botswana 2003 second generation hiv/aids surveillance

Ministry of State PresidentTHE NATIONAL AIDS COORDINATING AGENCY (NACA)

��BOTSWANA 2003 SECOND GENERATION

HIV/AIDS SURVEILLANCEBOTSWANA 2003 SECOND GENERATION

HIV/AIDS SURVEILLANCE

A Technical ReportDecember 2003

For further details contact

National AIDS Coordinating Agency (NACA)Private Bag 00463

GaboroneBotswana

Tel: (+267) 390 31 88Fax: (+267) 390 32 73

www.naca.gov.bw

Photos front cover: O. Mangole - NHARSOC 2003

Design and lay-out: Op design (PTY) LTD

Botswana 2003 Second Generation HIV Surveillance Report

National AIDS Coordinating Agency (NACA) in collaboration with AIDS/STD Unit, the BOTUSA Project (CDC), District Health Teams, the Botswana Harvard Partnership and WHO

�

THE NATIONAL AIDS COORDINATING AGENCY (NACA)

BOTSWANA 2003 SECOND GENERATION HIV/AIDS

SURVEILLANCEA Technical Report

November 2003

www.naca.gov.bw

Edited by:

Dr. Kereng Masupu (NACA)

Dr. Khumo Seipone (AIDS/STD unit)

Dr. Thierry Roels (BOTUSA/CDC)

Dr. Soyeon Kim (BHP)

Mrs. Mpho Mmelesi (NACA)

Prof. Ekanem Ekanem (UNDP Consultant)

Mrs. Sarah Gaolekwe (NBTS)

Botswana is often cited as a success economic andgood governance story in Africa. Pivotal to thissuccess has been health, in which Botswana hadnotably reduced its infant and under-five mortal-ity and increased its life expectancy in the 90’s.

However there has been a threat to these achievementsdue to the scourge of HIV/AIDS that has reversed notableachievements made in the nation’s quality of life.

We are facing a situation where every Motswana is eitherinfected or affected; having lost a relative, friend, workmateor an acquaintance to the pandemic. For Botswana, factorsthat drive the epidemic are multiple, intertwined and com-plex and these have social-cultural and economicantecedents. In realizing the complexity and magnitude ofthe disease, Government has shown an unprecedented highlevel of political and economic commitment to its control bydeclaring war against it, and adopting a multi-sectoralapproach. Coupled with this was a call to the internationalcommunity to assist and this has resulted in tremendousresponse in the form of funding and technical support.

Locally, the private sector, civil societies including people liv-ing with HIV/AIDS (PLWA) organizations, have risen to theoccasion to form a partnership with government in fightingthe epidemic. The national response has resulted in settingup prevention programs such as behavior change and com-munication, Voluntary Counseling and Testing, STI Controland prevention of mother to child transmission (PMTCT).Care and support programs have been scaled up to includepublic provision of Highly Active Antiretroviral Therapy(HAART) and Community Home Based Care Programs.Impact mitigation and reduction in stigma have beenaddressed at all levels by providing funding for incomegenerating activities, support for orphans and vulnerablechildren, and greater involvement of PLWA in the nationalresponse.

Sentinel surveillance has been quite useful over years inproviding information on the magnitude of the problem inthe country. There is also a need to closely evaluate theextent of the scourge and the impact of the nationalresponse through special population-based survey.

The nation’s vision 2016 is halting the epidemic; reversingtrend in incidence of HIV infection and improving the qual-ity of life of the people.

“Batswana, letsema le thata ka mong wa lona!”

Ntwa e bolotse!

Festus G. MogaePresident of the Republic of Botswana(Chairman, National AIDS Council)November, 2003

i



FOREWORD

i i



i i i



PREFACE

HIV/AIDS is spreading relentlessly worldwide

with 40 million people infected and over 70

percent of those in sub-Saharan Africa. The

death toll continues to rise. In many devel-

oping countries HIV/AIDS has become one

of the leading causes of mortality.

Botswana is not spared, with its prevalence among preg-

nant women aged 15-49 in 2003 reaching 37.4%. The

prevalence in 2002 was 35.4% and 36.2% in 2001 sug-

gesting that the epidemic curve may have reached its

plateau state. For Botswana, there is a glimpse of hope that

the number of new infections may not be increasing dra-

matically as in the early phases of the epidemic. This asser-

tion is based on the observation that HIV prevalence in the

15-19 years old pregnant women has remained fairly stable

over the last four years. A disturbing trend however is

emerging where rural prevalence is on the increase while

urban prevalence is stabilizing. This might be a reflection of

the disparity of intervention programmes nationwide and

therefore efforts need to be re-enforced to bridge the gap

and therefore reverse the trend.

The high prevalence is coupled with an increased number

of AIDS, TB and Genital Herpes cases and other AIDS-relat-

ed illnesses. The result has been a huge burden in a limited

resource health care system, with increased bed occupancy

rates to over 100% in most medical wards and increased

average length of stay to over 14 days for medical patients

over the years. However, this trend is expected to reverse

with the introduction of anti retroviral treatment provision

in 2002, which currently has enrolled 9228 patients out of

the estimated 110 000 living with AIDS. The success of the

ARV and PMTCT programs are further expected to result in

increased life expectancy currently estimated at 56 years

and infant mortality rate at 57 per 1000 years.

Since there is no cure for AIDS at the moment and no vac-

cines against the virus are currently available, the impact of

HIV/AIDS will only be reduced through behavior change

combined with the provision of ART to those already affect-

ed as well as VCT for those with uncertain sero-status. For

Botswana, this is a bigger challenge because PMTCT data

and VCT data reveal low testing rate due to reluctance of

the population to access these services. The adoption of

positive attitude to testing is the key to prevention and

treatment, hence the reduction of the impact of the epi-

demic.

Hon MP, L Motsumi

Minister of Health

Vice Chairperson, National AIDS Council

i v



v



ACKNOWLEDGMENTS

The National AIDS Coordinating Agency in col-

laboration with the Ministry of Health,

AIDS/STD Unit, Ministry of Local Government,

Central Statistics Office and all the district

teams would like to pass their sincere gratitude

to all those who contributed in making the 2003 Second

Generation HIV surveillance a success.

Our sincere gratitude goes to all district health teams, made

up of the public health specialists, nurses and laboratory

scientists. All these personnel have shown their undivided

commitment in making this survey a success despite their

day-to-day workload.

We would like to thank all those who participated in the

data management consensus meetings, which were held in

Kasane, Maun and Gaborone for contributions they made

towards the compilation of this report. Mention must be

made to the notable contributions made by NASTAD and

CDC Regional Office in Harare. We are indebted to valuable

contributions made by Mr. Peter Carr and Dr Dennis Nash

(NASTAD) and Dr A. D. McNaghten (CDC) especially in pro-

viding technical support in the area of data management.

This report would not have been successful without the

technical contribution of institutions such as WHO,

BOTUSA/CDC, Botswana Harvard AIDS Institute, NASTAD

and other stakeholders.

Finally I would like to extend my sincere gratitude to all the

staff of National AIDS Coordinating Agency, the Ministry of

Health, Ministry of Local government, CSO staff and the

Data Management Team for the commitment and dedica-

tion they have placed in making this document a success.

A. B. Khan, MD, MPH

National Coordinator

National AIDS Coordinating Agency (NACA)

v i



Foreword i

Preface iii

Acknowledgements v

List of Figures viiiList of Tables ixList of Abbreviations x

Executive Summary 1

1. Introduction 3

2. Survey Objectives 4

3. Methodology 5

3.1. HIV sentinel survey 53.1.1 Sentinel population 53.1.2 Sentinel sites 53.1.3 Sample size 53.1.4 Sampling scheme 53.1.5 Duration of survey 63.1.6 Training 63.1.7 Support visits 63.1.8 Specimen handling 73.1.9 Laboratory 73.1.10. Data management 7

3.1.10.1 Data compilation, data entry and data cleaning: 73.1.10.2 Data analysis: 8

3.1.11 Assumptions in estimations 93.1.12 Limitations 10

3.2. Drug-Resistance among HIV-1c Infected, Treatment-Naive Adults in Botswana 113.3 CD4 Cellcounts among HIV-Negative Batswana 113.4 Tebelopele HIV Voluntary Counseling and Testing (VTC) Program 123.5 HIV/AIDS Case Reporting and Mortality Data 123.6 Prevention of Mother to Child Transmission (PMTCT) 123.7 Behavioural Surveys 13

CONTENTS

v i i



3.8 Data on Sexually Transmitted Infections 133.9 Data on Tuberculosis 13

4. Results 14

4.1. HIV sentinel surveillance 144.2. Drug-Resistance Among HIV-1c Infected, Treatment -Naive Adults in Botswana 344.3. CD4 Cell Counts Among HIV-Negative Batswana 354.4. Tebelopele VCT Programme Data. 364.5. HIV/AIDS Case Reporting and Mortality 394.6 PMTCT 444.7 Behavioural Surveys 454.8. Sexually Transmitted Infection Programme Data 484.9. Tuberculosis Programme Data 49

5. Discusssion 51

6. Conclusions 54

7. Recommendations 55

8. Appendices 57

8.1. Calculated sample sizes per district 578.2. Sentinel Survey Data Collection Form 588.3. Aggregate syphilis test result reporting form, 2003 HIV sentinel survey 598.4. First time ANC attendees during the survey period and their syphilis test results by age 608.5. Laboratory results form 618.6. a: Worksheet for calculating district and national adjusted prevalence (females). 62

b: Worksheet for Adjusted HIV Prevalence by District (Males) 638.7. Tebelopele VCT Form (Page 1) 648.7. Tebelopele VCT Form (Page 2) 658.8. HIV request form 668.9. BANGUI & ABIDJAN DEFINITIONS OF CLINICAL AIDS (IN ADULTS) 678.10. TB Register form 688.11. Comparison of 2002 and 2003 HIV Results by Individual Age Groups 698.12. Enrollment of first time Tebelopele VCT Program Attendees by Sex and Age Group 728.13. HIV Prevalence by Education Among First Time VTC Attendees 738.14. Demographic Characteristics of Makgabaneng Radio Listenership Respondents 748.15. Names of Participating Staff and Health Facilities 758.16. HIV Prevalence by site, 1992 to 2003 82

v i i i



Fig 1. Age-specific seroprevalence of HIV among Batswana pregnant women, 2003 HIV SentinelSurveillance

Fig 2. Adjusted HIV prevalence by residence and age, pregnant women, 2003 Sentinel Surveillance, Botswana

Fig 3. Adjusted HIV prevalence in pregnant women by district, 2003 Sentinel Surveillance, Botswana

Fig 4. HIV prevalence distribution by district, 2003 Sentinel Surveillance, pregnant women, Botswana

Fig 5. Adjusted HIV prevalence trends, 2001-2003, Sentinel Surveillance, Botswana

Fig 6. Age specific HIV prevalence trends, 2001-2003, Sentinel Surveillance, Botswana

Fig 7. Trend in HIV prevalence among pregnant women by age group, Sentinel Surveillance 1992-2003,2003 Sentinel Surveillance, Botswana

Fig 8. Syphilis test results by age group, pregnant women, 2003 Sentinel Surveillance, Botswana

Fig 9. HIV prevalence among men and women aged 15-49. Tebelopele VCT centers, 2003 Botswana

Fig 10. HIV prevalence by residence, Tebelopele VCT centers, 2000-2003, Botswana

Fig 11. HIV prevalence according to reported condom use over the past three months by gender, TebelopeleVCT centers, 2000-2003, Botswana

Fig 12. Percentage of respondents reporting consistent condom use in the previous 3 months by gender,Tebelopele VCT centers, 2000-2003, Botswana

Fig 13. Age and sex specific prevalence of HIV among those requested to undergo testing, 2000-2003,Botswana

Fig 14. HIV Positivity rates by residence, AIDS case reporting 2000 –2003, Botswana

Fig 15. Cumulative AIDS Cases in Botswana, 2000 - 2003

Fig 16. Distribution of reported AIDS cases by age, 2000-2003

Fig 17. Number of reported AIDS cases in Botswana by district, 2000-2003

Fig 18. Crude mortality rate, Botswana, 1995-2000

Fig 19. AIDS Proportional mortality ratio, Botswana, 1995-2000

Fig 20. Knowledge of HIV/AIDS among men and women: percent with correct responses to five AIDS knowl-edge questions, Makgabaneng Radio Listenership Survey 2003

Fig 21. Percentage of Respondents who ever had an HIV test by age group and gender, Makgabaneng RadioListenership Survey, 2003

Fig 22. Number of sexual partners in the last year among those who had sex (percent distribution),Makgabaneng Radio Listenership Survey, 2003

Fig 23. Condom use by gender at last act with a non-marital or non-cohabiting partner by age,Makgabaneng Radio Listenership Survey, 2003

Fig 24. Annual number of STI cases in Botswana, 1995-2001

Fig 25. Annual trends of new cases of TB per 100,000, 1991-2002

LIST OF FIGURES

17

23

24

25

27

28

29

33

36

37

37

38

38

39

40

41

42

43

43

45

46

46

47

48

50

ix



1. Enrollment and completeness of information, 2003 Sentinel Surveillance, pregnant women, Botswana

2. Socio-demographic characteristics of women enrolled in the 2003 Sentinel Surveillance, Botswana

3. Results of laboratory quality assurance, Pregnant Women, Botswana 2003 HIV Sentinel Surveillance

4. HIV prevalence according to reported marital status, pregnant women, 2003 HIV Sentinel Surveillance,Botswana

5. HIV prevalence according to education, pregnant women, 2003 HIV Sentinel Surveillance, Botswana

6. HIV prevalence by employment status, pregnant women, 2003 HIV Sentinel Surveillance, Botswana

7. HIV prevalence according to occupation, pregnant women, 2003 HIV Sentinel Surveillance, Botswana

8. HIV prevalence according to number of pregnancies, 2003 HIV Sentinel Surveillance, Botswana

9. Comparison of 2001, 2002 and 2003 HIV prevalence by district, pregnant women, 2003 HIV SentinelSurveillance, Botswana

10. Estimated number of HIV infected adult females per health district and age group in Botswana, basedon prevalences in pregnant women 2003 Sentinel Surveillance, Botswana

11. Estimated number of HIV infected adult males (15-49 years) per health district and age group, derivedfrom 2003 prevalence data for pregnant women, combined male and female infection rate ratiosfrom Tebelopele VCT centers and health facilities, and 2001 census population figures, 2003 SentinelSurveillance, Botswana

12. Syphilis test results per district, pregnant women, 2003 HIV Sentinel Surveillance, Botswana

13. Prevalence of genotypic resistance to ARV drugs among HIV-1C infected adult Batswana from the2001 Sentinel survey (n=71)

14. CD4 Lymphocyte Counts (Cells/mm3) of HIV-negative adults in Botswana

15. Number of HIV Requests and positivity rates by year, 2000 - 2003

16. AIDS cases by age group and year, 2000-2003

17. 2002 PMTCT participation, HIV Testing and AZT Therapy

18. 2002 TB Case notification by district, by age group, National TB Programme, Epidemiology andDisease control unit, MoH, Botswana

LIST OF TABLES

14

15

16

18

19

20

21

22

26

30

31

32

34

35

39

41

44

49

x



LIST OF ABBREVIATIONS

AIDSANCARVASUBAISBHPBHRIMSBOTUSACDCCICSODHTDNAEDTAELISAEPTBESRFBCHAARTHIVMOHNACANASTADNGONHRLNNRTIPCRPIPMRPMTCTPPTPTBRTSTDSTITBUNAIDSUNDPUNICEFVCTWHO/AFRO

Acquired Immuno-deficiency SyndromeAntenatal ClinicsAnti-retroviralAIDS/STD UnitBotswana AIDS Impact SurveyBotswana Harvard PartnershipBotswana HIV Response Information Management SystemPartnership between Botswana and the United States of America GovernmentsCenters for Disease Control and Prevention, Atlanta, GeorgiaConfidence IntervalCentral Statistics OfficeDistrict Health TeamDe-oxyribonucleic acidEthyl-diamino Tetra AcetateEnzyme Linked Immunosorbent AssayExtra Pulmonary TuberculosisErythrocyte Sedimentation RateFull Blood CountHighly Active Anti-Retroviral TherapyHuman Immunodeficiency VirusMinistry of HealthNational AIDS Coordinating AgencyNational Alliance of State/Territorial AIDS DirectorsNon-Governmental OrganizationNational HIV Reference LaboratoryNon-nucleotide reverse transcriptase inhibitorPolymerase Chain ReactionProtease InhibitorProportional Mortality RatioPrevention of mother-to-child transmissionPlasma Preparation TubePulmonary TuberculosisReverse TransciptaseSexually Transmitted DiseasesSexually Transmitted InfectionsTuberculosisJoint United Nations Programme on AIDSUnited Nations Development ProgrammeUnited Nations Children’s FundVoluntary Counseling and TestingWorld Health Organization Regional Office for Africa

1



EXECUTIVE SUMMARY

Since 1992, Botswana has been monitoring theHIV epidemic through annual sentinel surveil-lance of pregnant women attending antenatalclinics. This approach, tagged “first generationHIV surveillance” has been found useful in pro-

viding data for creating awareness of the problemamong the public and decision makers. The data havebeen used for making estimates and projections for thecountry and for mobilizing support for national HIVintervention programmes. The first generation surveil-lance did not however provide an opportunity for track-ing risky behaviours that may be fueling the epidemic. Italso did not provide a link between behavioural and bio-logical data; hence there was always the difficulty inexplaining the epidemiological patterns of the infectionand changes in prevalence observed over time. The sec-ond generation HIV/AIDS surveillance strategy embarkedupon, and presented in this report, is an attempt toexamine data from various sources in order to increasethe explanatory power of sentinel survey data andenhance use of data from other sources.

