominantly benign aetiologies. There was also a lack of awareness of cryptococcal meningitis, and it was often after HIV was diagnosed or disclosed that the pathway accelerated, resulting in hospital admission. We outline key recommendations to reduce mortality and argue for the integration of social and behavioural interventions within differentiated service delivery models for advanced HIV disease., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2023 The Authors.)

Background: Chlamydia trachomatis ( C. trachomatis ) and Neisseria gonorrhoeae ( N. gonorrhoeae ) are curable sexually transmitted infections (STIs) that cause adverse pregnancy and neonatal outcomes. Most countries, including Botswana, do not offer C. trachomatis or N. gonorrhoeae screening during antenatal care (ANC) and instead use a syndromic approach for management of STIs., Methods: The Maduo Study is a prospective, cluster-controlled trial in Botswana evaluating the impact of diagnostic screening for antenatal C. trachomatis and N. gonorrhoeae infections to prevent adverse neonatal outcomes. Using baseline data from the Maduo Study (March 2021-March 2022), we determined the prevalence of C. trachomatis and N. gonorrhoeae infection among asymptomatic pregnant women in Botswana and correlates of infection using multivariable logistic regression., Results: Of 251 women who underwent C. trachomatis and N. gonorrhoeae screening at first ANC visit, 55 (21.9%, 95%CI 17.0-27.5) tested positive for C. trachomatis , 1 (0.4%, 95%CI 0-2.2) for N. gonorrhoeae ; and 2 (0.8%, 95%CI 0-2.8) for dual C. trachomatis and N. gonorrhoeae infection. Older age was associated with lower odds (aOR 0.93; 95%CI 0.88-0.98; p = 0.011) while any alcohol use during pregnancy was associated with higher odds (aOR = 3.53; 95%CI 1.22-10.16; p = 0.020) of testing positive for C. trachomatis or N. gonorrhoeae ., Conclusions: A high frequency of C. trachomatis infections was detected among asymptomatic pregnant women in Botswana indicating that many antenatal STIs are missed by the syndromic management approach. Our results highlight the need for diagnostic C. trachomatis screening during ANC in Botswana and other low- and middle-income countries that rely solely on the syndromic approach for management of STIs.

Introduction: Uninterrupted access to HIV and sexual and reproductive health (SRH) services is essential, particularly in high HIV prevalence settings, to prevent unintended pregnancy and vertical HIV transmission. Understanding the challenges that COVID-19 and associated social distancing measures (SDMs) posed on health service access is imperative for future planning., Methods: This cross-sectional study was conducted in Botswana between January-February 2021. A web-based questionnaire was disseminated on social media as part of the International Sexual Health and REproductive Health (I-SHARE) Survey. Respondents answered questions on SRH, before and during COVID-19 SDMs. Subgroup analysis and comparison of descriptive data was performed for people living with HIV (PLWH)., Results: Of 409 participants, 65 were PLWH (80% female, 20% male). During SDMs, PLWH found it more difficult to access condoms and treatment for HIV and STIs; attend HIV appointments; and maintain adherence to antiretroviral therapy. Compared to HIV-negative women, a higher proportion of women living with HIV used condoms as their primary method of contraception (54% vs. 48%), and had lower use of long-acting reversible contraception (8% vs. 14%) and dual contraception (8% vs. 16%)., Discussion: Mirroring global trends, COVID-19 disrupted HIV and SRH service access in Botswana. However, in high HIV-prevalence settings, disruption may more severely impact population health with disproportionate effects on women. Integration of HIV and SRH services could build health system capacity and resilience, reduce missed opportunities for delivering SRH services to PLWH and limit the consequences of future restrictions that may cause health system disruption., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2023 Ensor, Mechie, Ryan, Mussa, Bame, Tamuthiba, Moshashane and Morroni.)