The specific objectives of this expanded surveillanceapproach were to:

• Determine the prevalence of HIV and syphilis infec-tion among pregnant women in different geograph-ic locations of Botswana

• Estimate the current number of infected personsaged 15-49 years in the general population

• Investigate the existence of HIV strains resistant toARV drugs in the Botswana population

• Describe the socio-cultural behaviours and other fac-tors that may be fueling the epidemic

• Determine the level of CD4 counts among HIV-nega-tive Batswana

The sentinel survey in 2003 was conducted in all the 22districts and a total of 7251 pregnant women attendingantenatal clinics participated. Blood samples were col-lected from June 30 to September 19, 2003 and testedfor HIV antibodies in an unlinked anonymous approachusing the Murex HIV 1.2.0 test kit and for syphilis byRapid Plasma Reagin (RPR) test.

Data from other sources were analyzed. These includedprogramme data from Tebelopele VCT centers; data onAIDS cases as well as Tuberculosis, PMTCT and sexuallytransmitted infections reported from health facilities.Behavioural data were based on the MakgabanengRadio Listenership Programme Evaluation Survey, whichcovered seven districts.

The FASCount system was used to determine absoluteCD4 and CD8 values while ViroSeq HIV-1 GenotypingSystem was used for evaluating viral resistance to ART.

Overall HIV prevalence in the country was 37.4% andranged from 25.7% in Southern to 52.2% in SelebiPhikwe district. In more than two-thirds of the countrythe prevalence was over 30% and in over one-third ofthe country the prevalence exceeded 40%. There wasno marked difference in HIV prevalence between urbanand rural areas.

The highest age-specific prevalence was observedamong those aged 25-29 years. VCT data showed sig-nificantly higher HIV prevalence among young womenthan in men of similar ages.

While the prevalence in older age groups appears to beincreasing, the prevalence in the age group 15-19 yearshas remained fairly stable ranging from 21 to 23%between 2002 and 2003. Currently, about 283,764adult Batswana aged 15-49 years are living withHIV/AIDS.

2



A median CD4+ count among HIV-negative Batswanawas 599 cells/mm3. Prior to the introduction of country-wide HAART, Batswana did not harbour HIV strainsresistant to ARV drugs.

The number of TB cases in the country is on the increase.Similarly, the crude mortality rate over the last decadehas been increasing while the proportional mortalityratio of AIDS has remained stable in the last few years.

From the seven districts sampled for the RadioListenership Program Evaluation Survey, about one infive young persons have correct knowledge on HIVtransmission. Condom use in the last sexual act with anon-marital and non-cohabiting partner was over 60%.However, the proportion of people with multiple part-ners in the surveyed 7 districts was still high at 32% formen and 17% for women.

From the available data, it can be observed thatHIV/AIDS in Botswana remains a great challenge. Itwould be misleading to assume that the epidemic isover. It would be tragic if there were complacency inresponse. Currently about one in three persons aged 15-49 years are living with HIV. This is a threat to the veryexistence of the nation of Botswana.

Fortunately, there is good leadership as demonstrated byhigh level of political and economic commitment on thepart of the government of Botswana. The private sector,civil societies including PLWA organizations have risen tothe occasion to form a partnership with government infighting the epidemic. The national response has result-ed in setting up prevention programs such as behaviorchange communication, Voluntary Counseling andTesting, STI Control and Prevention of mother to childtransmission (PMTCT). Care and support programs havebeen scaled up to include provision of Highly ActiveAntiretroviral Therapy and Community Home Based

Care Programs. Impact mitigation and reduction in stig-ma have been addressed at all levels by providing fund-ing for income generating activities, support for orphansand vulnerable children, and greater involvement ofPLWA. The Government, people of Botswana and col-laborating partners must maintain this momentum so asto bring the epidemic under control.

Based on the results above, the following recommenda-tions are made:

• There is a need to intensify HIV/AIDS interventionprogrammes especially among the young persons soas to reduce the rate of new infections

• In addition to sentinel surveillance, there is a need toclosely evaluate the extent of the scourge and theimpact of the national response through special pop-ulation-based surveys

• Survey design strategies that would eliminate or min-imize ecological fallacies need to be adopted in theconduct of future behavioural studies so as to enableproper linkage with biological data

• There is a need for extensive community mobilizationfor increased patronage of voluntary counseling andtesting services

• Tuberculosis control programme efforts need to beintensified and national treatment algorithms forTuberculosis as well as for STIs need to be reviewed

• There should be a scaling up of anti-retroviral pro-gramme to meet the needs of the increasing numberof infected persons

• In subsequent sentinel surveys, the minimum numberof specimens tested during quality control per labo-ratory should be increased. Criteria for acceptance ofresults should be specified in the survey protocol

3



1. INTRODUCTION

According to The Joint United NationsProgramme on AIDS (UNAIDS) estimates,globally, about 40 million people are cur-rently living with HIV/AIDS. An estimated5 million people became infected with

HIV/AIDS in 2003. Over the next decade, withouteffective treatment and care, they will join the ranksof the more than 20 million people who have died ofAIDS since the first case in 1981. However, the vastmajority of people have not yet acquired the HIV,enabling them to protect themselves against it.Providing adequate and affordable treatment andcare to people living with HIV, represents two of thebiggest challenges facing mankind today.

HIV/AIDS marks a severe development crisis in sub-Saharan Africa, which remains by far the worstaffected region of the world. The total number ofpeople living with HIV/AIDS in sub-Saharan Africa by2003 is between 25-28.2 million. As the impact ofAIDS continues to threaten the African society,African leaders are mounting a large-scale response tofight HIV/AIDS, targeting all sectors. Botswana isamong the 19 African nations that have establishedNational AIDS councils or commissions personallychaired by the Head of State to take charge of amulti-sectoral response to AIDS. The epidemic insome countries is still in its early stages and effectiveresponses are possible. In other countries, the epi-demic has reached an advanced stage affecting alarge percentage of the population. The epidemic issteeped in stigma and discrimination. Fear and denialalso hinder the collection of adequate data to ade-quately assess the exact magnitude of the problem.

The interplay of multiple factors obscures causal link-ages and prevents categorical conclusions. Secondgeneration surveillance compares information on HIVprevalence and the behaviours that spread it. InBotswana where the epidemic is generalized, second

generation provides information to help better under-stand the behaviours driving the epidemic and indi-cates the success of the response and provides essen-tial information for planning care and support.

The epidemic in the country is fueled by several fac-tors such as the extreme mobility of the population,high prevalence of some sexually transmitted dis-eases, sexual behavior pattern which include multiplepartners and frequent change in partners, rapidurbanization leading to breakdown of the traditionalmechanisms for controlling social and sexual behavior.Poverty and relative gender inequality among womenare all contributing factors.

Since 1992, Botswana has been monitoring the HIVepidemic through annual sentinel surveillance ofpregnant women attending antenatal clinics. Thisapproach, tagged “first generation HIV surveillance”has been found useful in providing data for creatingawareness of the problem among the public and deci-sion makers. The data have been used for makingestimates and projections for the country and formobilizing support for national HIV intervention pro-grammes. The first generation surveillance did nothowever provide an opportunity for tracking riskybehaviours that may be fueling the epidemic neitherdid it provide a link between behavioural and biolog-ical data; hence there was always the difficulty inexplaining the epidemiological patterns of the infec-tion as well as changes in prevalence observed overtime. The second generation HIV/AIDS surveillancestrategy embarked upon, and presented in this reportis an attempt to pool data from various sources (HIVsentinel seroprevalence survey, VCT programme data,PMTCT, STI and TB surveillance results, behavioral sur-veillance findings and AIDS case reporting) in order toincrease the explanatory power of sentinel surveydata and to better understand the dynamics of theepidemic.

4



2. SURVEY OBJECTIVES

The overall objectives of the expanded HIV surveillance survey were to obtain relevant, appropriate,sufficient and accurate data on the status of the epidemic in order to guide programming, interven-tions and policies in the country.

The specific objectives of this expanded surveillance approach were to:

• Determine the prevalence of HIV and syphilis infection among pregnant women in different geographic loca-tions of Botswana

• Estimate the current number of infected persons in the general population

• Investigate antiretroviral drug resistance (ART), resistant HIV strains

• Describe the socio-cultural behaviours and other factors that may be fueling the epidemic

• Determine the level of CD4 counts among HIV-negative Batswana

5



3. METHODOLOGY

3.1.1 Sentinel population

In 2003, only pregnant women were included in thesentinel survey. Inclusion and exclusion criteria (eligi-bility criteria) were developed to delineate the targetpopulation and to minimize the risk of multiple sam-pling of individuals.

Inclusion criteria:

• Pregnant women 15-49 years old with a first ANCvisit of their current pregnancy.

• Attending a public health facility that has beenselected to participate in the 2003 survey duringthe survey period that lasted from 30th Junethrough 19th September 2003.

3.1.2 Sentinel sites

The 2003 HIV sentinel surveillance survey included all22 Health Districts. Of these, seven districts wereinvolved in a resistance testing study. A major districtclinic was selected as the primary sentinel site.However, due to the inability of many major districtclinics to yield the required sample size, satellite clinicsites were also included to achieve the targeted sam-ple size. The satellite health facilities selected werethose with the highest number of ANC attendees inthe previous year.

The major criteria for selecting participating sentineland satellite sites:

• The candidate facility provides services for theselected sentinel population

• Blood is routinely drawn from patients/clients aspart of routine care or service provided at the facil-ity

• A reliable laboratory is available to perform theroutine laboratory tests as well as the serologictests for HIV antibody

• The facility is readily accessible• The facility provides services to relatively large

number of people so that an adequate sample sizecan be obtained

• The facilities are located in different geographicareas, urban and rural, or areas of special concernfor the prevention programme

• Facility staff is capable of conducting surveillance

3.1.3 Sample size

Sample sizes were calculated for each sentinel sitetaking into consideration the 2002 HIV prevalence inthe particular health district, the level of confidencedesired for the prevalence estimate, the accuracy andthe logistical feasibility.

Appendix 8.1 shows the targeted sample sizes calcu-lated for the 22 health districts. The calculated samplesize ranged from 116 to 400.

3.1.4 Sampling scheme

A consecutive sampling scheme was used. Clinic per-sonnel knowledgeable about the inclusion criteriaascertained patient eligibility and enrolled womeninto the survey at the time of the prenatal consulta-tion. During this routine antenatal consultation, thesurvey form (Appendix 8.2) was completed in additionto the collection of routine service information in theANC. Demographic Information on age, sex, maritalstatus, parity, employment status, occupation, andeducation was collected on the survey form.Aggregate syphilis data for the 12-week survey periodwas compiled from service records at the end of thesurvey using the syphilis survey form (Appendix 8.3and 8.4).

Each survey form was completed in triplicate usingserially numbered self-carbonating forms; the thirdcopy of the form remained at the originating healthfacility, the second copy of the form was sent to the

3.1. HIV SENTINEL SURVEY

6



District Health Office, whilst the original copy of theform was sent to NACA in batches at the end of eachweek.

Once the form was completed, the routine ANCblood was drawn consisting of one red top (5ml) tubewithout anticoagulant and one purple top (5ml) withEDTA anticoagulant. For the seven districts participat-ing in the resistance testing study, different tubeswere used. One white top tube with PPT anticoagu-lant and one purple top (5ml) with EDTA anticoagu-lant were used. No additional blood was collected.Personal identifiers were removed from the specimen(see specimen handling section) before being sent tothe laboratory.

Efforts were made to over sample women in the agegroup 15 to 19 years in three districts Gaborone,Kweneng East, and Francistown.

3.1.5 Duration of survey

The enrollment period was 12 weeks from June 30thto September 19th, 2003. All sites commenced sam-ple collection at the same time and stopped at theend of the survey period. Samples collected beyondthe survey period were not included in the analysis.

3.1.6 Training

The Surveillance Technical Working Group conducteda series of training sessions at the district level inMarch/April 2003. Health officials trained includedpublic health officers, community health nurses,matrons, and laboratory personnel. Four training ses-sions were held for the 22 DHTs (two in the south andtwo in the north). Topics that were covered included:Second generation HIV surveillance, standard operat-ing procedures, data collection tools, laboratory tech-niques, national training requirements for BHRIMS,universal safety precautions, antiretroviral therapy, andpresentation of the 2001 resistance study results. The

importance of high levels of cooperation and supportwas highlighted for the surveillance programme to besuccessful.

A consensus was reached regarding the guidelines ata fifth consensus meeting with all 22 districts repre-sented. The final guidelines were then used for train-ing health personnel at the facility level. Training washeld in June 2003 for all participating facilities. Thetraining was conducted by DHT health personnel andwas supported by the surveillance technical workinggroup in 20 districts.

The main objective was to train staff (midwives) onthe sentinel surveillance protocol and procedures,using the finalized version of the guidelines and todistribute survey material. Non-midwives and stafffrom facilities that were not on the participation listwere also trained by some DHTs in order to limit theconstraints of staff shortage.

3.1.7 Support visits

The NACA surveillance team conducted support visitsthat covered 22 districts and five follow up visits dur-ing the survey period. The objectives of these visitswere to:

• Discuss general issues regarding compliance to theguidelines

• Provide support materials• Reconcile data received at NACA with data

received from the DHT • Reconcile laboratory sentinel survey book numbers

with those received at NACA and verify fax copiesfor legibility from original copies

• Verify the sentinel survey booklet distribution listgenerated at NACA against the actual surveybooklet distribution list at DHT

• Confirm availability of survey materials using astandardized checklist

• Assess storage conditions of specimens

7



3.1.8 Specimen handling

After the blood was drawn, the two blood tubes werekept in a rack upright at room temperature. The pur-ple top tube was labeled with the woman’s name andwas sent to the laboratory for routinely performedtests of hemoglobin level, rhesus factor, and ABOgrouping.

After allowing the natural clotting process to occur,the serum in the red top tube was then separated intotwo 1.8 ml cryovials by the facility staff. One vial waslabeled with the patient’s name and served for theroutine syphilis test. The other vial served for theanonymous HIV test and was labeled with an adhesiveunique code number that was found on the corre-sponding form.

The blood specimens were sent to the respective dis-trict laboratories on the same day. When this was notpossible, specimens were kept in the facility’s refriger-ator at 4ºC until transportation was available.

For women who consented for an HIV test as part ofthe nation-wide PMTCT program, a separate HIVrequest form was completed and a third tube (redtop) was collected and labeled with the HIV requestcode according to the national PMTCT guidelines. TheHIV surveillance program therefore did not interferewith the PMTCT program at any stage.

3.1.9 Laboratory

Twenty-five laboratories participated in the surveyfrom the 22 districts. Seventeen of the sites did theHIV testing in their districts, while others sent theirsamples to the National Health Laboratory inGaborone. Laboratories were asked to fax the testresults on laboratory summary sheets (Appendix 8.5)to NACA at the end of each week.

Left over specimens were stored in the district labora-tory refrigerators at 4ºC and later transferred in coolboxes containing ice to the National HealthLaboratory for Quality Assurance. These leftover spec-imens were stored in a serum bank at -76ºC for fur-ther studies.

All laboratories used a standardized test kit for thesurvey specimens. The coded unlinked aliquots werescreened for HIV antibodies by Murex HIV 1.2.0 test(Murex Biotech Limited). This test has a specificity of99.91% and a sensitivity of 100%. The Rapid PlasmaReagin, RPR test (Randox Laboratories) was used forsyphilis testing.

An independent central laboratory (Botswana HIVReference Laboratory) participated in the qualityassurance (QA) program by parallel testing randomlyselected samples using diagnostic ELISA algorithm(Murex HIV 1.2.0 (Murex Biotech Limited). For eachstorage box, random numbers between 1 and 100were generated and used to select 17% of the speci-mens from each box based on sample locations with-in the 10x10 or 9x9 grid storage boxes. The sampleswere thawed for a maximum of 2 hours before beingtested and read on the universal plate reader ELx800(Bio-Tek). Some of the selected specimens could notbe tested due to insufficient volumes and clotting.

3.1.10. Data management

3.1.10.1 Data compilation, data entry and data cleaning

A team made up of technical officers from theNational AIDS Coordinating Agency (NACA), theBOTUSA/CDC Project, Botswana-Harvard AIDSInstitute Partnership, the Ministry of Health AIDS/STDUnit (ASU), the National Health Laboratory, wasresponsible for the daily management of the surveyand met weekly to discuss survey progress.

8



NACA staff received survey data weekly from twoindependent sources:

1) district health teams mailed batches of question-naires with the socio-demographic data and

2) participating laboratories faxed HIV test results.Before entry, data collection forms were firstchecked for completeness of data, obvious errorsand inconsistencies. Phone calls were made to thedistricts for clarification and correcting errors.

Data entry and laboratory result forms were thenscanned and entered in an Information BankDatabase system. This procedure allows for efficientlong-term electronic storage and retrieval of docu-ment, images of data collection forms. Two inde-pendent pairs of data entry clerks then entered thescanned images into the database.

The databases were exported in a dbase IV (DbF) for-mat and were compared for inconsistencies. EpiInfo2002 statistical software (Centers for Disease Controland Prevention, Atlanta, GA, USA) was used for thisvalidation procedure. A series of validation runs anddata entry error corrections were performed beforethe two datasets were 100% concordant.

Consensus meetings (two in the North, two in theSouth) were organized with representatives fromNACA, NASTAD, National Health Laboratory, the dis-trict health teams, and the laboratory personnel toreconcile missing data, such as forms without corre-sponding results, or results for which there were nocorresponding forms.

3.1.10.2 Data analysis

Analysis was done using EpiInfo 2002, STATA (STATACorporation, College Station, TX, USA), StatXact ver-sion 3.0.2. (Cytel Software Corporation) and SAS.

For each district, crude HIV prevalence per age group,civil status, education, employment, occupation, andnumber pregnancies were calculated.