Competing Interests: Conflict of Interest and Sources of Funding: This research is supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development R21 HD100821-01. The funding source had no role in the design and conduct of the study, data collection, analysis, reporting, and decision to submit the manuscript for publication. The authors declare no competing interests.

Background: The AMBITION-cm trial for HIV-associated cryptococcal meningitis demonstrated that a single, high-dose of liposomal amphotericin (AmBisome) plus 14-days of oral flucytosine and fluconazole was non-inferior in terms of all-cause mortality to 7-days of amphotericin B deoxycholate and flucytosine followed by 7-days of fluconazole (Control). The AmBisome regimen was associated with fewer adverse events. We explored the acceptability of the AmBisome regimen from the perspective of participants and providers., Methods: We embedded a qualitative methods study within the AMBITION-cm sites in Botswana and Uganda. We conducted in-depth interviews with trial participants, surrogate decision makers, and researchers and combined these with direct observations. Interviews were transcribed, translated, and analysed thematically., Results: We interviewed 38 trial participants, 20 surrogate decision makers, and 31 researchers. Participant understanding of the trial was limited; however, there was a preference for the AmBisome regimen due to the single intravenous dose and fewer side effects. More time was required to prepare the single AmBisome dose but this was felt to be acceptable given subsequent reductions in workload. The AmBisome regimen was reported to be associated with fewer episodes of rigors and thrombophlebitis and a reduction in the number of intravenous cannulae required. Less intensive monitoring and management was required for participants in the AmBisome arm., Conclusions: The AmBisome regimen was highly acceptable, being simpler to administer despite the initial time investment required. The regimen was well tolerated and associated with less toxicity and resultant management. Widespread implementation would reduce the clinical workload of healthcare workers caring for patients with HIV-associated cryptococcal meningitis., Competing Interests: The authors have declared that no competing interests exist.

Adolescents with suboptimal medication taking may deceive caregivers about non-adherence. We conducted a 5-year longitudinal study of adolescents monitored simultaneously with both easily manipulated (e.g., self-report) and hard to manipulate (e.g., microelectronic data) strategies. Adolescents with repeatedly high adherence on the former and low adherence on the latter were invited along with their parental figures ("parents") to participate. We conducted focus groups and semi-structured interviews, separately for adolescents and parents, to elucidate drivers of discordant measures. Forty-seven adolescents and 26 parents participated in focus groups and 4 adolescents were interviewed. Adolescents described hiding pills, discarding pills, and lying. Their motivations included fear of disappointing those who care about them, desire to avoid admonishment by parents and clinic staff, and desire to avoid remedial adherence counseling. Both adolescents and parents considered negative feedback for prior poor adherence to be key motivation to hide current poor adherence from clinic staff. Providing positive feedback for truth-telling, rather than for "evidence" of excellent adherence, might help adolescent patients and their parents to develop stronger treatment alliances with each other and with clinic staff. Such alliances would allow adherence interventions to be better targeted and more fruitful in increasing adherence.