HIV prevalence by location type (urban vs. rural) wasalso calculated. The Health districts were classified asurban or rural as follows: Urban: Serowe/Palapye, Kweneng East, Southern,Mahalapye, Kgatleng, South East, Gaborone,Francistown, Lobatse, Selebi Phikwe.

Rural: Ngami, North East, Bobirwa, Gantsi, Chobe,Kgalagadi, Tutume, Boteti, Okavango, KwenengWest, Goodhope, Hukuntsi.

HIV prevalence was calculated using direct standardi-zation as follows:

An estimate of female HIV prevalence for each districtand Botswana as a whole was calculated using directstandardization as follows: (Appendix 8.6.a):

A) Estimating female HIV prevalence for eachdistrict and Botswana

• The exact female population for each district in the6 age groups of interest (15-19 years, 20-24 years,25-29 years, 30-34 years, 35-39 years, and 40-49)was obtained from the 2001 national census data(Appendix 8.6.a - yellow columns).

• HIV prevalence was calculated for each of the 22districts by age group, using 2003 BotswanaSentinel Surveillance data. For Gantsi 2001 and2002 data were combined to estimate 2003 preva-lence.

• This age-specific prevalence was then multiplied bythe corresponding age and district-specific popula-tion to determine the number of infected womenin each age category by district.

• The sum of the number of infected women for allage groups and districts yielded the total infected

9



women 15-49 years in Botswana• This number of infected women was divided by the

total female population for each age group by dis-trict to provide an adjusted district HIV prevalence

• The adjusted national prevalence was then calcu-lated by dividing the total number of infectedwomen for all districts divided by the total femalepopulation 15-49 years in Botswana. Robust vari-ances obtained from logistic regression modelswere used to calculate the 95% CI for the adjust-ed prevalence

NOTE: Statistical comparisons of HIV prevalenceexclude Gantsi in determining p-values.

B) Estimate of the total number of HIV infectionamong males 15-49 years old

• The exact male population for each district in the 6age groups of interest (15-19 years, 20-24 years,25-29 years, 30-34 years, 35-39 years, and 40-49)was obtained from the 2001 national census data(Appendix 8.6.b).

• The age-specific HIV prevalence from the 2003survey for each of the six age groups in pregnantwomen in each of the 22 districts was used as thestarting point.

• This prevalence was then multiplied by a male tofemale infection ratio correction factor, i.e. thecombined male-to-female HIV infection ratiosobtained from the Tebelopele Stand Alone VCTand integrated VCT from health facilities.

• This “corrected” prevalence was then multiplied bythe 2003 (15-49 years old) male population todetermine the number of infected men per district.

C) Estimate of the total number of infections(both males and females)

A correction factor for females and males, reflectingthe natural increase in population from 2001 to 2003,

was applied to this number. The correction factor forwomen was 2.5% per year and for men was 2.6%per year.

The addition of the number of infected females andinfected males gave the total number of infected per-sons (age 15-49) in Botswana.

D) HIV Prevalence TrendsFor sentinel surveys conducted from 1992 to 1999,crude estimates of prevalence were calculated andincluded women from non-consistant health districtsexcept for Francistown and Gaborone. Raw data fromsurveys from 1992 to 1999 were not available to re-compute the adjusted prevalences. The 2000 surveyincluded 6 health districts and women aged 15 to 49years. From 2001 to 2003, surveys included womenfrom all 22 health districts and of ages 15 to 49. Forcomparisons of HIV prevalence for various age groupsthat are made over time the following was done:

1) The prevalence for women aged 15-19 and aged20-24 for 1992 to 2000 are crude estimates.Prevalence for women aged 15-19 and aged 20-24for 2001 to 2003 are district adjusted estimates.

2) For comparison of the young age groups to olderwomen, prevalence for women 25-49 are present-ed. The prevalence for women aged 25-49 for1992 to 2000 are based on data for ages 25-44.Estimates are adjusted to the age distribution ofBotswana in 2001 and for 2001 to 2003 are ageand district adjusted.

3.1.11 Assumptions in estimations

The assumptions made by the data managementteam were as follows:

Females:The HIV prevalence among pregnant women aged

10



15-49 years attending public antenatal clinics in a dis-trict is representative of the HIV prevalence among allpregnant women in the same age group in that dis-trict.

The HIV prevalence among pregnant women 15-49years in a district is representative of the HIV preva-lence among women of the same age group in thatdistrict.

The rate of natural increase in the female populationremained fairly stable over the two- year period 2002-2003.

Males:Male-to-female HIV infection ratios of the first timeattendees at both stand-alone (Tebelopele) and inte-grated Voluntary Counseling and Testing (VCT) cen-ters in Health facilities are representative of the male-to-female infection ratios in the general population.

The following male-to-female prevalence ratios wereused:

Age Group Prevalence Correction Ratio15-19 0.0820-24 0.3025-29 0.5630-34 0.8235-39 1.0540-49 1.24

The rate of natural increase in the male populationremained fairly stable over the two-year period 2002-2003.

3.1.12 Limitations

The 2003 HIV sentinel surveillance had the followinglimitations:

• The WHO guidelines recommend working with ahealth facility as a sentinel site. In the Botswanacontext, however, several satellite sites needed tobe combined to achieve the required sample size.

• The WHO recommended minimum sample size of250 was not feasible for some districts. The samplesizes obtained for each district had a wide range.Hence, the HIV prevalence estimates of the respec-tive districts have varying degrees of accuracy,which might affect the accuracy of the nationalsummary estimate.

• Data from Gantsi collected in 2003 was excludedfrom analysis for two main reasons. Out of the 91samples retested by an independent QA laborato-ry, 28 (31%) yielded discordant results.Furthermore, a comparison of the results for thisyear with that of last year indicate that HIV preva-lence in the district has doubled within this inter-val. From the general pattern observed in all theother districts, and from epidemiological point ofview, this doubling in prevalence in one yearseemed an unlikely occurrence. For these reasons,data from this district was excluded from theanalysis. In making national estimates for the num-ber of infections in the country, the prevalenceused for this District was the weighted mean of the2001 and the 2002 prevalence.

• Projected population figures for 2003 by agegroups were not available. Therefore the correctionfactor reflecting population increase applied uni-formly to all age groups might have differed fromthe actual.

11



In order to evaluate the prevalence of drug resistanceon a population level prior to the initiation ofBotswana’s public national ARV treatment program(background baseline resistance), samples from the2001 HIV Sentinel Surveillance were analysed forbaseline drug resistance of HIV-1C by genotyping arepresentative number of samples from the northernand the southern part of the country (71 samples intotal) and key results are summarized in Table 13. Viralgenotyping was performed by using ViroSeq HIV-1Genotyping System (Celera Diagnostics (formerApplied Biosystems, Inc. (ABI)), Alameda, CA), accord-ing to the manufacturer’s instructions. Briefly, HIV-1RNA was extracted from viral particles pelleted fromplasma by isopropanol/ethanol precipitation, convert-

ed to cDNA and then amplified in PCR. The amplicon(~ 1500 bp) represented the HIV-1 pol region span-ning the entire protease and the first 335 codons ofRT. The PCR product was then sequenced (bothstrands) using 6 different primers and Big Dye chem-istry on an ABI 3100 Genetic Analyser. ViroSeq HIVAnalysis software was used for assembling and edit-ing the sequences. The software compares the samplesequence with HXB2 and identifies mutations knownto be associated with resistance to the different drugs.The Stanford HIV resistance database was also used toanalyze for resistance mutations. This databaseincludes more recently identified resistance mutationscompared to the Viroseq Software.(2000).

3.2 DRUG-RESISTANCE AMONG HIV-1C INFECTED, TREATMENT- NAIVE ADULTS IN BOTSWANA

3.3 CD4 CELLCOUNTS AMONG HIV-NEGATIVE BATSWANA

Samples from the Botswana 2001 HIV SentinelSurveillance survey were used to describe CD4+ lym-phocyte reference ranges. In total, 589 SentinelSurveillance samples were collected, and of these 499were suitable for T-lymphocyte subset enumeration ofwhich 251 (50%) were HIV-negative. Unlysed, wholeblood samples were collected in EDTA (BectonDickinson) to prevent clotting. Blood samples werecollected in the morning and were transported to theNational HIV Reference Laboratory at ambient tem-perature. Only samples that arrived at the laboratorywithin 24 hours of collection were analyzed.

HIV-1 screening of all samples was performed by par-

allel ELISA testing using Murex HIV 1.2.0 (AbbottPharmaceuticals, Inc.) and Ortho HIV-1/HIV-2 AB-Capture ELISA Test System (Ortho-Clinical Diagnostics,Inc) assays to detect the presence of HIV-1 and HIV-2antibodies.

FACSCount System (Becton Dickinson) was used toenumerate absolute values for CD4 (helper/ inducer Tlymphocytes) and CD8 (suppressor/ cytotoxic T lym-phocytes) as well as CD4+ to CD8+ ratios for eachsample. The FACSCount instrument used for thisstudy was validated against two independentFACSCount Systems.

12



3.4 TEBELOPELE HIV VOLUNTARY COUNSELING AND TESTING (VCT) PROGRAM

3.5 HIV/AIDS CASE REPORTING AND MORTALITY DATA

3.6 PREVENTION OF MOTHER TO CHILD TRANSMISSION (PMTCT)

The main objective of this program is to establish anetwork of 16 free standing Tebelopele VCT centersin Botswana. Secondary objectives include the mobi-lization of the community in support of VCT andbehavior change, establishing a network for referralprocedures for clients, and discouraging stigmatiza-tion of HIV/AIDS. The first centre was opened in April2000 and currently 16 centres are operational.Several centers have established satellite as well asmobile testing sites. At all centers, qualified andtrained personnel provide HIV voluntary counseling(pre and post) and testing with same-day test results.

An algorithm consisting of two rapid immunoassaystests is used to test the whole blood for HIV antibod-ies. In case of discordant results, a third rapid test is

used as a tiebreaker or the specimen is re-tested bydouble ELISA algorithm. The Ministry of Health hasvalidated the rapid test kit algorithm. A standard formis completed for all clients who visit the center regard-less first or second visit (Appendix 8.7).

Anonymous information is collected on socio-demo-graphics, occupation, number of sexual partners, con-dom use, clinical symptoms, and a few other charac-teristics of interest. Clients go through an extensivepost-counseling session with the development of a riskreduction plan. HIV sero-positive persons are referred toappropriate clinics and/or organizations for follow-upand support (Isoniazid preventive therapy, ARV evalua-tion, mother-to- child transmission for pregnantwomen, associations of People living with AIDS).

A standardized HIV request form (Appendix 8.8) isused in the country to report HIV and AIDS cases fromhealth facilities. The form captures information ondemographic characteristics, reasons for testing, pre-senting symptoms, and exposure to specific risk fac-tors. Clinicians complete the form for various servicereasons: voluntary counseling, Prevention of Motherto Child Transmission (PMTCT), rape, injury, and clini-cal suspect cases. Forms are routinely completed atthe health facility and sent to the Ministry of Health

(MOH) on a monthly basis. The AIDS case definitionused in the country as well as for this data analysis isthe Abidjan definition (Appendix 8.9 Bangui defini-tion plus a confirmatory HIV laboratory test).

The crude mortality data are analyzed from the facili-ty inpatient deaths within public health delivery sys-tem. Sources of these data were the annual CentralStatistics Office Vital Statistics reports 1995-2002.

In Botswana, staff at the health facilities maintainslogbooks with aggregate PMTCT programme data.Information collected includes amongst others,numbers of ANC attendance, number of pregnantwomen counseled and tested for HIV, number of HIVpositive women, provision of AZT, Nevirapine, and

infant formula as replacement feeding. Women con-senting for HIV testing complete the standardizedHIV request form mentioned above. This formtogether with the blood sample is forwarded to therespective district laboratories where it will be testedby parallel ELISA.

13



3.7 BEHAVIOURAL SURVEYS

The behavioural data used in this report is based onthe Makgabaneng radio drama listenership survey.Makgabaneng is a weekly, nationally broadcastentertainment-education radio serial drama firstaired in 2001 to support HIV prevention efforts inBotswana. It is written and produced by Batswanawith support from the U.S. Centers for DiseaseControl and Prevention, Media Support Solutions,and the Government of Botswana’s Ministry ofInformation and Broadcasting.

To assess listenership, a random sample of 1730households was selected from seven districts:Ngami, Serowe/Palapye, Southern, Francistown,Kgatleng, Selebi Phikwe, and Gaborone. 60 clusters(enumeration areas or EAs) were selected from theseseven districts with the number of EAs per district

proportional to the population size. 30 householdswere randomly selected per EA, and one 15-49 yearold, Setswana-speaking household member wasrandomly selected per household and approachedfor interview. Protocol and questionnaires were sub-mitted and cleared by Institutional ethical reviewboards in Botswana and the United States.Interviewers were trained for 2 weeks and 3 pilottests were conducted before the 4 teams startedfieldwork. Data was collected between February andMay 2003. Interviews were sex-matched. The surveyinstrument included questions about radio-listeningpatterns, response to Makgabaneng, knowledgeand psychosocial measures related to HIV/AIDS, sex-ual behavior, VCT, PMTCT, and stigma towards thoseinfected.

3.8 DATA ON SEXUALLY TRANSMITTED INFECTIONS

In Botswana, the STI program is based on the syn-dromic management approach. The STI data were

derived from the CSO Health statistics reports 1995-2000.

3.9 DATA ON TUBERCULOSIS

The Botswana National TB program reports all diag-nosed cases including pulmonary Tuberculosis (PTB)cases that were not confirmed by positive sputumresults and all cases of extra pulmonary tuberculosis(EPTB). The reporting system follows theInternational Union Against Tuberculosis and LungDisease/WHO guidelines for TB recording andreporting.

Most of the case finding for tuberculosis is done pas-sively. Patients present voluntarily to facilities. Adiagnosis of TB is suspected on the basis of symp-toms and clinical findings. Screening of tuberculosisis done by all health workers in the different facili-ties. Sputum is usually the first investigation to becarried out. Other diagnostic procedures such as

chest x-ray, blood FBC and ESR are also done.Each facility keeps a register of TB cases (Appendix8.10). These forms are submitted to the DHT on amonthly basis. The DHT collates this information in auser-friendly menu driven computer program using aDOS based software (Epi-Info 6).

The desk review was done using the following doc-uments:• The Global Plan to Stop Tuberculosis. • The Tuberculosis Statistics-2002 in Botswana. • Evaluation of the Botswana National Tuberculosis

(TB) Programme 1999. • National Tuberculosis Control Programme Report

of 2002.

14



4.1. HIV SENTINEL SURVEILLANCE

NgamiNorth EastSerowe/PalapyeBobirwaKweneng EastSouthernGantsiMahalapyeKgatlengChobeKgalagadi Tutume BotetiOkavangoGaboroneFrancistownSouth EastLobatseSelebi PhikweKweneng WestGoodhopeHukuntsi

Total

403233423266555437195394369121170454318352577647317251321198146104

7251

6060126238532612106101210742

177

561468610472121011385100020

147

16514513101821392593511839939132

403

3762223892555223590

326353115161429260328555593306246302190137100

6524

93%95%92%96%94%82%0%83%96%95%95%94%82%93%96%92%97%98%94%96%94%96%

90%

Sentinel Site Enrolled

No.

Forms no result Result no form

No.

Unusable for

other reasons*

Used for analysis

No. %

Table 1: Enrollment and completeness of information, pregnant women, 2003 Sentinel Surveillance,Botswana.

A total of 7,251 women were enrolled in the 2003 survey out of which 6,524 or 90% (median of 304 per dis-trict, range 0 – 593) were eligible for inclusion in the analysis. The other 727 were excluded from the analysis forvarious reasons such as missing results (24%), missing forms (20%), hemolyzed specimens (6%), failure to meetthe specified age and date inclusion criteria (20%), unusually high discordance rates (23%) or other reasons(6%). All districts enrolled at least 100 women.

*44 women had hemolyzed specimen and could not be tested, 48 had an interview date outside the survey, 96 were younger than 15 or older than 49, 168

for high discordance, and 47 for other reasons.

4.RESULTS

15



115022891449867514255

4457705242

48314594290237

13572385464346

14037165693696

227628251423

17.635.122.213.37.93.9

6.911.981.2

7.522.666.33.7

20.93.78.467.0

22.011.28.957.9

34.943.321.8

Characteristic N %

Table 2: Socio-demographic characteristics of women enrolled in the 2003 Sentinel Surveillance,Botswana.

Age group (n=6524)15-1920-2425-2930-3435-3940-49

Marital status (n=6457)Living togetherMarriedSingle

Educational level (n=6469)NonePrimarySecondaryUniversity

Employment status (n=6487)Regular jobSelf-employedTemporary jobsUnemployed

Occupation (n=6384)Domestic workerOffice workerStudentOther

Number of pregnancies (n=6524)12 to 3>3

The mean age of the women was 25.6 years (median 24 years); 18% of the women surveyed were younger than20 years of age and 35% of women were 20-24 years of age. Over 80% of the women were single. Close to8% of the women had received no formal education and approximately two-thirds of them were unemployed.The most frequent single occupation cited by the women was domestic worker. Students comprised 9% of thegroup. For about a third of the women, this was their first pregnancy.

16



Table 3: Results of laboratory quality assurance, pregnant women, Botswana 2003 HIV SentinelSurveillance

Laboratoy

95% Cl

Discordance

% No.