Potential participants for clinical trials which aim to define treatments for life-threatening conditions are often extremely unwell. When exploring why individuals participate in clinical trials one common observation is a misplaced expectation of personal benefit - a therapeutic misconception. The care offered in some clinical trials is of a higher standard than is routinely available and this has led to criticism around the freedom of choice to enrol - structural coercion. We embedded an ethnographic study within a randomised controlled trial for HIV-associated cryptococcal meningitis in Gaborone, Botswana and Kampala, Uganda. We aimed to gain an understanding of decision-making around the trial and how this was impacted by the study design and broader social context. We conducted in-depth interviews with trial participants, surrogate decision makers and researchers, combined these with direct observations and analysed data using thematic analysis. Between January 2020 and June 2021 we interviewed 89 individuals. We found previous exposure to and awareness of clinical research was limited, as was understanding of the trial objectives and design. Through observations and engagement with healthcare facilities decision-makers were able to identify the trial as providing the best possible chance of survival. Hesitation and reluctance were mostly due to fear of lumbar punctures which was sometimes based on rumours but often based on tragic personal experience. Despite fear, and sometimes conviction that they would die, individuals agreed to consent, often against the wishes of family members. Reassurance and confidence came from trust in routine care staff and the research team but also from fellow participants and their surrogates. We argue that participants made informed decisions based on a therapeutic expectation from the trial and that rather than being the result of structural coercion this was an informed and voluntary choice., (Copyright © 2022 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: A significant proportion (20-59%) of people living with HIV in sub-Saharan Africa desire childbearing, are of reproductive age, and are in sero-different relationships (~50%). Thus it is plausible that some portion of new HIV transmissions are due to attempts to become pregnant. Safer conception (SC) methods that effectively reduce the risk of HIV transmission exist and can be made available in resource-constrained settings. Few studies in the region, and none in Botswana, have quantitatively examined the correlates of information, motivation, and behavioral skills for SC uptake., Methods: We surveyed 356 women living with HIV from 6/2018 to 12/2018 at six public-sector health clinics in Gaborone, Botswana. Participants were 18-40 years old, not pregnant, and desired future children or were unsure about their childbearing plans. We examined correlates of SC information, motivation, and behavioral skills using nested linear regression models, adjusting for socio-demographic, interpersonal, and structural variables., Results: Knowledge of SC methods varied widely. While some SC methods were well known (medical male circumcision by 83%, antiretroviral therapy for viral suppression by 64%), most other methods were known by less than 40% of participants. Our final models reveal that stigma as well as relationship and partner factors affect SC information, motivation, and behavioral skills. Both internalized childbearing stigma (ß=-0.50, 95%CI:-0.17, -0.02) and perceived community childbearing stigma were negatively associated with SC information (ß=-0.09, 95%CI:-0.80, -0.21). Anticipated (ß=-0.06, 95%CI:-0.12, -0.003) and internalized stigma (ß=-0.27, 95%CI:-0.44; -0.10) were associated with decreased SC motivation, while perceived community childbearing stigma was associated with increased SC motivation (ß=0.07, 95%CI:0.02, 0.11). Finally, internalized childbearing stigma was associated with decreased SC behavioral skills (ß=-0.80, 95%CI: -1.12, -0.47) while SC information (ß=0.24, 95%CI:0.12, 0.36), motivation (ß=0.36, 95%CI:0.15, 0.58), and perceived partner willingness to use SC (ß=0.47, 95%CI:0.36, 0.57) were positively associated with behavioral skills CONCLUSIONS: Low SC method-specific information levels are concerning since almost half (47%) of the study participants reported they were in sero-different relationships and desired more children. Findings highlight the importance of addressing HIV stigma and partner dynamics in interventions to improve SC information, motivation, and behavioral skills., (© 2021. The Author(s).)

Background: Sexually transmitted infection (STI) testing is not routinely offered in many countries, and management is symptoms based. Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) are associated with an increased risk of HIV transmission. We assess the feasibility and acceptability of integrating CT/NG testing into routine HIV care in Botswana, as well as the prevalence and correlates of CT/NG infections., Method: A prospective study was conducted at an HIV clinic in Gaborone between February and October 2019. Eligibility criteria included the following: ≥18 years, HIV infected, and not treated for CT/NG in the past month. Participants self-collected samples and responded to a questionnaire on sociodemographic and health characteristics. Samples were processed using the GeneXpert. Patients were offered same-day results in person or by telephone. Those who tested positive were treated., Results: Of 806 patients informed of the study, 526 (65%) expressed interest and 451 (60%) were enrolled. The median age was 48 years, and 66% were women. All participants provided self-collected samples, were successfully tested, and received results. Almost all reported sample self-collection was easy. The prevalence of CT/NG was 5%. Most participants (73%) with a positive result were asymptomatic. Among infected, 20 (91%) received same-day results and all were treated. Younger age, female sex, and pain during sex were associated with having CT/NG., Conclusions: Integrating STI testing into routine HIV care was feasible, self-collecting specimens was highly acceptable, but uptake of testing was low. Where blanket screening to the entire clinic population may not be feasible because of resource limitation, one strategy could be to prioritize sexually active patients, younger patients, and women., Competing Interests: Conflict of Interest and Sources of Funding: None declared., (Copyright © 2021 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Sexually Transmitted Diseases Association.)