% of totallaboratoryspecimens

Number of specimen re-tested

Number of results

used in analysis

Athlone Laboratory Gweta Primary Hospital LaboratoryTutume Primary Hospital LaboratoryGantsi Hospital Laboratory *Mahalapye Hospital LaboratorySefhare LaboratoryHukuntsi Primary Hospital LabDRM Hospital Laboratory Masunga Primary HospitalRakops Primary Hospital Scottish Livingstone Hospital LabThamaga Primary Hospital LabSelebi Phikwe Government HospitalNational Blood Transfusion LabBobonong LabBamalete Lutheran LabLetlhakane Hospital LabGoodHope Hospital LabTotal excluding Gantsi*

24663

36616922572

10034922270

578134302

321218574

190136

6524

19090

91187

716

15800

9517

27145326100

111450

261

na281012

11nana92

443820

na1

147

13.711.1

na30.85.3

14.312.57.0nana

9.511.816.28.47.70.0na

9.110.1

9.1-19.40.3-48.2

na21.5-41.32.6-9.60.4-57.91.6-38.33.5-12.2

nana

4.4-17.21.5-36.412.1-21.26.0-11.30.9-25.10.0-30.8

na0.2-41.38.6-11.8

77.214.30.0

53.883.19.7

16.045.30.00.0

16.412.789.714.114.113.50.08.1

22.2

The independent National HIV Reference Laboratory (B.H.P.) re-tested 1450 (22%) of the 6523 specimens col-lected for the survey for which we had results and demographics. Overall, 175 specimens gave discordant results.One laboratory (Gantsi Hospital laboratory) gave an unusually high discordance rate of 31% and the site wassubsequently excluded from the analysis. The overall discordance rate excluding Gantsi was 10%.

* Not used in the analysis

17



Figure 1: Age- specific seroprevalence of HIV among Batswana pregnant women, 2003 HIV Sentinel Survey

The highest HIV prevalence is consistently in the 25-29 year age group in which prevalence has been atapproximately 50% for the past three years. The lowest rates are among women aged 15-19 years.

18



HIV prevalence differed by marital status. Overall HIV prevalence was highest among unmarried women liv-ing together with partners (range: 0.0% in Chobe to 73.7% in Selebi-Phikwe) compared to those who weremarried. HIV prevalence was also consistently higher among single women (range: 26.9% in Southern to56.7% in Bobirwa) than those who were married (range: 14.8% in Kweneng West to 43.2% in Boteti) forall districts except for Ngami, Kgatleng, Kgalagadi, and Boteti.

NgamiNorth EastSerowe/PalapyeBobirwaKweneng EastSouthernMahalapyeKgatlengChobeKgalagadiTutumeBotetiOkavangoGaboroneFrancistownSouth EastLobatseSelebi PhikweKweneng WestGoodhopeHukuntsi

Total%

29317731321542829727530810113833320424447546020519624814011676

524281.2

36.244.647.056.733.426.942.531.253.530.443.236.834.445.949.829.334.754.430.037.132.9

40.2

53315424634031321112713739596550203127911

77011.9

39.622.631.541.722.222.516.137.518.233.322.543.233.337.318.520.015.038.714.822.227.3

27.8

26111714271618122101915432062462519201112

4456.9

61.563.664.757.155.643.833.358.30.0

50.047.453.339.565.054.823.936.073.715.063.625.0

47.2

37221938425351835332435211416042325632655458730124129818713699

6457

Sentinel Site SingleNo. % Pos

MarriedNo. % Pos

Living TogetherNo. % Pos

Total No.

11 women were divorced, 10 separated, 28 were widowed and 18 did not answer.

Table 4: HIV prevalence according to reported marital status, pregnant women, 2003 SentinelSurveillance, Botswana.

19



Table 5: HIV prevalence according to education, pregnant women, 2003 Sentinel Surveillance, Botswana.


Total%

3217271828281712517403571191910101739148

4837.5

53.135.355.661.121.414.347.133.340.029.415.025.723.952.636.840.050.058.838.514.337.5

34.4

905886661177883673350117461207392504349704031

145922.6

38.946.653.553.040.234.639.849.363.632.045.347.844.253.452.240.041.963.332.935.035.5

44.7

2461432551583492382162657692258159135436454212168222797950

429066.3

36.642.744.755.132.726.540.328.743.432.642.239.031.945.646.724.531.552.716.543.030.0

38.8

74161119127912101812421332012136

2373.7

14.325.06.3

63.621.125.028.633.30.00.0

20.033.3

100.016.738.124.225.025.00.0

100.016.7

26.6

37522238425351335632335311516142525832755258630524130018913695

6469

Sentinel Site NoneNo. % Pos

PrimaryNo. % Pos

SecondaryNo. % Pos

UniversityNo. % Pos

Total N0.

For 55 women, educational background could not be determined.

There was no consistent pattern of relationship between level of education and HIV prevalence. It appearshowever that those with primary education generally had higher rates than their counterparts. The samplesizes for respondents with university level of education in all, but one district was very small (less than 30).

20



Table 6: HIV prevalence by employment status, pregnant women, 2003 Sentinel Surveillance, Botswana

There was little variation in HIV prevalence between employment categories. In five districts, HIV prevalencewas highest among those with regular employment compared with those in other employment categories.In seven other districts, HIV prevalence was highest among those self-employed.


Total%

2761332711953672532262246311431517027129836015215119314910164

434667.0

39.535.348.352.833.025.736.332.655.631.639.034.733.945.044.729.633.848.726.838.628.1

38.2

64427334896246784116655227214160105697661721

135720.9

34.452.441.167.631.533.943.532.143.937.541.530.848.145.850.021.931.959.216.747.128.6

40.8

1940302143322937925352721203634201734134

5468.4

42.155.046.761.932.631.337.935.133.332.045.755.633.330.050.035.340.070.629.446.275.0

41.9

137124201020142514108223214611167

2383.7

30.857.133.350.040.030.065.035.70.0

20.035.790.037.563.653.128.633.363.60.00.0

28.6

45.0

37222238625451935732135311516042925932755458830524629719013796

6487

Sentinel Site UnemployedNo. % Pos

Regular JobNo. % Pos

Temporary JobNo. % Pos

Self EmployedNo. % Pos

TotalNo.

37 women did not reveal their employment status.

21




Total%

644481421288282753746121814071110564069644822

140322.0

48.443.255.661.933.635.447.646.759.534.847.940.732.536.648.219.632.552.229.733.318.2

41.8

43334327383121276112711403967342130695

5698.9

27.927.348.840.713.212.919.011.166.718.229.60.0

17.523.134.314.719.043.316.733.340.0

26.4

40224016563921441682926151126768373531012

71611.2

32.536.442.562.525.030.847.638.643.837.531.030.846.742.952.223.521.660.00.0

50.033.3

38.0

22411822016729119919619654922491332323123391461361621086557

369657.9

38.447.543.255.137.126.138.830.140.731.538.242.137.951.047.534.939.054.325.941.529.8

40.5

37121738425251335132034211315742625132753458330423429618113296

6384

Sentinel Site Domestic WorkerNo. % Pos

StudentNo. % Pos

Office workerNo. % Pos

OtherNo. % Pos

TotalNo.

Table 7: HIV prevalence according to occupation, pregnant women, 2003 Sentinel Surveillance, Botswana.

140 women did not reveal their occupation.

In seven of the districts, HIV prevalence was highest among domestic workers, ranging from 18.2% inHukuntsi to 61.9% in Bobirwa. Students had the lowest prevalence (range: 0.0% in Boteti to 66.7% inChobe). The association between HIV prevalence and occupation is confounded by age. Students tend to beyounger and younger people have lower prevalence. When adjusted for age group, office workers ratherthan students have the lowest prevalence.

22



Table 8: HIV prevalence according to number of pregnancies, 2003 Sentinel Surveillance, Botswana.

The prevalence of HIV was consistently higher in women with two to three pregnancies (range: 34.5% inHukuntsi to 66.0% in Bobirwa) than in women with a first pregnancy (range 12.5% in Kweneng West to47.7% in Selebi Phikwe). Women with two or three pregnancies generally had higher HIV prevalence thanwomen with more than 3 pregnancies (range 24.7% in Southern to 60.0% in Chobe).


Total%

12173126692221311061414251127819921422111689109645420

227634.9

28.928.842.146.424.320.630.224.126.217.628.334.628.327.134.416.421.347.712.537.020.0

28.8

173961671062011471441394863193124127272252132107148755358

282543.3

40.557.347.966.044.335.446.541.062.539.746.644.441.758.153.636.443.059.537.341.534.5

47.4

825396809981767325471095510269120585045513022

142321.8

47.635.847.948.830.324.740.834.260.036.241.330.933.353.655.829.336.051.129.436.731.8

40.2

376222389255522359326353115161429260328555593306246302190137

100.0

6524

Sentinel Site First pregnancy

No. % Pos

2-3 pregnancy

No. % Pos

>3 pregnancy

No. % Pos

Total No.

The mean number of pregnancies was 2.5 (range 1 - 13); the median number was 2.

23



Figure 2: Adjusted HIV prevalence by residence and age, pregnant women, 2003 Sentinel Surveillance,Botswana.

The prevalence of HIV infection is essentially the same in urban and rural areas. Women with rural residencehad an overall prevalence of 36.5% compared to 37.9% prevalence for women with urban residence. In thethree youngest age groups, women in rural areas had higher HIV prevalence than those in urban areas. Inboth urban and rural areas, HIV prevalence was highest among women in the 25-29 year age group.

24



Figure 3: Adjusted HIV prevalence in pregnant women by district, 2003 Sentinel Surveillance, Botswana.

Age-adjusted HIV prevalence by district is shown in Figure 3. The prevalence in the 22 districts ranged from25.7% in Southern to 52.2% in Selebi Phikwe. Five districts had prevalence between 25% and 30%, eightdistricts between 30% and 40%, and for eight districts, the prevalence was greater than 40%.

25



Figure 4: HIV prevalence distribution by district, 2003 Sentinel Surveillance, pregnant women, Botswana.

0% to 19.9%

20% to 29.9%

30% to 39.9%

40% to 49.9%

50% and above

The prevalence of HIV was higher in northern and north eastern parts of the country than the southern andwestern districts. Notably, northern border districts were worst affected than all other districts (Figure 4).

26



Table 9 shows the age-specific and age group adjusted prevalence from the 2001, 2002, and 2003 surveysfor women, all ages combined. Although prevalence increased from 35.4% to 37.4% between 2002 and2003, the trend over the three year period is relatively stable and does not show a significant increase(p=0.22).

NgamiNorth EastSerowe/PalapyeBobirwaKweneng EastSouthernGantsiMahalapyeKgatlengChobeKgalagadiTutumeBoteti OkavangoGaboroneFrancistownSouth EastLobatseSelibe PhikweKweneng WestGoodhopeHukuntsiAdjusted Prevalence

137/37230/75

150/33766/148175/537117/34339/147114/32671/22731/8141/118134/261110/26574/206225/573221/49362/19277/230195/34935/12036/9515/59

2155/5554

35.8 (30.0, 41.6)39.7 (26.8, 52.6)40.3 (33.8, 46.8)43.7 (33.3, 54.0)29.5 (25.3, 33.7)30.3 (24.5, 36.2)21.9 (15.0, 28.8)30.6 (25.0, 36.2)24.2 (17.6, 30.8)38.9 (25.6, 52.2)28.3 (18.5, 38.2)50.0 (42.2, 57.8)36.4 (28.2, 44.6)39.2 (30.3, 48.0)39.3 (33.6, 45.1)45.6 (40.1, 51.0)32.3 (23.5, 41.2)30.9 (24.0, 37.8)51.2 (45.0, 57.5)24.3 (15.8, 32.7)30.0 (19.1, 40.9)23.2 (11.6, 34.9)36.2 (34.5, 37.9)

111/25383/196156/425142/286189/567120/36324/112130/303106/31045/10547/172166/37095/250104/284260/666190/45887/28893/241193/37249/15846/14631/82

2467/6407

40.7 (33.6, 47.7)38.6 (30.9, 46.4)35.2 (27.8, 42.6)45.3 (38.3, 52.2)29.2 (25.0, 33.3)30.5 (24.6, 36.5)18.8 (11.2, 26.5)39.8 (33.7, 46.0)30.9 (22.8, 39.1)38.4 (28.0, 48.7)28.3 (17.9, 38.8)40.7 (34.6, 46.9)35.6 (27.0, 44.2)34.2 (28.3, 40.1)38.2 (33.3, 43.0)40.2 (34.9, 45.5)26.5 (20.4, 32.5)34.6 (27.3, 41.9)48.1 (42.1, 54.1)28.7 (21.2, 36.1)26.3 (18.7, 33.9)40.0 (26.7, 53.3)35.4 (33.9, 36.9)

144/37695/222179/389141/255173/52299/359

na130/326116/35356/11551/161171/429100/260115/328253/555278/59384/30683/246163/30251/19053/13731/100

2629/6783

District2001

HIV+/N % (95CI)

All Ages **

2002

HIV+/N % (95CI)

2003

HIV+/N % (95CI)

Table 9: Comparison of 2001, 2002, and 2003 HIV prevalence by district, pregnant women, 2003 SentinelSurveillance, Botswana.

38.4(32.6,44.2)40.4(32.2,48.5)43.3(37.7,49.0)49.3(41.7,57.0)32.1(26.8,37.5)25.7(20.1,31.3)

na37.4(31.2,43.6)30.6(25.0,36.1)47.0(36.2,57.7)28.9(21.4,36.5)37.7(31.6,43.9)31.9(24.5,39.3)32.7(27.4,38.1)44.8(38.9,50.8)45.8(40.7,50.9)27.9(21.8,34.1)32.4(25.2,39.7)52.2(45.0,59.5)27.0(19.8,34.3)40.9(24.4,57.3)28.4(16.8,39.9)

37.4 (35.8, 39.0)**

* All prevalences are adjusted to the district-specific age distribution and overall prevalence is age and district adjusted.

**For calculating overall adjusted prevalence, Gantsi's prevalence for 2003 was estimated by a weighted average of 2001 and 2002 prevalence.

27



Figure 5: Adjusted HIV Prevalence Trends, 2001 – 2003 Sentinel Surveillance, Botswana.

Sentinel surveillance has been conducted in all 22 health districts since 2001. The 2001 census data wereused to adjust prevalence for all three years. Comparisons across the three years indicate no significant dif-ferences (p=0.22). In addition, trend analysis for the three years also indicates that prevalence has remainedfairly stable.

28



Figure 6: Age-specific HIV Prevalence Trends, 2001 – 2003 Sentinel Surveillance, Botswana.*

The highest HIV prevalence is consistently in the 25-29 year age group in which prevalence has been atapproximately 50% for the past three years. The lowest rates are among women aged 15-19 years.

* Prior to 2001 not all 22 health districts were included in the sentinel surveillance survey. Standardization methods varied by year and age group (see

methodology).

29



Figure 7: Trend in HIV prevalence among pregnant women by age group, Sentinel Surveillance 1992-2003,2003 Sentinel Surveillance, Botswana.*

HIV prevalence in the 15 -19 year age group peaked in 1995, decreased over the next four years and hasremained stable since 1999. For the 20-24 year old age group, HIV prevalence peaked in 1998, decreasedthe following year and has remained stable since 1999. There have been steady increases in the 25-49 yearage group since 1992, although prevalence may be stabilizing over the past three years. The prevalence ofHIV in the country had been increasing between 1992 and 1999. Between 2000 and 2003, the prevalencehas remained relatively stable

*Prior to 2001 not all 22 health districts and age groups were included in the sentinel surveillance survey. Standardization methods varied by year and

age group (see methodology).

30



Table 10: Estimated number of HIV infected adult females per health district and age group in Botswana,based on prevalences in pregnant women, 2003 Sentinel Surveillance, Botswana.

1,302897

3,4961,6422,1191,085

2721,968

854220354

2,091549827

2,1451,465

852344

1,32225484665

24,96714.0

109,373

1,6061,0373,1931,8094,1771,742

5781,6931,104

525350

2,0621,3421,0186,5863,231

800672

1,892437630241

36,72420.5

95,046

1,646897

3,1301,8193,9662,061

3602,2011,396

546527

2,1481,3721,0977,5152,9341,017

8152,413

669744321

39,59422.1

79,731

1,046568

2,6481,2002,0311,913

3731,5691,080

621365

1,451910562

5,9832,0051,032

6221,511

274415167

28,34215.8

61,733

931470

2,757704

1,8351,012

871,4581,016

274195

1,273311517

4,4411,433

773450734521726171

22,08812.3

53,258

1,266969

2,1061,0683,5531,742

1251,397

598345227

2,221739466

4,0641,885

917423

1,198483

1,157209

27,15715.2

78,843

7,7964,838

17,3318,242

17,6819,5551,793

10,2866,0472,5312,018

11,2465,2224,486

30,73512,9525,3913,3259,0692,6384,5181,174

178,873100

477,984

Sentinel Site 15-19 yrs 20-24 yrs 25-29 yrs 30-34 yrs 35-39 yrs 40-49 yrs Total

Age and district specific HIV rates were applied to the projected population in each age bracket per district.

2001 population data were provided by Central Statistics Office (CSO).

The estimated number of females 15 to 49 years who are HIV positive in Botswana is 178,873. Although,Selebi Phikwe had the highest HIV prevalence, the actual disease morbidity burden (in terms of number ofinfected women) is highest in Gaborone, Kweneng East, Serowe/Palapye, Francistown, and Tutume. Womenin age group 15 to 24 years represent 34.5% of the total of adult women infected with HIV in Botswana.

NgamiNorth East Serowe/PalapyeBobirwa Kweneng EastSouthernGantsiMahalapyeKgatlengChobeKgalagadiTutumeBotetiOkavangoGaboroneFrancistownSouth EastLobatseSelebi/PhikweKweneng WestGoodhopeHukuntsi

Total of HIV infected women % of N=178,873Total of women in 2003 (denominator)



Table 11: Estimated number of HIV infected adult males (15-49 years) per health district and age group,derived from 2003 prevalence data for pregnant women, combined male to female infection rate ratiosfrom Tebelopele VCT centers and health facilities, and 2001 census population figures, 2003 SentinelSurveillance, Botswana.