Partner notification and treatment are essential to sexually transmitted infection (STI) management. However, in low- and middle-income countries, half of partners do not receive treatment. A mixed methods study was conducted to explore experiences and preferences around partner notification and treatment in patients seeking STI care in Gaborone, Botswana. Thirty participants were administered a quantitative survey, followed by a semi-structured interview on partner notification, treatment, and expedited partner therapy (EPT). Among the 30 participants, 77% were female with a median age of 28 years (IQR = 24-36), 87% notified their partner, and 45% of partners requiring treatment received treatment. Partners who received a contact slip were more likely to have been treated than those who did not (75% vs. 25%). Contact slips were identified as facilitators of notification and treatment, while asymptomatic partners and limited clinic resources were identified as barriers to treatment. Few participants expressed a preference for EPT and concerns included preference for medical supervision, a belief their partner would refuse, and an inability to explain the treatment. Despite successful notification, partner treatment was modest within this population. Information for partners, provider counseling, and improved access to services may increase partner treatment. Education on STIs and treatment options may improve EPT acceptability.

Study Objective: Botswana has a high pregnancy rate among adolescent girls and young women (AGYW). Long-acting reversible contraceptive (LARC) use among AGYW in Botswana is low, despite its high effectiveness for preventing pregnancy. Using an implementation science framework, we assessed barriers and facilitators to LARC implementation among AGYW in Botswana., Design: Cross-sectional mixed methods., Setting: Gaborone, Botswana., Participants: Twenty sexually active AGYW ages 18-24 years; 20 health system stakeholders., Interventions: Surveys and semistructured interviews grounded in the Consolidated Framework for Implementation Research., Main Outcome Measures: Themes reflecting barriers and facilitators of LARC implementation., Results: The median age for AGYW was 22 (interquartile range, 21-23) years. Twenty percent were using an implant and none had ever used an intrauterine device. Barriers and facilitators of LARC implementation spanned factors at each Consolidated Framework for Implementation Research domain: (1) LARC characteristics like side effects; (2) the clinics' inner settings, including availability of youth-friendly services; (3) characteristics of health system stakeholders, such as LARC skills, and AGYW experiences, attitudes, and beliefs about LARCs; (4) the outer setting external to clinics and Botswana's health system including reproductive health law and policy for minor adolescents; and (5) the implementation process level such as the availability of free or low-cost LARCs., Conclusion: We identified multilevel, context-specific factors that affect LARC implementation. Our findings can inform the development of interventions to increase LARC implementation in Botswana by addressing intersecting factors across patient, clinic, health system, and sociopolitical levels, such as providing confidential services to minors and improving LARC training and supply chain pipelines., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Various safer conception methods to limit HIV transmission risks can be offered in resource-constrained settings. However, implementation of safer conception services remains limited in many countries, including Botswana. Understanding perceptions about safer conception methods and the benefits and challenges to use can help with the development of policies, interventions, and service delivery models. Forty-five women living with HIV in the greater Gaborone, Botswana area participated in focus group discussions. Themes were analyzed using interpretive phenomenology. Despite low knowledge of specific safer conception methods that can be used to prevent transmission of HIV when trying to achieve pregnancy, there was noted interest in pre-exposure prophylaxis and vaginal insemination. Challenges to greater uptake were noted including a lack of knowledge about a range of SC methods, limited partner support and communication, provider stigma, health systems barriers, current policies, and the cultural acceptability of methods. Interventions will need to address these challenges and be responsive to the needs and reflect the realities of WLHIV who desire pregnancy in order for safer conception uptake to become a common practice., Competing Interests: The authors have declared that no competing interests exist.

Safer conception interventions that address HIV care, treatment, and prevention for HIV-affected couples are increasingly available in sub-Saharan Africa. Botswana, an HIV endemic country, is yet to offer formal safer conception services although universal test-and-treat approaches mean that increasing numbers of young, sexually active people living with HIV will start treatment and likely desire childbearing. In order to advance the safer conception discussion in Botswana, it is necessary to understand the current safer conception knowledge, practices, and preferences of healthcare providers and women living with HIV (WLHIV). We conducted qualitative in-depth interviews with ten HIV healthcare providers and ten WLHIV in Gaborone. Interviews were analyzed using a phenomenological approach. Safer conception knowledge was limited and safer conception discussions were rare. Healthcare provider and WLHIV preferences were at odds, with providers preferring WLHIV to initiate safer conception discussions, and WLHIV desiring providers to initiate safer conception discussions. Quotes from women and providers highlight deeper issues about power dynamics, concerns about stigma among women, and provider fears about promoting pregnancy. Providers emphasized the need for guidelines and training in order to improve the provision of safer conception counseling. These findings point to areas where safer conception in Botswana can be improved. Both WLHIV and providers would benefit from having information about a range of safer conception methods and approaches. In addition, since WLHIV felt hesitant about initiating safer conception conversations and feared stigma, and because putting the onus for starting safer conception discussions on women is a reversal of normal roles and power structures, providers must take the lead and routinely initiate fertility desire and safer conception discussions. Assisting healthcare providers with clear safer conception guidelines and training would improve the provision of accurate safer conception counseling and facilitate reproductive choice., Competing Interests: Disclosure statement / Conflict of interest The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Despite advances in clinical care, safer conception services are not utilised in many high HIV prevalence countries, including Botswana. We conducted in-depth interviews with 10 HIV healthcare providers and 10 women living with HIV to develop a deeper understanding of attitudes surrounding childbearing and pregnancy planning. Interviews were analysed using a phenomenological approach. Providers felt it was a human right and normative for women living with HIV to have children but also expressed concern about women living with HIV having children. Women themselves anticipated stigma from providers regarding childbearing, although most described supportive care and had not experienced stigmatising treatment. Although providers believed pregnancies amongst women living with HIV were unplanned, women described discussing pregnancy desires with sexual partners. Despite providers voicing a rights-based approach to childbearing amongst women living with HIV, hesitancy towards pregnancy remains. This is felt by women living with HIV and perceived as stigma, which may make them less likely to seek fertility and safer conception advice. Safer conception interventions are unlikely to be successful if women do not feel comfortable discussing childbearing with health-care providers.

Safe and effective low-cost safer conception (SC) methods are increasingly available and being integrated into national guidelines in sub-Saharan African contexts. Sero-different couples of childbearing age can benefit from such services and the routine provision of SC counselling. Pre-exposure prophylaxis (PrEP) to prevent HIV acquisition to uninfected partners can reduce the chances of HIV transmission when trying to achieve pregnancy. Botswana has a strong commitment to reducing new HIV infections but PrEP is not yet widely available and little guidance has been offered on counselling sero-different couples. We conducted qualitative in-depth interviews in Gaborone, Botswana with 10 HIV healthcare providers and 10 women living with HIV of childbearing age because they act as a key conduit for reaching sero-different partners with information about PrEP. We examined knowledge and attitudes towards PrEP to assess the viability and develop a deeper understanding of this SC option. Interviews were analysed using an interpretive phenomenological approach. Three themes emerged: (1) awareness of PrEP is limited, (2) providers and women overwhelmingly showed interest in PrEP and (3) women living with HIV and providers have concerns about PrEP use. With the correct support, PrEP could be a useful SC option for sero-different couples in Botswana and other sub-Saharan contexts.