9776

2821441588921

164691627

1764362

1389165227723786

1,9231.8%

104,850

448268847472

1,092433176469308194101482367239

1,83482120616844513717980

9,76511.6%84,370

925415

1,573823

2,144979221

1,237718340309967795488

4,2811,550

534431

1,247435386196

20,99327.7%75,663

812373

1,811796

1,5481,369

3531,173

766584317923704338

5,0601,742

781486

1,283244319146

21,92937.9%57,894

894342

2,252531

1,613829102

1,250954297211947320398

4,9741,579

694456781438583169

20,61443.9%47,003

1,456745

1,954878

3,6951,725

1741,364

630494272

1,738992397

5,3442,3701,014

5261,918

5291,188

265

29,66843.5%68,223

4,6322,2198,7193,644

10,2495,4231,0475,6583,4451,9251,2375,2343,2201,922

21,6308,1523,2942,0885,7531,8072,732

862

104,89225.2%

438,003

Sentinel Site 15-19 yrs 20-24 yrs 25-29 yrs 30-34 yrs 35-39 yrs 40-49 yrs Total

The estimated number of males 15 to 49 years who are HIV positive in Botswana is 105,084. Analyses usingdifferent male to female ratios (freestanding Tebelopele centers only and integrated VCT centres in facilitiesonly) yielded estimates ranging from 104,614 to 121,662 infected men. For men, the actual disease mor-bidity burden is highest in Gaborone, Kweneng East, Serowe/Palapye, and Francistown. Men in age group15-24 years represent 11.0% of the total of adult men infected with HIV in Botswana; while those aged 25-34 years represent 41.0%.

NgamiNorth East Serowe/PalapyeBobirwa Kweneng EastSouthernGantsiMahalapyeKgatlengChobeKgalagadiTutumeBotetiOkavangoGaboroneFrancistownSouth EastLobatseSelebi PhikweKweneng WestGoodhopeHukuntsi

Total of HIV infected men% of total N=104892Total men (denominator)

31

32



Table 12: Syphilis test results per district, pregnant women, 2003 Sentinel Surveillance, Botswana.

Sentinel Site

95% Cl

Positive Syphilis Results

% No.

Testedfor Syphilis

No.

Sentinel Surveillance Participants

NgamiNorth EastSerowe/PalapyeBobirwaKweneng EastSouthernGantsiMahalapyeKgatlengChobeKgalagadi Tutume BotetiOkavangoGaboroneFrancistownSouth EastLobatseSelebi/PhikweKweneng WestGoodhopeHukuntsi

Total

376222389255522359168326353115161429260328555593306246302190137100

6692

*153424258510366173306349116166329182335*

628308185**49*

4837

*4

2438

12365

1031183

37*

4272**2*

217

2.6%5.7%1.2%1.6%3.3%1.7%2.0%1.4%8.6%

18.7%5.5%1.6%

11.0%*

6.7%2.3%1.1%

**

4.1%*

4.5%

0.1-5.13.5-7.90.0-2.50.5-2.61.5-5.10.0-3.70.4-3.50.2-2.7

3.5-13.712.7-24.63.0-7.90.0-3.5

7.7-14.4*

4.7-8.60.6-2.60.0-2.6

**

0.0-9.6*

3.9-5.1

Of the 4,837 women who were tested for syphilis during the survey, 217 (4.5%, 95% CI: 3.9 – 5.1%) were pos-itive. Kgalagadi (18.7%), followed by Okavango (11.0%) and Chobe (8.6%) were the three districts with thehighest syphilis rates.

* Data were not available for Ngami, Gaborone, Kweneng West, and Hukuntsi. Valid test results were not avail-able for Selebi Phikwe.

33



Figure 8: Syphilis test results by age group, pregnant women, 2003 Sentinel Surveillance, Botswana.

Syphilis positivity was highest in the 30-34 year age group at 9.9% followed by the 25-29 year age group with 8.6%positive for syphilis. This contrasts with HIV prevalence, which is highest in the 25-29 year age group.

34



4.2.DRUG-RESISTANCE AMONG HIV-1CINFECTED, TREATMENT-NAIVE ADULTSIN BOTSWANA

The population-based genotyping data show that, prior to the initiation of its’ countrywide public HAART pro-gram, HIV-1C infected Botswana did not harbour primary HIV-1B mutations that confer resistance to any of thethree major ARV drug classes. A considerable number of secondary protease inhibitor (PI) mutations and poly-morphic sites in the RT enzyme predicate the need for continuous population monitoring.

Table 13: Prevalence of genotypic resistance to ARV drugs among HIV-1C infected adult Batswana fromthe 2001 Sentinel Surveillance survey (n=71).

Type of Mutation

NNRTI NNRTINRTI

PrimarySecondary

noneG333E/R* (2.8%)

noneA98S* (1.4%)V179T* (1.4%)

noneL10I (1.4%)K20R (5.6%)M36I (80%)L63 P/Q/S/H/T (38%)V77I (11.3%)I93L (97.2%)

Class of ARV Drug

* not known to be associated with drug resistance

25 (35%) samples analysed had 3 or more secondary mutations at PI coding region (pol region codon 1-99)NOTE: Above genotypic resistance data is evaluated in relation to known HIV-1B resistance data(http://hivdb.stanford.edu/hiv/) (Shafer, R. W. (2002). "Genotypic testing for human immunodeficiency virus type1 drug resistance." Clin Microbiol Rev 15(2): 247-77).

35



4.3.CD4 CELL COUNTS AMONG HIV-NEGATIVE BATSWANA

A total of 589 sentinel surveillance samples (from the 2001 survey) were collected, and of these 499 were suit-able for T-lymphocyte subset enumeration of which 251 (50%) were HIV-negative. Of the 2001 sentinel sur-veillance participants, 207 were female (median age 23 years) and 44 were male (median age 26 years). SentinelSurvey samples were representative of both urban (61%) and rural (39%) populations from a large catchmentarea of 11 health districts situated throughout Botswana. Table 14 summarizes the results. The median CD4+LC values were 599 cells/mm3. The median absolute CD8+ LC was 434 cells/mm3 and the CD4+ to CD8+ ratiowas 1.40.

Table 14: CD4+ lymphocyte counts (cells/mm3) of HIV-negative adults in Botswana

20744

251

612591599

152 -1245208 - 1282152 - 1282

626626626

200246208

(599, 653)(551, 701)(600, 652)

Sex N Median Range 2.5th-97.5thpercentile

Mean Standarddeviation

95% CI formean

FemaleMaleBoth

276 - 1062233 - 1276275 - 1114

36



4.4. TEBELOPELE VTC PROGRAMME DATA

The number of centres have increased over the years. Whereas in 2000 only three centers were opened, it hadincreased to 16 in 2003. A total of 35,723 persons made one or more visits to these centers between 1 January,2003 and 30 September, 2003. Of those, 34 439 (96.4%) were tested for HIV. Of those tested 26,741 (77.6%)were first time attendees. The two urban centers Gaborone and Francistown had more than 50% of the clients(Appendix 8.12).

Figure 9: HIV prevalence by age group among men and women aged 15-49. Tebelopele VCT Centres, 2003,Botswana.*

Among the women tested at Tebelopele sites, prevalence was highest in the 30-34 year age group (61.5%),whereas among men the highest prevalence was in the 35-39 year age group (59.6%). Prevalance amongwomen is strikingly higher than among men in the three youngest age groups, with female prevalence rang-ing from 13 times higher in 15-19 year olds to twice as high in 25-29 year olds. However, men have high-er prevalence than women in the two highest age groups.

*2003 data through to 30th September only

37



Overall and consistently during the four years, for both women and men, persons with rural residence had slight-ly higher HIV prevalence than persons with an urban residence. Degree of education is clearly related with theHIV prevalence. Women and men with higher education levels tend to have lower HIV prevalence than personswith lower education. However, HIV prevalence has risen over time within all educational groups for men andwomen (Appendix 8.13).

Figure 10: HIV prevalence by residence, Tebelopele VCT centers, 2000-2003*, Botswana.

Figure 11: HIV prevalence according to reported condom use over the past three months by gender,Tebelopele VCT centers, 2000-2003, Botswana.

*2003 data through 30 September only

HIV prevalence was observed to be lower among persons who reported regular condom use than among thosereporting irregular or no use.

38



Figure 12: Percentage of respondents reporting consistent condom use in the previous 3 months by gender, Tebelopele VCT centers, 2000-2003, Botswana.

The percentage of respondents reporting regular condom use during the past three months has remained rela-tively stable over the past four years for both men and women. Regular condom use did not vary dramaticallyby gender.

39



Table 15: Number of HIV Requests and positivity rates by year, 2000-2003

4.5. HIV/AIDS CASE REPORTING AND MORTALITY

Between 2000 and 2003, a total of 61,350 HIV request forms were sent from the District Health Teams to theMinistry of Health. Of all the records analyzed, 59,127 had results and about half of the subjects (51%) wereHIV-positive.

Positivity rate was highest in the year 2000 but remained relatively stable over the next three years. Amongyoung people (<30 years) positivity rate was consistently higher among women than men while in the older agegroups, a reverse pattern was observed. Among males, the highest prevalence was observed in those 30-39 yearswhereas among females, persons aged 25-34 years had the highest rate.

10998157511893115670

61350

10914155891813914485

59127

6001780390817457

30342

55.050.150.151.5

51.3

Year Number ofrecords

Number withtest results

Numberpositive

PercentPositive

2000200120022003

Total

Figure 13: Age and sex specific prevalence of HIV among those requested to undergo testing, 2000-2003,Botswana

40



Among the 59,127 records with results, 3,239 were classified as AIDS cases. Of the 3,239 cases, gender was indi-cated for 3,197 of which 1644 (51.4%) were females and 1,553 (48.6%) were males. The number of cases washighest in 2000 and declined over the next three years. It should be noted that the data for 2003 was not com-plete at the time of this analysis thus the actual number cases for the year will be higher than what is reportedhere. The cumulative number of cases is shown in Figure 15.

Figure 15: Cumulative AIDS cases in Botswana, 2000-2003.

AIDS CASES

Figure 14: HIV positivity rates by residence, AIDS case reporting 2000-2003, Botswana.

The proportion of patients who were positive was consistently higher in rural than urban areas. The differencewas more pronounced in 2000 and 2003.

41



Table 16: AIDS cases by age group and year, 2000-2003

12326

104196217158198119

1141

1262263

17217713816890

956

846

4513614310513265

717

519

227376658346

425

38463

234577613466582320

3239

Age group2000 2001 2002 2003 Total

<1515-1920-2425-2930-3435-3940-4950+

Total

In each of the years, the highest number of cases was observed among those aged 30-34 years. In the youngerage groups (<35 years) there were more female cases than males whereas in the older, the opposite was thecase.

Figure 16: Distribution of reported AIDS cases by age, 2000-2003.

42



The districts with highest caseloads were Gaborone, Mahalapye, Palapye and Francistown. Those with the low-est were Hukuntsi, Kweneng East, Okavango and Kgatleng.

Figure 17: Number of reported AIDS cases in Botswana by district, 2000-2003.

43



Figure 18: Crude mortality rate, Botswana, 1995-2000.

Figure 19: AIDS proportional mortality ratio, Botswana, 1995-2000.

Since 1995 the crude mortality continues to increase. Between 1995 and 1999, the crude mortality rate hasincreased by 73.2%, an annual increase of about 15%. In the early stages of the epidemic, the proportional mor-tality ratio of AIDS was about 10%. Between 1998 and 1999 nearly one in every five deaths in Botswana can beattributed to AIDS. In 2000, the percentage of deaths attributable to AIDS among men declined to 14.5%.

Sources:

1) CSO population projections, 1991-2001

2) CSO Health Statistics Report, 1995-2000

44



Table 17: 2002 PMTCT participation, HIV testing, and AZT therapy.

In 2002, the first year of the Prevention of Mother to Child Transmission (PMTCT) program, 80% of new ANCattendees were offered pre-test counseling. Of those counseled, 47% went on to be tested, and of those 40%were positive. Sixty-four percent of the mothers testing positive went on to receive AZT. Across the 22 healthdistricts, this number ranged from a high of 84% in Gaborone to a low of 31% in Gantsi.

As of November 2003, MASA reported that as part of the ARV eligibility 16,400 persons had been tested forCD4 and viral load. Of those, 10,264 patients have started ARVs.

4.6. PMTCT

NgamiNorth EastSerowe/PalapyeBobirwaKweneng EastSouthernGantsiMahalapyeKgatlengChobeKgalagadi Tutume BotetiOkavangoGaboroneFrancistownSouth EastLobatseSelebi PhikweKweneng WestGoodhopeHukuntsi

Total

1,3561,1272,3561,4811,7632,713808

1,9661,472389628836

1,141660

4,9023,2121,2841,2501,567389740333

32,373

6898607882919683856887437560839993918968

10078

80

558625

1,372484

1,1831,386557963

1,054259341393329143

2,1231,034582811473259266181

15,376

41555833675169497267544729224332456530673654

47

1772425032985663591434373151597812113851

1,0685661332462281599483

6,164

32393762482626453061233142365055233048613546

40

10413237618037523030237142893977654089238981161127893937

3,931

59557560666421544556506447788469616556564145

64

1,9891,1523,9251,8942,1472,990846

2,3641,724572719

1,9401,5311,1005,8733,2321,3871,3701,753572740428

40,248

Sentinel Site Pre-testNo. % Pos

TestedNo. % Pos

PositiveNo. % Pos

Started AZTNo. % Pos

New ANCNo.

45



The demographic characteristics of the respondents to the Makgabaneng Radio Listenership survey are shown inAppendix 8.14. Among 15-24 year olds, women (28.1%) were more likely than men (18.1%) to have correctresponses on all five AIDS knowledge questions. Substantive knowledge was low for both genders in the 25-49year old age group. The five HIV knowledge questions included knowing that condom use and having one faith-ful partner can prevent HIV, that a healthy looking person can transmit HIV, that mosquitoes do not transmit HIV,and that AIDS cannot be cured by sex with virgin.

4.7. BEHAVIOURAL SURVEYS

Figure 20: Knowledge of HIV/AIDS among men and women: percent with correct responses to five AIDSknowledge questions, Makgabaneng Radio Listenership Survey, 2003.

46



Women in both age groups were more likely to have ever having had an HIV test than men. Among 15-24 yearolds, the percentage of women reporting ever having had an HIV test was over twice as great as that of men.Among those ever tested for HIV, men were more likely than women to report having been tested in the past yearacross both age groups.

Figure 21: Percentage who ever had an HIV test by age group and gender, Makgabaneng Radio ListenershipSurvey, 2003.

Among respondents who were sexually active in the last year, 68.3% of men and 83.1% of females reportedhaving one sexual partner in the past year while 32% of men and 17% of women reported having more thanone sexual partner in the last year.

Figure 22: Number of sexual partners in the last year among those who had sex (percent distribution),Makgabaneng Radio Listenership Survey, 2003.

47



Condom use at the last sex act with a non-marital or non-cohabiting partner was higher among men (84.4%)than women (77.2%) among persons 15-24 but the reverse was true in the older age group. Overall condomuse was somewhat higher among young people than among persons aged 25-49.

Figure 23: Condom use by gender at last act with a non-marital or non-cohabitating partner by age,Makgabaneng Radio Listenership Survey, 2003

48



Source: CSO Health Statistics Report, 1995-2001

Data on sexually transmitted infections are also routinely collected through the epidemiological reporting systemin the country. Reporting covers aetiological and syndromic information on STIs as a determinant of the epidemic.Over the period 1995 to 2001 STIs have declined.

Figure 24: Annual number of STI cases, Botswana, 1995-2001.

4.8.SEXUALLY TRANSMITTED INFECTION PROGRAMME DATA

49



4.9. TUBERCULOSIS PROGRAMME DATA

58249251585848833418297278444386441732322330

1,054545509

59378048

140918085501446646741

21375664269413547

1,490551939

13462

25114032223299

2431064585

16112170

556292116111164507961

3,5001,7791,721

10452

15595

218152120177862460

13411551

34821611697

119374137

2,5541,612

942

30198048

122995286541325515620

13571664354243517

1,200812388

37376832

112915384569

295055316956411815273619

1,025708317

422231726414972723452758386123274532492257

1364796449328453211249211

10,8236,0074,816

Sentinel Site 0-14No.

15-24 No.

25-34No.

35-44 No.

45-54No.

>54No.

TotalNo.

NgamiNorth EastSerowe/PalapyeBobirwaKweneng EastSouthernGantsiMahalapyeKgatlengChobeKgalagadiTutumeBotetiOkavangoGaboroneFrancistownSouth EastLobatseSelebi PhikweKweneng WestGoodhopeHukuntsi

Botswanatotal malestotal females

Table 18: 2002 TB Case notification by district, by age group, National TB Programme, Epidemiology andDisease control unit, MoH, Botswana.

The total number of TB cases registered during 2002 was 10,823 resulting in a TB notification rate of 623 per100,000 of population. Of the 10,823 cases,1,054 were among children aged 0-14.

The two districts with the highest reported TB case load were Gaborone and Kweneng East. Persons aged 25 to34 years had the greatest number of TB cases reported in 2002 (32% of all cases).

The male/female TB case ratio for 2002 was 1.25. The male to female case ratio varied considerably among thedifferent age groups, ranging from 0.6 for 15-24 year olds to 2.2 for persons greater than 54.

50



Figure 25: Annual trend of new cases of TB per 100,000, 1991-2002

The rate of reported TB has increased steadily between 1991 and 2002, with an increase of 100% over that time.This corresponds with an annual increase of approximately 10%. In 2002, the BOTUSA project in conjunctionwith the Ministry of Health conducted a nation-wide multi-drug resistance evaluation. Among the 2425 TBpatients, HIV co-infection rate was found to be 60%.