Objective: To assess the acceptability and preferences of HPV screening with self-sampling and mobile phone results delivery among women living with HIV (WLWH) in Botswana, as an alternative to traditional speculum screening., Methods: WLWH aged 25 years or older attending an infectious disease clinic in Gaborone were enrolled in a cross-sectional study between March and April 2017. Women self-sampled with a flocked swab, had a speculum exam, and completed an interviewer-administered questionnaire about screening acceptability, experiences, and preferences., Results: Of the 104 WLWH recruited, 98 (94%) had a history of traditional screening. Over 90% agreed self-sampling was easy and comfortable. Ninety-five percent were willing to self-sample again; however, only 19% preferred self-sampling over speculum exam for future screening. Preferences differed by education and residence with self-sampling being considered more convenient, easier, less embarrassing, and less painful. Speculum exams were preferred because of trust in providers' skills and women's low self-efficacy to sample correctly. Almost half (47%) preferred to receive results via mobile phone call. Knowledge of cervical cancer did not affect preferences., Conclusion: HPV self-sampling is acceptable among WLWH in Botswana; however, preferences vary. Although self-sampling is an important alternative to traditional speculum screening, education and support will be critical to address women's low self-efficacy to self-sample correctly., (© 2019 International Federation of Gynecology and Obstetrics.)

Background: Partner notification is an essential component of sexually transmitted infection (STI) management. The process involves identifying exposed sex partner(s), notifying these partner(s) about their exposure to a curable STI, and offering counselling and treatment for the STI as a part of syndromic management or after results from an STI test. When implemented effectively, partner notification services can prevent the index patient from being reinfected with a curable STI from an untreated partner, reduce the community burden of curable STIs, and prevent adverse health outcomes in both the index patient and his or her sex partner(s). However, partner notification and treatment rates are often low. This study seeks to explore experiences and preferences related to partner notification and treatment for curable STIs among pregnant women receiving care in an antenatal clinic with integrated HIV and curable STI testing. Results are intended to inform efforts to improve partner notification and treatment rates in Southern Africa., Methods: We conducted qualitative interviews among women diagnosed with Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG), and/or Trichomonas vaginalis (TV) infection while seeking antenatal care in Gaborone, Botswana. Semi-structured interviews were used to obtain women's knowledge about STIs and their experiences and preferences regarding partner notification., Results: Fifteen women agreed to participate in the study. The majority of women had never heard of CT, NG, or TV infections prior to testing. Thirteen out of 15 participants had notified partners about the STI diagnosis. The majority of notified partners received some treatment; however, partner treatment was often delayed. Most women expressed a preference for accompanying partners to the clinic for treatment. Experiences and preferences did not differ by HIV infection status., Conclusions: The integration of STI, HIV, and antenatal care services may have contributed to most women's willingness to notify partners. However, logistical barriers to partner treatment remained. More research is needed to identify effective and appropriate strategies for scaling-up partner notification services in order to improve rates of partners successfully contacted and treated, reduce rates of STI reinfection during pregnancy, and ultimately reduce adverse maternal and infant outcomes attributable to antenatal STIs.