51



5. DISCUSSION

The World Health Organization and the Joint UnitedNations Programme on AIDS have advocated formany years, the adoption of second generation HIVsurveillance as a strategy for addressing the limita-tions of the first generation. Second generationHIV/AIDS surveillance is designed to track behaviour,link behaviour to biological surveillance data, and,pool data from various sources together in order toincrease the explanatory power of sentinel surveydata. In Botswana this is the second time that behav-ioural data, VCT, TB, STI and AIDS case reporting havebeen linked with HIV sentinel survey data. In addition,we have examined ARV resistance and documentednormal CD4 levels among HIV-negative Batswana.

From the available data, it can be observed thatHIV/AIDS in Botswana remains a great challenge witha prevalence of 37.4%. The epidemic has affected alldistricts and localities. Rural areas are affected withequal (and in some cases, greater) intensity as theurban areas. It would be misleading to assume thatthe epidemic is over. Currently the epidemic affectsmore than one in every three persons aged 15-49years. This is a threat to developmental process and tothe very existence of the nation of Botswana. Even indistricts with lower prevalence, almost one in everyfour persons aged 15-49 years is affected. Personsaged 25-34 years are those that constitute the mostproductive age of a nation, but they are now over-burdened with HIV/AIDS and are the worst affected.This will likely lead to a depletion of the work force.Indeed, this has already occurred in some sectors suchas mining and agriculture and education.

Many factors continue to exacerbate the epidemic inthe country. Developmental projects such as miningand road construction has attracted a large number ofeconomically buoyant young men of different nation-

alities to various parts of the country thus bringingthem in contact with susceptible and vulnerableyoung women who are less economically empow-ered. In major mining districts like Selebi Phikwe theprevalence of HIV is over 50% among young adultsaged 15-49 years. Mining towns are endemic foci forthe spread of HIV as majority of the miners are usual-ly away from homes for extended period of time andare known to have multiple sex partners. Many citiesand towns in Botswana serve as transit and restingpoints for long distance truckers en-route to neigh-bouring countries. Francistown in particular, wherethe prevalence is now 46% is the hub of these majorroads.

The increasing trend in prevalence among those over35 years of age may be a reflection that AIDS-relatedmortality is slowing down while infected cohorts fromyounger age groups survive to graduate in to olderages. With the introduction of the ARV programme,there is bound to be a lower AIDS proportionate mor-tality ratio and the number of people living withHIV/AIDS will increase even if there is a reduction inincidence. This scenario in itself is a challenge becausethere will to be a large demand for counseling, as wellas for therapy.

The significantly higher HIV prevalence amongwomen (than men) in the young age groups supportsobservation made in many countries that older menprefer and engage in sex with younger women. Fromthe behavioural survey, it was observed that sex withmultiple partners was a common practice amongyoung persons (15-24 years). There is need for intensesexuality education and programmes promoting absti-nence and safer sex to be designed for young peoplegenerally and for young women in particular.

52



It has been shown that decreasing HIV prevalencereported in some parts of the world are due in part toa decrease in the prevalence of risky sexual behaviour.The behavioural data used in this report were notbased on a national sample as only seven districtswere purposively selected hence representativeness ofthe findings is not assured. Moreover, it needs to bepointed out that behavioural information collectedfrom a cross-sectional survey may not be a goodmeasure of the risk of current HIV infection. For exam-ple, individuals may use a condom because they arealready HIV-positive and therefore relating condomuse to HIV prevalence in cross-sectional surveybecomes difficult.

Available data indicate a high level of sexual activityamong unmarried Batswana. In fact over 80% of theantenatal attendees in the sentinel survey were singlemothers. From the behavioural survey, about twothirds of young persons are sexually active. This mayexplain in part the persistent high prevalence of HIV inthe country. The high prevalence among single par-ents may likely facilitate an epidemic of orphans in thecountry.

The increasing number of TB cases has been observedin many countries in sub-Saharan Africa. HIV pan-demic has worsened the problem of TB during thepast two decades. HIV infection renders a personinfected with Mycobacterium tuberculosis much morelikely to develop overt TB and the evolution of the dis-ease is much more accelerated. It has been observedthat about 8 – 10% of all TB cases are related to HIVinfection and the association is stronger in Africancountries. There is an urgent need for the provision ofnot only of anti-retroviral drugs, but also drugs forother opportunistic infections, which will reduce thepublic health complications of the HIV epidemic and

also reduce the incidence of tuberculosis.

CD4 levels among Batswana were found to be lowerthan those reported from other countries in the sub-region. It will be important to validate the low CD4+LC level in Botswana especially as predictors of theextent and rate of HIV disease progression.Furthermore, the increasing reliance on CD4+ LC val-ues for the initiation and monitoring of HAARTamong HIV-infected individuals in resource-limitedsettings makes it imperative to adopt and utilize stan-dard methodologies for CD4+ LC counting. The lowCD4 levels among Batswana may mean that corre-spondingly, lower values (than the conventional200/mm3 used in many countries) may be indicativeof the need for therapy. In some countries, decidingon a CD4 cut-off point in determining eligibility forART has been problematic. While this report has pre-sented normal values for HIV-negative individuals, it isalso desirable to compare such values with those ofHIV-positive individuals followed over time. Suchinformation would likely form a stronger scientificbasis for determining HAART eligibility in Botswana.For many years many have questioned the validity ofsentinel survey results. Data from several sources, sen-tinel survey, VCT, PMTCT, HIV Request from Healthfacilities, presented in this report, as well as last yearsreport have shown very high degree of agreement interms of the epidemiological features of HIV infectionin the country. In particular prevalence data fromPMTCT was quite comparable with the results fromsentinel survey data. For this year, from the PMTCTservice data, the prevalence was found to be 40%while it was 37.4% from sentinel survey data. Indeedsentinel surveys need not be undertaken as an annu-al event. Service data from PMTCT could be used tocompliment sentinel data.



HIV/AIDS marks a severe development crisis in sub-Saharan Africa, which remains by far the worst affect-ed region in the world. Botswana currently has thehighest prevalence of HIV in the sub region. A largeproportion of the work force in all sectors of the econ-omy is affected. Children are orphaned and familiesare affected and many are disillusioned.

Fortunately, as the impact of AIDS continues to threat-en the African society, many African leaders aremounting a full-scale response to fight HIV/AIDS, tar-geting all sectors. There is a high level of political andeconomic commitment of the part of the governmentof Botswana. Botswana is among the 19 Africannations that have established National AIDS councilsor commissions personally chaired by the Head ofState to take charge of a multisectoral response toAIDS. The private sector, civil societies including PLWAorganizations have risen to the occasion to form apartnership with government in fighting the epidem-ic. The national response has resulted in setting upprevention programs such as behavior change andcommunication, Voluntary Counseling and Testing,STI Control and Prevention of mother to child trans-mission (PMTCT). Care and support programs havebeen scaled up to include public provision of HighlyActive Antiretroviral therapy and Community HomeBased Care Programs. Impact mitigation and reduc-tion in stigma have been addressed at all levels by pro-viding funding for income generating activities, sup-port for orphans and vulnerable children, and greaterinvolvement of PLWA. The government of Botswanamust stoop to conquer this scourge. It must continueto sustain this momentum so as to bring the epidem-ic under control.

53

54



6. CONCLUSION

HIV/AIDS remains a major public health problem inBotswana affecting all districts and localities.

HIV prevalence in the country ranges from 25% to52% with a national prevalence of 37.4%. The dis-tricts worst affected are Selebi Phikwe, Bobirwa,Chobe and Francistown with prevalence over 45%.Even in districts least affected, the prevalence is over25%.

The highest age-specific prevalence was observedamong those aged 25-29 years. VCT data show sig-nificantly higher HIV prevalence among youngwomen than in men of similar ages.

The epidemiological features of HIV infection asobserved from various data sources (VCT, PMTCT, HIVTest Requests) in the country are essential the same.

Mean CD4+ counts among Batswana was lower thanvalues reported in other African countries.

Condom use in the last sex with a non-marital, non-cohabitating risk partner was encouraging as morethan two-thirds of sexually active young persons inthe behavioural survey responded in the affirmative.There appeared to be no significant behaviour changehowever (using condom use as an indicator) betweenthe 2001 BAIS survey and the Makgabaneng survey of2003. Specifically, from the BAIS survey, condom usewith a non-marital, non-cohabiting partner was 88%among young men 15-24 years compared to 84% inthe Makgabaneng survey. Only about one in fiveyoung persons had all correct answers to knowledgequestions on HIV/AIDS.

The percentage of sexually young persons who hadmultiple partners was significantly higher in the latest

survey than in the BAIS of 2001.

There is a growing number of AIDS as well as TB caseswhile STI cases are decreasing.

A large proportion of mothers attending ANCs weresingle mothers and the prevalence among this groupwas higher than those who were married. This is apotential pool for a large number of orphans.

55


1. There is a need to scale up HIV/AIDS interven-tion programmes especially among the youngpersons so as to reduce the rate of new infec-tions. Such programmes should include inschool as well as out of school youths.

2. In addition to sentinel surveillance, there is aneed to closely evaluate the extent of thescourge and the impact of the nationalresponse through special population-based sur-veys.

3. There is a need for extensive community mobi-lization for increased patronage of voluntarycounseling and testing services.

4. Tuberculosis control programme efforts need tobe intensified and national treatment algo-rithms for Tuberculosis as well as for STIs needto be reviewed.

5. There should be a scaling up of anti-retroviralprogramme to meet the needs of the increasingnumber of infected persons.

6. In subsequent sentinel surveys, the minimumnumber of specimens tested during qualityassurance per laboratory should be increased.Criteria for acceptance of results and usage inthe report should be specified in the survey pro-tocol.

7. The Ministry of Health needs to implementmeasures that would improve the performanceof the laboratories so as to minimize discordantrates in future surveys

7. RECOMMENDATIONS


56



57



8.1. CALCULATED SAMPLE SIZES PER DISTRICT

The targeted sample sizes calculated for the 22 health districts are shown in the Table below. The calculated sample sizeranged from 116 to 400. The targeted sample size was achieved in six districts

Ngami

North East

Serowe/Palapye

Bobirwa

Kweneng East

Southern

Gantsi

Mahalapye

Kgatleng

Chobe

Kgalagadi

Tutume

Boteti

Okavango

Gaborone

Francistown

South East

Lobatse

Selebi/Phikwe

Kweneng West

Goodhope

Hukuntsi

393

391

372

400

355

354

187

392

360

139

190

396

377

371

381

388

337

379

399

238

176

116

376

222

389

255

522

359

168

326

353

115

161

429

260

328

555

593

306

246

302

190

137

100

District Target Sample Size Actual Sample Size

8.APPENDICES

58



8.2. SENTINEL SURVEY DATACOLLECTION FORM

59



8.3. AGGREGATE SYPHILIS TEST RESULTREPORTING FORM, 2003 HIV SENTINEL SURVEY

Health facility’s listing of syphilis test results of pregnant women participating in the sentinel surveillance 2002,to be completed by staff of participating health facilities. This form should be completed at the end of the sur-vey when the exact dates of the surveillance are known and be brought to the consensus meetings in October2002.

The Record Book of the facility should be consulted retrospectively and the syphilis test results of all pregnantwomen who came to a specific clinic and who participated in the surveillance should be noted on this form.

Facility’s identification number:........................................................................................................................See Botswana Health Facility Master List

Surname of staff person completing this form: ____________________________________

Given Name of staff person completing this form: _________________________________

ANC sentinel surveillance

Date sentinel survey began at this facility:

Date sentinel survey ended at this facility:

During this exact, same period (consult and tally from facility logbooks):

Number of first time ANC attendees during this period visit seen at this facility:

Number of first time ANC attendees during this period that have a syphilis test result:

Number of women in 2 above that had a syphilis test result:

Please complete table on next page for all women in 3 above

North West North EastSerowe/PalapyeBobirwaKweneng East

SouthernGantsiMahalapyeKgatlengChobe

KgalagadiTutmeBobetiOkavangoGaborone

FrancistownSouth EastLobatseSelibe PhikweKweneng West

GoodhopeHukuntsi

Health District number: (Tick correct box:)

60



No. Age Syphilis test Results (Pos or Neg)

8.4. List of individual first time ANC attendees during this period and their syphilis testresults (either RPR or TPHA)

61



8.5. LABORATORY RESULTS FORM

62



Total

2001 FEMA

LE POPU

LATIO

N PER

DISTR

ICT A

ND

AG

E

GR

OU

P BA

SED O

N 2001 N

ATIO

NA

L CEN

SUS D

ATA

AG

E GR

OU

P (YR

S)

Total

infected

wo

men

Ag

e adju

sted D

istrict

HIV

prevalen

ce, 2003

2003 DISTR

ICT A

GE SPEC

IFIC H

IV PR

EVA

LENC

E

AG

E GR

OU

P (YR

S)

NU

MB

ER O

F INFEC

TED W

OM

EN PER

DISTR

ICT, 2003

AG

E GR

OU

P (YR

S)

15-19

4770

3075

9451

4080

12354

8649

1809

6556

4334

1046

1494

7614

3656

3323

11322

5579

3706

1910

3414

2316

2718

927

104103

District

North W

est (1)

North East (2)

Serowe/Palapye (3)

Bobirwa (4)

Kw

eneng East (5)

Southern (6)

Gantsi (7)

Mahalapye (8)

Kgatleng (9)

Chobe (10)

Kgalagadi (11)

Tutume (12)

Boteti (13)

Okavango (14)

Gaborone (15)

Francistown (16)

South East (17)

Lobatse (18)

Selebi/Phikwe (19)

Kw

eneng West (20)

Goodhope (23)

Hukuntsi (24)

Total

20-24

4109

1943

6947

2815

10718

6575

1539

4632

3590

1070

1300

4891

3126

2546

14944

5947

3919

2131

3658

1576

1733

757

90466

25-29

3217

1565

5682

2413

8572

5210

1491

3653

3076

1040

1218

3903

2506

2118

13206

5174

3308

1809

3243

1401

1417

667

75889

30-34

2464

1277

4653

1838

6590

4350

1115

3216

2398

728

810

3204

2078

1606

9814

3707

2478

1396

2222

1128

1184

502

58758

35-39

2142

1243

4174

1705

5675

3974

1035

3053

2014

587

744

3115

1773

1422

7246

2932

2116

1102

1708

1178

1266

488

50692

40-49

2611

2306

7160

3049

8454

6632

1187

5054

3412

656

1079

5637

2462

2040

8704

3588

2838

1408

2280

1687

2203

597

75044

19313

11409

38067

15900

52363

35390

8176

26164

18824

5127

6645

28364

15601

13055

65236

26927

18365

9756

16525

9286

10521

3938

454952

15-19

26.0

27.8

35.2

38.3

16.3

11.9

14.3

28.6

18.8

20.0

22.6

26.1

14.3

23.7

18.0

25.0

21.9

17.1

36.8

10.4

29.6

6.7

20-24

37.2

50.8

43.8

61.2

37.1

25.2

35.7

34.8

29.3

46.7

25.6

40.1

40.9

38.0

41.9

51.7

19.4

30.0

49.2

26.4

34.6

30.3

25-29

48.7

54.5

52.4

71.7

44.0

37.6

23.0

57.4

43.2

50.0

41.2

52.4

52.1

49.3

54.2

54.0

29.3

42.9

70.8

45.5

50.0

45.8

30-34

40.4

42.3

54.2

62.2

29.3

41.9

31.8

46.4

42.9

81.3

42.9

43.1

41.7

33.3

58.0

51.5

39.6

42.4

64.7

23.1

33.3

31.6

35-39

41.4

36.0

62.9

39.3

30.8

24.2

8.0

45.5

48.0

44.4

25.0

38.9

16.7

34.6

58.3

46.5

34.8

38.9

40.9

42.1

54.5

33.3

40-49

46.2

40.0

28.0

33.3

40.0

25.0

10.0

26.3

16.7

50.0

20.0

37.5

28.6

21.7

44.4

50.0

30.8

28.6

50.0

27.3

50.0

33.3

15-19

1,239

854

3,328

1,563

2,017

1,033

258

1,873

813

209

337

1,990

522

787

2,042

1,395

811

327

1,258

241

80562

23,764

104,103

22.8

20-24

1,529

987

3,039

1,722

3,976

1,658

550

1,611

1,051

499

333

1,963

1,277

969

6,269

3,075

761

639

1,800

416

600

229

34,955

90,466

38.6

25-29

1,566

854

2,980

1,731

3,775

1,961

342

2,095

1,329

520

502

2,044

1,306

1,044

7,153

2,792

968

775

2,297

637

709

306

37,686

75,889

49.7

30-34

995

540

2,520

1,143

1,933

1,821

355

1,493

1,028

592

347

1,381

866

535

5,695

1,908

982

592

1,438

260

395

159

26,977

58,758

45.9

35-39

886

447

2,624

670

1,746

96383

1,388

967

261

186

1,211

296

492

4,227

1,364

736

429

699

496

691

163

21,023

50,692

41.5

40-49

1,205

922

2,005

1,016

3,382

1,658

119

1,330

569

328

216

2,114

703

443

3,868

1,794

873

402

1,140

460

1,102

199

25,849

75,044

34.4

7,421

4,605

16,496

7,844

16,829

9,094

1,707

9,790

5,756

2,409

1,921

10,704

4,970

4,270

29,254

12,328

5,131

3,165

8,632

2,511

4,300

1,117

170,253

454,952

37.4

38.4

40.4

43.3

49.3

32.1

25.7

20.9

37.4

30.6

47.0

28.9

37.7

31.9

32.7

44.8

45.8

27.9

32.4

52.2

27.0

40.9

28.4

37.4

Total p

op

in ag

e gro

up

Overall ad

justed

age-sp

eific prev (%

)

8.6.A WORKSHEET FOR CALCULATING DISTRICT AND NATIONAL ADJUSTED PREVALENCE (FEMALES)

Growth adjustment factor

of 1.05 not applied to the

number infected per site

63



8.6.B WORKSHEET FOR ADJUSTED HIV PREVALENCE BY DISTRICT (MALES)