Background: Alcohol and illicit drug use has been recognized as a growing problem among adolescents in Botswana. Little is known about factors affecting alcohol and drug use among Botswana's secondary school students. To aid the design and implementation of effective public health interventions, we sought to determine the prevalence of alcohol and drug use in secondary school students in urban and peri-urban areas of Botswana, and to evaluate risk and protective factors for substance use., Methods: We performed a 72-item cross-sectional survey of students in 17 public secondary schools in Gaborone, Lobatse, Molepolole and Mochudi, Botswana. The World Health Organization's (WHO) Alcohol Use Disorder Identification Test (AUDIT) was used to define hazardous drinking behavior. Using Jessor's Problem Behavior Theory (PBT) as our conceptual framework, we culturally-adapted items from previously validated tools to measure risk and protective factors for alcohol and drug use. Between-group differences of risk and protective factors were compared using univariate binomial and multinomial-ordinal logit analysis. Relative risks of alcohol and drug use by demographic, high risks and low protections were calculated. Multivariate ordinal-multinomial cumulative logit analysis, multivariate nominal-multinomial logit analysis, and binominal logit analysis were used to build models illustrating the relationship between risk and protective factors and student alcohol and illicit drug use. Clustered data was adjusted for in all analyses using Generalized Estimating Equations (GEE) methods., Results: Of the 1936 students surveyed, 816 (42.1%) reported alcohol use, and 434 (22.4%) met criteria for hazardous alcohol use. Illicit drug use was reported by 324 students (16.7%), with motokwane (marijuana) being the most commonly used drug. Risk factors more strongly associated with alcohol and drug use were reported alcohol availability, individual and social vulnerability factors, and poor peer modeling. Individual and social controls protections appear to mitigate risk of student alcohol and drug use., Conclusions: Alcohol and illicit drug use is prevalent among secondary school students in Botswana. Our data suggest that interventions that reduce the availability of alcohol and drugs and that build greater support networks for adolescents may be most helpful in decreasing alcohol and drug use among secondary school students in Botswana.

Rates of unintended pregnancy in sub-Saharan Africa range from 20-40%. Unintended pregnancy leads to increased maternal and infant mortality, and higher rates of abortions. Potentially high levels of unintended pregnancy in Botswana, against the backdrop of the popularity of short-acting, less-effective contraception, could suggest that the methods available to women are not meeting their contraceptive needs. Little data exists on unintended pregnancy in Botswana. We assessed levels of unintended pregnancy and contraceptive use among 231 pregnant women presenting to the antenatal clinic at the largest hospital in Botswana. Forty-three percent of pregnancies were reported as unintended. Of women with an unintended pregnancy, 72% reported using a contraceptive method to prevent pregnancy at the time of conception. Of the women with unintended pregnancy despite contraceptive use, 88% were using male condoms as their only method of contraception. Women reporting unintended pregnancy were more likely to have had more previous births (p=0.05). While barrier protection with condoms is essential for the prevention of HIV and other STIs, condom use alone may not be meeting the contraceptive needs of women in Botswana. Increased promotion of dual-method contraceptive use with condoms is needed.

Objectives: Chlamydia trachomatis (CT) , Neisseria gonorrhoeae (NG) and Trichomonas vaginalis (TV) are curable, mostly asymptomatic, STIs that cause adverse maternal and perinatal outcomes. Most countries do not test for those infections during antenatal care. We implemented a CT, NG and TV testing and treatment programme in an antenatal clinic in Gaborone, Botswana., Methods: We conducted a prospective study in the antenatal clinic at Princess Marina Hospital in Gaborone, Botswana. We offered pregnant women who were 18 years or older and less than 35 weeks of gestation, CT, NG and TV testing using self-collected vaginal swabs. Testing was conducted using a GeneXpert® CT/NG and TV system. Those who tested positive were given directly observed antibiotic therapy and asked to return for a test of cure. We determined the prevalence of infections, uptake of treatment and proportion cured. The relationships between positive STI test and participant characteristics were assessed., Results: We enrolled 400 pregnant women. Fifty-four (13.5%) tested positive for CT, NG and/or TV: 31 (8%) for CT, 5 (1.3%) for NG and 21 (5%) for TV. Among those who tested positive, 74% (40) received same-day, in person results and treatment. Among those who received delayed results (6), 67% (4) were treated. Statistical comparisons showed that being unmarried and HIV infected were positively association CT, NG and/or TV infection. Self-reported STI symptoms were not associated with CT, NG and/or TV infection., Conclusion: The prevalence of CT, NG and/or TV was high, particularly among women with HIV infection. Among women with CT, NG and/or TV infection, those who received same-day results were more likely to be treated than those who received delayed results. More research is needed on the costs and benefits of integrating highly sensitive and specific STI testing into antenatal care in Southern Africa., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Levels of adherence to HIV treatment are lower among adolescents compared with older and younger individuals receiving similar therapies. We purposely sampled the most and least adherent adolescents from a 300-adolescent longitudinal HIV treatment adherence study in Gaborone, Botswana. Multiple objective and subjective measures of adherence were available and study participants were selected based on sustained patterns of either excellent or poor adherence over a one-year period. Focus group discussions (FGD) and in-depth interviews (IDI) were conducted with the adolescents and a subset of their caregivers with the goal of revealing barriers and facilitators of adherence. Focus groups were segregated by adherence classification of the participants. Following coding of transcripts, matrices were developed based on participants' adherence classifications in order to clarify differences in themes generated by individuals with different adherence characteristics. 47 adolescents and 25 adults were included. The non-adherent adolescents were older than the adherent adolescents (median age 18 years (IQR 16-19) vs. 14 years (IQR 12-15 years)), with median time on treatment near 10 years in both groups. Interference with daily activities, concerns about stigma and discrimination, side effects, denial of HIV status, and food insecurity arose as challenges to adherence among both those who were consistently adherent and those who were poorly-adherent to their medications. Low outcome expectancy, treatment fatigue, mental health and substance use problems, and mismatches between desired and received social support were discussed only among poorly adherent adolescents and their caregivers. Challenges raised only among adolescents and caregivers in the non-adherent groups are hypothesis-generating, identifying areas that may have a greater contribution to poor outcomes than challenges faced by both adherent and non-adherent adolescents. The contribution of these factors to poor outcomes should be explored in future studies.

Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG), and Trichomonas vaginalis (TV) are sexually transmitted infections (STIs) associated with adverse birth outcomes. Untreated partners contribute to high rates of STI reinfection; thus, partner notification and treatment remain important components of STI care and control. A prospective cohort study was conducted among 300 pregnant women presenting to the antenatal clinic at Princess Marina Hospital in Gaborone, Botswana who enrolled in an STI screening study. Following informed consent and sample collection for CT/NG/TV testing, participants were asked if they were willing to disclose their STI result and to deliver medications to their partner(s). Those who tested positive were asked at a follow-up appointment if they notified their partners. Among the 300 participants, 294 (98%) said they would be willing to tell their partner(s) about their test results if they tested positive, and 284 (95%) said they would be willing to give their partner(s) medication if the option was available. Of those who tested positive and returned for a test of cure, 27 of 32 (84%) reported that they told their partner about the results, and 20 of 32 (63%) reported that their partner received treatment. Almost all pregnant women reported willingness to tell their partner the STI test result and give their partner medications. At test of cure, most women reported informing their partner, although actual treatment receipt was lower. Our findings suggest that pregnant women are willing to utilize patient-based partner notification, but actual partner treatment might be lower than intended.

Introduction: Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG), and Trichomonas vaginalis (TV) are curable sexually transmitted infections (STIs) that can cause adverse maternal and birth outcomes. Most countries do not conduct routine testing during antenatal care. We present data on the acceptability and feasibility of testing and treating pregnant women for STIs in an antenatal clinic in Gaborone, Botswana., Materials and Methods: We offered CT, NG, and TV testing using self-collected vaginal swabs to eligible pregnant women. Participants received same-day test results. Those who tested positive were given treatment., Results: Among the 225 women who were eligible and recruited, 200 (89%) agreed to participate. The median age of our study sample was 30 years; most were unmarried (77%), with a median gestational age of 27 weeks and a 23% HIV prevalence. All participants received their results with at least 72% (n = 143) on the same day. Thirty participants (15%) tested positive for an STI, all were treated, and 24 (80%) were treated on the same day., Conclusion: The acceptability of STI testing was high, and the intervention was feasible. This study provides support for continued research into STI prevalence, cost-effectiveness, and the association of STIs with adverse maternal and infant outcomes.