Total

2001 MA

LE POPU

LATIO

N PER

DISTR

ICT A

ND

AG

E

GR

OU

P BA

SED O

N 2001 N

ATIO

NA

L CEN

SUS D

ATA

AG

E GR

OU

P (YR

S)

Total

infected

men

2003 Ag

e adju

sted

District H

IV

prevalen

ce

2003 DISTR

ICT A

GE-SPEC

IFIC H

IV PR

EVA

LENC

E RA

TES

AM

ON

G PR

EGN

AN

T WO

MEN

AG

E GR

OU

P (YR

S)

NU

MB

ER O

F INFEC

TED M

ALES PER

DISTR

ICT, U

SING

MA

LE:FEMA

LE HIV

INFEC

TION

RA

TIO

AG

E GR

OU

P (YR

S)

15-19

4,446

3,266

9,526

4,451

11,518

8,827

1,737

6,822

4,369

942

1,404

8,010

3,551

3,120

9,055

4,300

3,507

1,506

2,493

2,642

3,129

982

99603

District

North W

est (1)

North East (2)

Serowe/Palapye (3)

Bobirwa (4)

Kw

eneng East (5)

Southern (6)

Gantsi (7)

Mahalapye (8)

Kgatleng (9)

Chobe (10)

Kgalagadi (11)

Tutume (12)

Boteti (13)

Okavango (14)

Gaborone (15)

Francistown (16)

South East (17)

Lobatse (18)

Selebi/Phikwe (19)

Kw

eneng West (20)

Goodhope (23)

Hukuntsi (24)

Total

20-24

3,816

1,670

6,129

2,445

9,320

5,431

1,559

4,266

3,328

1,318

1,252

3,804

2,848

1,987

13,843

5,026

3,358

1,776

2,866

1,637

1,633

836

80148

25-29

3,222

1,291

5,089

1,945

8,258

4,412

1,634

3,660

2,818

1,153

1,273

3,133

2,587

1,680

13,407

4,872

3,095

1,706

2,987

1,623

1,308

724

71877

30-34

2,330

1,020

3,874

1,483

6,113

3,790

1,284

2,928

2,071

833

856

2,481

1,956

1,174

10,102

3,921

2,284

1,327

2,297

1,226

1,110

537

54997

35-39

1,955

860

3,241

1,224

4,742

3,093

1,157

2,488

1,799

605

763

2,202

1,736

1,040

7,714

3,071

1,806

1,060

1,728

942

967

458

44651

40-49

2,416

1,426

5,346

2,019

7,076

5,285

1,331

3,972

2,895

757

1,042

3,551

2,660

1,400

9,211

3,631

2,525

1,410

2,939

1,487

1,820

610

64809

18,185

9,533

33,205

13,567

47,027

30,838

8,702

24,136

17,280

5,608

6,590

23,181

15,338

10,401

63,332

24,821

16,575

8,785

15,310

9,557

9,967

4,147

416085

15-19

26.0

27.8

35.2

38.3

16.3

11.9

14.3

28.6

18.8

20.0

22.6

26.1

14.3

23.7

18.0

25.0

21.9

17.1

36.8

10.4

29.6

6.7

20-24

37.2

50.8

43.8

61.2

37.1

25.2

35.7

34.8

29.3

46.7

25.6

40.1

40.9

38.0

41.9

51.7

19.4

30.0

49.2

26.4

34.6

30.3

25-29

48.7

54.5

52.4

71.7

44.0

37.6

23.0

57.4

43.2

50.0

41.2

52.4

52.1

49.3

54.2

54.0

29.3

42.9

70.8

45.5

50.0

45.8

30-34

40.4

42.3

54.2

62.2

29.3

41.9

31.8

46.4

42.9

81.3

42.9

43.1

41.7

33.3

58.0

51.5

39.6

42.4

64.7

23.1

33.3

31.6

35-39

41.4

36.0

62.9

39.3

30.8

24.2

8.0

45.5

48.0

44.4

25.0

38.9

16.7

34.6

58.3

46.5

34.8

38.9

40.9

42.1

54.5

33.3

40-49

46.2

40.0

28.0

33.3

40.0

25.0

10.0

26.3

16.7

50.0

20.0

37.5

28.6

21.7

44.4

50.0

30.8

28.6

50.0

27.3

50.0

33.3

15-199776

282

144

1588921

164691627

1764362

1389165227723786

1,923

104850

1.8%

20-24

448

268

847

472

1,092

433

176

469

308

194

101

482

367

239

1,834

821

206

168

445

137

17980

9,765

84370

11.6%

25-29

925

415

1,573

823

2,144

979

221

1,237

718

340

309

967

795

488

4,281

1,550

534

431

1,247

435

386

196

20,993

75663

27.7%

30-34

812

373

1,811

796

1,548

1,369

353

1,173

766

584

317

923

704

338

5,060

1,742

781

486

1,283

244

319

146

21,929

57894

37.9%

35-39

894

342

2,252

531

1,613

829

102

1,250

954

297

211

947

320

398

4,974

1,579

694

456

781

438

583

169

20,614

47003

43.9%

40-49

1,456

745

1,954

878

3,695

1,725

174

1,364

630

494

272

1,738

992

397

5,344

2,370

1,014

526

1,918

529

1,188

265

29,668

68223

43.5%

4,632

2,219

8,719

3,644

10,249

5,423

1,047

5,658

3,445

1,925

1,237

5,234

3,220

1,922

21,630

8,152

3,294

2,088

5,753

1,807

2,732

862

104,892

438003

25.2%

25.5%

23.3%

26.3%

26.9%

21.8%

17.6%

12.0%

23.4%

19.9%

34.3%

18.8%

22.6%

21.0%

18.5%

34.2%

32.8%

19.9%

23.8%

37.6%

18.9%

27.4%

20.8%

23.9%

Total p

op

in ag

e gro

up

Overall ad

justed

age-sp

eific prev (%

)

64



8.7. TEBELOPELE VCT FORM (PAGE 1)

65



8.7. TEBELOPELE VCT FORM (PAGE 2)

66



8.8. HIV REQUEST FORM

67



8.9. BANGUI & ABIDJAN DEFINITIONSOF CLINICAL AIDS (IN ADULTS)

Bangui Definition

In adults, AIDS is defined as the co-existence of at least two major symptoms and at least one minor one, in theabsence of any known cause of immunodepresssion such as malignancy, sever malnutrition or of any otherknown etiology.

- Major symptoms: A - Loss of weight > 10%B - Chronic diarrhea persisting > 1 monthC - Fever of over 1 month’s duration (intermittent or continuous

- Minor symptoms: A - Cough persisting > 1 monthB - Generalized pruritic dermatitisC - Recurrent Herpes ZosterD - Oropharyngeal CandidiasisE - Generalized progressive Herpes InfectionF - Generalized lymphadenopathy

The presence of generalized Kaposi’s sarcoma or cryptococcal meningititis is sufficient to diagnose AIDS

ABIDJAN DEFINITION = BANGUI definition + HIV positive serology

Revised WHO case definition for AIDS in Africa (Abidjan Conference)

68



8.10. TB REGISTER FORM

69



Ngami (1)North East (2)Serowe/Palapye (3)Bobirwa (4)Kweneng East (5)Southern (6)Gantsi (7)Mahalapye (8)Kgatleng (9)Chobe (10)Kgalagadi (11)Tutume (12)Boteti (13)Okavango (14)Gaborone (15)Francistown (16)South East (17)Lobatse (18)Selebi Phikwe (19)Kweneng West (20)Goodhope (23)Hukuntsi (24)Adjusted Prevalence

16/6114/4314/7913/4014/1049/451/1818/584/463/167/4422/7610/4817/6515/7211/714/329/3422/606/293/275/18

237/1086

20/7715/5425/7118/4716/988/67na

18/6312/643/157/3123/885/3518/7611/6127/1087/326/3514/385/488/271/15

274/1199

26.027.835.238.316.311.9na

28.618.820.022.626.114.323.718.025.021.917.136.810.429.66.722.8

-0.3-4.817.55.82.9-8.1na

-2.510.11.36.7-2.8-6.5-2.5-2.89.59.4-9.30.2

-10.318.5-21.11.8

District2002

HIV+/N %

Age 15 to 19 Years

2003

HIV+/N % Difference %

26.232.617.732.513.520.05.631.08.718.815.928.920.826.120.815.512.526.536.720.711.127.821.0


40/8428/6261/16840/10171/20334/12010/3543/10844/11611/3313/4355/11736/8133/7392/27266/17627/9533/8160/12418/5217/4510/28

842/2217

48/12932/6356/12852/8569/18629/115

na40/11536/12321/4510/3959/14738/9335/9299/236121/23420/10327/9063/12814/5318/5210/33

922/2359

37.2 50.8 43.8 61.2 37.1 25.2 na

34.829.3 46.725.6 40.1 40.9 38.0 41.9 51.7 19.430.049.2 26.4 34.630.3 38.6

-10.45.67.421.62.1-3.1na

-5.0-8.713.3-4.6-6.9-3.6-7.28.1 14.2 -9.0-10.70.8 -8.2-3.2-5.41.2

District2002

HIV+/N %

Age 20 to 24 Years

2003


47.6 45.2 36.3 39.6 35.0 28.3 28.6 39.8 37.9 33.3 30.2 47.0 44.445.2 33.8 37.5 28.4 40.7 48.4 34.6 37.8 35.7 37.4

8.11. A/B COMPARISON OF 2002 AND 2003HIV RESULTS BY INDIVIDUAL AGE GROUPS


32/5714/3242/8454/7257/12339/877/2230/5221/6214/2513/4350/8024/4529/6483/17358/10032/7929/6768/10011/2512/287/16

726/1436

37/7624/4443/8233/4648/10932/85

na39/6835/8113/2614/3444/8437/7134/6978/14468/12624/8227/6351/7215/3315/3011/24

736/1510

48.754.5 52.4 71.7 44.037.6na

57.4 43.2 50.041.252.4 52.149.354.2 54.0 29.342.970.8 45.5 50.045.8

49.7

-7.510.8 2.4-3.3-2.3-7.2na

-0.39.3-6.010.9 -10.1-1.24.0 6.2 -4.0-11.2-0.42.8 1.57.1 2.1

-0.3

District2002

HIV+/N %

Age 25 to 29 Years

2003


56.1 43.8 50.075.0 46.344.831.8 57.7 33.956.0 30.262.5 53.345.3 48.0 58.0 40.5 43.2 68.0 44.042.9 43.8

50.0


15/2518/3122/4518/3433/7326/564/1821/3824/539/188/2518/4920/4813/4347/9236/6315/4616/4029/556/199/215/13

412/905

21/5211/2626/4823/3722/7518/43

na13/2818/4213/1615/3525/5815/3614/4247/8135/6821/5314/3322/346/265/156/19

404/911

40.442.354.262.2 29.3 41.9 na

46.442.981.342.9 43.141.7 33.358.051.5 39.6 42.4 64.723.133.3 31.6

45.9

-19.6-15.85.39.2

-15.9-4.6na

-8.8-2.431.310.96.40.03.16.9-5.77.0 2.4 12.0-8.5-9.5-6.9

-0.8

District2002

HIV+/N %

Age 30 to 34 Years

2003


60.0 58.1 48.9 52.945.246.422.255.345.350.0 32.036.741.7 30.251.157.1 32.640.052.731.642.938.5

46.7

70



8.11. C/D COMPARISON OF 2002 AND 2003HIV RESULTS BY INDIVIDUAL AGE GROUPS AGE GROUPS


6/185/1414/4110/209/356/371/1314/2411/278/105/1415/303/238/2018/4313/337/265/1210/195/182/103/4

178/491

12/299/2522/3511/2812/398/33na

15/3312/254/93/1214/363/189/2614/2420/438/237/189/228/196/112/6

210/539

41.4 36.0 62.9 39.330.824.2 na

45.5 48.0 44.425.038.9 16.7 34.658.3 46.534.838.9 40.942.154.533.3 41.5

8.00.328.7 -10.75.18.0na

-12.97.3

-35.6-10.7-11.13.6 -5.416.57.1 7.9-2.8-11.714.3 34.5 -41.75.2*

District2002

HIV+/N %

Age 35 to 39 Years

2003


33.335.734.150.025.716.2 7.758.340.7 80.035.750.013.040.041.939.4 26.941.752.6 27.8 20.0 75.0 36.2


2/84/143/87/195/296/181/64/232/60/31/36/182/54/195/146/152/101/74/143/153/151/3

72/272

6/134/107/254/126/154/16na

5/193/182/42/106/162/75/234/97/144/132/74/83/111/21/3

83/265

46.240.028.023.340.0 25.0 na

26.316.750.0 20.0 37.528.6 21.7 44.4 50.0 30.828.650.0 27.350.0 33.3

34.4

21.211.4 -9.5-3.522.8-8.3na8.9

-16.750.0 -13.34.2

-11.40.7 8.7 10.010.814.3 21.47.3 30.0 0.0

5.7*

District2002

HIV+/N %

Age 40 to 49 Years

2003


25.028.637.536.8 17.2 33.316.717.433.3 0.0 33.333.340.021.1 35.7 40.020.014.328.6 20.020.033.3

28.8

8.11. E/F COMPARISON OF 2002 AND 2003HIV RESULTS BY INDIVIDUAL AGE GROUPS AGE GROUPS

71



72



8.12. ENROLLMENT OF FIRST TIME VCT ATTENDEES BY SEX AND AGE GROUP, TEBELOPELE VCT PROGRAM, 2000-2003*, BOTSWANA

(*INCOMPLETE YEAR, AS OF 30 SEPTEMBER 2003)

326629

018000100000000

974

363112766633542141803125960000000

6695

4777182686747139331380768751075824055523828940

12564

413020651031891404239878533591719347654586906267772

15013

12864579625611734101173219971280110714775871209824934361772

35246

TebelopeleCentre

2000

No

2001

No

2002

No

2003*

No

Total

No

GaboroneFrancistownSelebi PhikweMaunJwanengKasaneSeroweLobatseLetlhakanePalapyeGantsiMochudiKanyeMolepololeTsabongMahalapyeTotal

Men

Women

304609

016000000000000

929

309811085483902082912284270000000

5920

3356159273746334541356461156052625044116022990

10139

29581612710671384297520467590507385473445521271499

11310

971649211995154093710011312112011571033635914605543370499

28298

TebelopeleCentre

2000

No

2001

No

2002

No

2003*

No

Total

No

GaboroneFrancistownSelebi PhikweMaunJwanengKasaneSeroweLobatseLetlhakanePalapyeGantsiMochudiKanyeMolepololeTsabongMahalapyeTotal

73



Women

8.13.HIV PREVALENCE BY EDUCATION AMONG FIRST TIME VCT ATTENDEES, TEBELOPELE VCT PROGRAM, 2000-2003*, BOTSWANA

(*INCOMPLETE YEAR, AS OF 30 SEPTEMBER 2003)

None PrimarySecondaryTertiary

9115560284

66.753.035.716.2

5861331882155

53.455.033.617.1

234159854702445

57.761.239.422.1

7923,5638,0802,771

52.958.245.924.4

1,2286,502

19,2658,377

53.658.741.321.3

Education2000

No. % Pos2001

No. % Pos2002

No. % Pos2003*

No. % PosTotal

No. % Pos

Men

None PrimarySecondaryTertiary

21121482300

47.640.519.112.3

151613

2,8352,289

45.050.621.014.5

4991,6834,9542,963

56.958.823.617.5

9632,5575,2072,695

57.959.529.019.4

1,6344,974

13,4788,247

56.357.725.017.1

Education2000

No. % Pos2001

No. % Pos2002

No. % Pos2003*

No. % PosTotal

No. % Pos

74



8.14. DEMOGRAPHIC CHARACTERISTICS OF MAKGABANENG RADIO LISTENERSHIP RESPONDENTS

1582470

405

2766651750

405

5499200520

405

162611136702

405

208721214

405

1632381

402

24983561112

402

29103230391

402

131291746800

402

133901754

402

3214851

807

5251491078162

807

83202430911

807

2939028713502

807

3411622968

807

Characteristic Male 25-29 yrs 35-39 yrs

Age Group15-1920-24missingTotal

Marital StatussinglecohabitingmarrieddivorcedwidowedmissingTotal

Educationnoneprimarysecondarypost-secondarymissingTotal

Occupationformal employmentinformal/casual employmentsubsistence/housewife/unemployedstudentothermissingTotal

# Birthsnoneonemore than onemissingTotal

*all values are not weighted

75



1. Ngami

2. North East

3. Serowe/Palapye

4. Bobirwa

5. Kweneng East

6. Southern

Jwaneng

7. Gantsi

8. Mahalapye

9. Kgatleng

10. Chobe

11. Kgalagadi

12. Tutume

13. Boteti

14. Okavango

15. Gaborone

16. Francistown

17. South East

18. Lobatse

19. Selebi Phikwe

20. Kweneng West

23. Goodhope

24. Hukuntsi

Dr J.E.O Aruwa

Dr. D.S. Phiri

D. Kabamba

Dr. B.M Wafuwana

Dr. Elyetu

Dr. K. Kazadi

K. J. Kashaija

Dr. G.G. Mbugua

Dr. J. Chambo

Dr. Baraza

Dr I.M. Kempanju

Dr. G. Oriokot

Dr. Nsiala, Dr Chinkoyo

Dr Malanguka

Dr Thuku

Dr. Medhin

Dr Tsadik

Dr Hlangabeza

Dr Mpoyo

Dr. Malaba

B.F. Nfila

K. Mabula

S. Chikunyana

K.K. Sekga

B. Ali

S. Ngwako

E. Rannoba

S. Paulus, V. Morebodi

D. Otswakae

E.B. Dube

M. Pone

P. Maphanyane

M. Mopedi

K. Mabechu S. Chite

Mrs Kebalefetse

M. Mabebe

B.B Mbwe

M. Dintweng

M.K. Lobelo

K. Malesela

W. Setlhogile

N. Mogwera

L. Kgwetane

B. Opelo

M. Kgosimolao

A.M. Mabreden

G. Kedikilwe

U. Letsholathebe

B. Lekaukau

G.G. Dubani

A. Ramhitshana

Maruapula

T.S Mautenyane

M. Nyathi

M. Tapela

C.K Baakile

E. Dintwe

V. Ntapu

D. Nkgageng, G Rabasiako

T. Leipego

District SDMO/DMO Matron CHN

8.15. NAMES OF PARTICIPATING STAFF AND HEALTH FACILITIES

76



Maun General Hospital

Gumare Primary Hospital

Rakops Primary Hospital

Letlhakane Primary Hospital

Orapa Mine Hospital

Ditsweletse Clinic

Kasane Primary Hospital

Selebi Phikwe Government Hospital

Mmadinare Primary Hospital

Bobonong Primary Hospital

Masunga Primary Hospital

Tutume Primary Hospital

Gweta Primary Hospital

Sekgoma Memorial Hospital

Palapye Primary Hospital

Thamaga Primary Hospital

Scottish Livingstone

Kanye SDA Hospital

Gantsi Primary Hospital

Mahalapye Primary Hospital

Sefhare Primary Hospital

Deborah Retief Memorial

Tsabong Primary Hospital

Jubilee Clinic

Bamalete Lutheran Hospital

Athlone Hospital

Goodhope Primary Hospital

Hukuntsi Primary Hospital

NBTC

C.N. Mokopane

J. Obatre

F. Samuel

J. Ditshenyegelo

Felix Mulenga

L. Keikotlhae

E. Mabona

J. Kerebotswe

D. Montshiwa

M. Sekgoa

C. Ramatapana

G. Mabusa

J. Mooki

G. Letsibogo

S. Kaartze

B. Basaakane

G. Malomo

M. Majoo

L. Molomo

M. Sekepe

Mr. Maruping

B. Lenkopane

Ramaja

I. Olebile

T. Boikanyo

S.Ranku

B. Gumbalume

G.J Mpoko

G. Motlhabane

K.E. Podi

S. Batlang

M. Mogotlhwane

B. Fundisi

T. Matsuokwane

V. Thadi

S. Moreetsi

C. Syabula

K. Gofamodimo

W. Kalake

MLT

CMLT

SMLT

MLT

SMLT

MLT

MLT

MLT

SLT

CMLT

SMLT

MLT

SMLT

MLT

SMLT

SLT

SLT

SMLT

MLT

SMLT

MLT

MLT

MLT

PRN

SLT

SMLT

MLT

SMLT

SMLS

MLT

MLT

MLT

MLT

MLT

MLT

Chief MLT

Name Hospital Designation

77



1. Ngami

2. North East

3.Serowe/Palapye

4. Bobirwa

5. Kweneng East

Maun Gen Hospital

Maun Clinic

Sehitwa Clinic

Boyei Clinic

Tsau Clinic

Sedie Clinic

Makalamabedi Clinic

Boseja Clinic

Shorobe Clinic

Thitoyamokolo Health Post

Masunga Clinic

Makaleng Clinic

Sekgoma Memorial Hosp.

Palapye P. Hospital

Newtown Clinic

Serowe Clinic

Moiyabana Clinic

Mmashoro Clinic

Lotsane Clinic

Kediretswe Clinic

Lerala Clinic

Bobonong P. Hospital

Mmadinare P. Hospital

Sefophe Clinic

Manga Clinic

Tsetsebjwe Clinic

Semolale Clinic

Mathathane Clinic

Borotsi Clinic

Moletemane H. Post

Scottish Livingstone

Kgosing Clinic

S. Mohube, G Obatre,

G. Mokubung

D. Oitsile, G. Mwale

R. Kusane, K. Kgoboge

T.K. Sehube, P. Mokwena,

T. Manyepedza, G. Segosele

L. Phiri, C. Boikanyo,

O. Waloka

V. Letshola, N. Kibakaya

K. Ditshotlo, C Katebe

R.P. Mongale, M. Mogende

P. Handukani, P. Tholo

S. Leshaga, O. Gubago

B. Radikgomo

G. Ranku

K. Buku

B. Monyika

E. Malamu

N. Chimidza, J. Bolebantswe

K. Kgomotsego

N. Motheo

M. Chamme

Balopi

O. Khao

D. Badisang

D. Malawana

J. Malema

N. Moitoi

G. Mwando

T. Nsakwa

R. Botshabelo

M. Ramolathla

G. Tsholo

A. Sankoloba

O. Phuthego

N. Mwanza

B. Gabobegwe

DISTRICT FACILITY PARTICIPATING OFFICIALS

78



6. Southern Jwaneng

7. Gantsi

8. Mahalapye

9. Kgatleng

Kanye Clinic

Mahikana Clinic

Kgwatlheng Clinic

Sebego Clinic

Mmamokhasi Clinic

Molapowabojang Clinic

Moshopa Council Clinic

Moshupa H. Post

Dada Clinic

Sese H. Post

Letlhakane East Clinic

Ntlhantlhe Clinic

Ditsweletse Clinic

Shha H. Post

Gantsi Clinic

D’Kar H. Post

Mahalapye P. Hospital

Sefhare P. Hospital

Leetile H. Post

Baitiredi Clinic

Madiba H. Post

Airstrip Clinic

Ramokgonami Clinic

Pilikwe Clinic

Macheng Clinic

Chadibe Clinic

Kalamare Clinic

Shoshong Clinic

Seleka Clinic

Mookane Clinic

DRM

Mochudi Clinic 1

Artesia Clinic

Bokaa Clinic

Mathubudukwane Clinic

Mochudi Clinic 2

Oodi Clinic

Boseja Clinic

D. Mokobane, G. Mudongo

S. Shadikong

Mrs. Moshimba

M. Dibeela

D. Sekgwa

E. Hlomani

C. Maswabi

Mrs. Leshope

S. Methikge

D. Ntsimako

Mrs. Nchoko

D. Searobi

M. Paulus, O. Montsho,

V. Mogonono

C. Viruwa

T. Mabaiwa

T. Taruvinga

M. Mabusa

S. Ntau

B. Nkane

G.M. Mooketsi

M. Kgosietsile

L. Sebego

K. Mophane

J. Mmereki

C. Tibone

M. Monageng

A. Gaetote

S. Siso

C. Molale

B. Nuku, P. Sejamitwa

K. Badumetse, O, Magashula

T. Mosugelo, T. Musonda

J. Soko, S. Monosi

M. Poonyane, F. Moyo

P. Setswamokwena, M. Meleki

L.S. Moyo, B. Bashanako

B. Phutego, S. Makhwaje


79



10. Chobe

11. Kgalagadi

12. Tutume

13. Boteti

14. Okavango

15. Gaborone

Makakatlela

Rasesa Clinic

Kasane P. Hospital

Kasane Health Post

Plateau Health Post

Mabele Health Post

Kachikau Clinic

Pandamatenga Clinic

Tsabong P. Hospital

Verda Clinic

Hereford Clinic

Middlepitts Clinic

Tsabong Catchment Area

Makopong Catchment Area

Tutume P. Hospital

Magapatona Health Post

Nkange Clinic

Maitengwe Clinic

Sebina Clinic

Mathangwane Clinic

Tonota Clinic

Mosetse Health Post

Dukwi Clinic

Sowa Clinic

Nata Clinic

Gweta P. Hospital

Letlhakane P. Hospital

Letlhakane Clinic

Gumare P. Hospital

Etsha 6 Clinic

Seronga Clinic

Shakawe Clinic

Nokaneng Clinic

Xakao Clinic

Sepopa Clinic

BTA

Old Naledi Clinic

Block 9 Clinic

L. Segare, L. Mbulawa

K. Kgosidialwa, C. Moremi

B. Maphanyane

S. Nginya

O. Phalayagae

N. Beunyengua

M. Mukono

D. Kebalepile

M. Matheatau, A. Samson

G.M. Bwalya

A. Morwamang

B. Chiroze

J. Mothupe

S. Lesole

P. Gothamodimo

M. Mokgetse

O. Rabasoma

T. Mabophiwa

P. Fanikiso

K. Motlamme

V. Montsho, L.K. Nthutang,

T. Negasa

P. Rapotsanyane

J. Kgosinkwe

Dr Mihigo

N. Otukile

N. Baliki

J. Molokwane

Mrs. Mapogo

B. Bolele

P. Silwamba

Ditsela

O. Tshipayagae

Q. Thusang

B. Mokhawe

E. Sigweni

J. Dintwe

R. Phindela

B. Moalosi


80



16. Francistown

17. South East

18. Lobatse

19. Selebi Phikwe

20. Kweneng West

23. Goodhope

Broadhurst 2 Clinic

Extension 2 Clinic

Area W Clinic

Tswaragano Clinic

Bamalete Lutheran Hospital

Lesetlhana Clinic

Siga Clinic

Nkaikela H. Post

Khayakholo H. Post

Taung Clinic

Otse Clinic

Tsopeng Clinic

Peleng East Clinic

Woodhall Clinic

Peleng Central Clinic

Athlone P. Hospital

Tapologong Clinic

Botshabelo Clinic

Letlhakeng Clinic

Botlhapatlou H. Post

Ngware Clinic

Khudumelapye Clinic

Salajwe Clinic

Motokwe Clinic

Takatokwane Clinic

Ditshegwane Clinic

Sesung H. Post

Moshaneng Clinic

Kotolaname Clinic

Goodhope P. Hosptital

Pitsane Clinic

Rakhuna Clinic

Ramatlabama Clinic

P. Zibochwa

M. Mmolawa, Mosomodi

C. Monyatsiwa

M. Mokgatlaotsile

D. Kitsiso, D. Moagi

J. Butale, E. Ntlhale

J. Mothupi, S. Montsho

R. Kowa, M. Majeka

D. Kazunguza, L.Bolatlhilwe

M. Hisayi, G. Dipholo

R. Mukwevho, S. Tutwane

B. Tshenyego, L. Segokgo

A. Segapo, M. Ramopedi,

Boemo

M. Molefhi, L. Kelebogile

M. Pheto, D. Humbu

S. Leposo, O. Kowa,

M. Motsamai, Dr Kambinda,

K. Motsuokwane

M. Modumedi

Ramosukwane

T. Smith

V. Mokone, G. Ramosenane, C.

Kgotlaname, C. Kwakwadi

G. Magapu, P.S. Otsheleng

L. Matjologwe

K. Radipati, T. Busang

K. Thebenyana, M. Phiri

T. Mafika, O. Hanqiwe

I. Ramotswetla, O. Muzvidziwa

C. Moleele-Segole

L. Moeti, I. Phathswane

C. Kasheeka, F. Bhusumane

M. Pilane

K. MokonyaneG. Pheto

Mrs Ranthadi, Ms Masepela

Mr Khumalo, Ms Seabo

Ms Mohutsiwa,


81



24. Hukuntsi

Hebron Clinic

Pitshane Molopo Clinic

Mabule Clinic

Tshidilamolomo Clinic

Mmathete Clinic

Digawana Clinic

Kang Clinic

Hukuntsi Clinic

Hukuntsi P. Hospital

Lehututu H. Post

Inalegolo H. Post

Ukhwi H. Post

Hunhukwi H. Post

Make H. Post

Monong H. Post

Tshane H. Post

Zutshwa H. Post

K. Mantswenabe

Ms Bareki, Mrs Thakanelo

Mrs Phale, Mrs Chavula

Ms Keraanang, Mrs

Rasetshwane

Ms Tautona

M. Seretse, M. Matoko,

Ms Setiko

S. Makhulumo, Mrs Chipausha

O. Seno, M. Maifala,

D. Chilwalo

T. Manewe, A. Mulapati

M. Sichinga, E. Wabo

M. Modisane, Y. Serwe,

G. Bengani, G. Thako,

E. Morwawakgosi

K. Bonang, B. Mogomotsi

L. Mosetlhane

K. Lekgatlhane

M. Segano

E. Mokgethi

A. Lekhutlanye

F. Tsebe

M. Mokgatle


82



Bots

wan

aBo

tsw

ana

Bots

wan

aBo

tsw

ana

Bots

wan

aBo

tsw

ana

Bots

wan

aBo

tsw

ana

Bots

wan

aBo

tsw

ana

Bots

wan

aBo

tsw

ana

Bots

wan

aBo

tsw

ana

Bots

wan

aBo

tsw

ana

Bots

wan

aBo

tsw

ana

Bots

wan

aBo

tsw

ana

Bots

wan

aBo

tsw

ana

AN

C1

AN

C1

AN

C1

AN

C1

AN

C1

AN

C1

AN

C1

AN

C1

AN

C1

AN

C1

AN

C1

AN

C1

AN

C1

AN

C1

AN

C1

AN

C1

AN

C1

AN

C1

AN

C1

AN

C1

AN

C1

AN

C1

Out

side

maj

or u

rban

are

asO

utsi

de m

ajor

urb

an a

reas

Out

side

maj

or u

rban

are

asM

ajor

urb

an a

reas

Maj

or u

rban

are

asO

utsi

de m

ajor

urb

an a

reas

Out

side

maj

or u

rban

are

asO

utsi

de m

ajor

urb

an a

reas

Out

side

maj

or u

rban

are

asO

utsi

de m

ajor

urb

an a

reas

Out

side

maj

or u

rban

are

asO

utsi

de m

ajor

urb

an a

reas

Out

side

maj

or u

rban

are

asO

utsi

de m

ajor

urb

an a

reas

Out

side

maj

or u

rban

are

asO

utsi

de m

ajor

urb

an a

reas

Out

side

maj

or u

rban

are

asM

ajor

urb

an a

reas

Out

side

maj

or u

rban

are

asO

utsi

de m

ajor

urb

an a

reas

Out

side

maj

or u

rban

are

asO

utsi

de m

ajor

urb

an a

reas

Bobi

rwa

Bote

tiC

hobe

Fran

cist

own

Gab

oron

eG

ants

iG

oodh

ope

Huk

unts

i K

gala

gadi

K

gatle

ngK

wen

eng

East

Kw

enen

g W

est

Loba

tse

Mah

alap

yeN

gam

i/Nor

th W

est

Nor

th E

ast

Oka

vang

o Se

lebi

-Phi

kwe

Sero

we/

Pala

pye

Sout

h Ea

st

Sout

hern

Tu

tum

e

23.7

14.9

34.2

19.2

9.5

29.7

27.8

27.0

16.0

23.1

39.6

28.7

18.9

43.1

31.4

33.1

21.8

30.0

42.9

34.0

43.0

38.1

22.3

49.9

24.7

37.5

50.8

(n=

120)

42.7

(n=

576)

37.1

(n=

480)

21.8

(n=

257)

29.5

(n=

271)

31.3

(n=

252)

32.0

(n=

362)

41.8

(n=

268)

44.4

(n=

702)

36.2

(n=

734)

30.4

(n=

349)

50.3

(n=

304)

40.7

n=

(513

)35

.4 (

n=33

9)

44.0

(n=

149)

36.7

(n=

281)

39.1

(n=

81)

49.6

(n=

494)

38.6

(n=

576)

21.8

(15

9)33

.1 (

n=96

)23

.3 (

n=62

)28

.5 (

n=12

0)24

.9 (

n=23

1)29

.6 (

n=54

0)25

.3 (

130)

30.6

(n=

232)

31.9

(n=

336)

35.8

(n=

376)

39.9

(n=

75)

40.6

(n=

225)

50.0

(n=

351)

41.0

(n=

341)

32.1

(n=

192)

31.5

(n=

347)

51.1

(n=

267)

45.3

(n=

286)

35.6

(n=

250)

38.4

(n=

105)

40.2

(n=

458)

38.2

(n=

666)

18.8

(n=

112)

26.3

(n=

146)

40.0

(n=

182)

28.3

(n=

172)

30.9

(n=

310)

29.2

(n=

567)

28.7

(n=

158)

34.6

(n=

241)

39.8

(n=

303)

40.7

(n=

253)

38.6

(n=

196)

34.2

(n=

284)

48.1

(n=

372)

35.2

(n=

425)

26.5

(n=

288)

30.5

(n=

363)

40.7

(n=

370)

49.3

(n=

255)

31.9

(n=

260)

47.0

(n=

115)

45.8

(n=

593)

44.8

(n=

555)

40.9

(n=

137)

28.4

(n=

100)

28.9

(n=

161)

30.6

(n=

353)

32.1

(n=

522)

27.0

(n=

190)

32.4

(n=

246)

37.4

(n=

326)

38.4

(n=

376)

40.4

(n=

222)

32.7

(n=

328)

52.2

(n=

302)

43.3

(n=

389)

27.9

(n=

306)

25.7

(n=

359)

37.7

(n=

429)

Co

un

try

Popu

latio

nU

rban

/Ru

ral

Site

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22

8.16. HIV PREVALENCE BY SITE,1992 TO 2003

0 to 2999

3000 to 4999

5000 to 9999

10 000 to 14 999

+ 15 000

6,408

12,428

4,456

16,479

2,839

3,255 7,250

26,05011,886

7,057

21,104

14,821

8,685

52,3645,414

8,442

2,035

14,978

4,4449,492

15,944

27,930

Estimated HIV adults 15-49 yearsin Botswana, 2003


0 to 2999

3000 to 4999

5000 to 9999

10 000 to 14 999

+ 15 000

6,408

12,428

4,456

16,479

2,839

3,255 7,250

26,05011,886

7,057

21,104

14,821

8,685

52,3645,414

8,442

2,035

14,978

4,4449,492

15,944

27,930



HIV Prevalence per health districtamong pregnant women in 2003HIV Prevalence per health districtamong pregnant women in 2003

0% to 19.9%

Data not available

20% to 29.9%

30% to 39%

40% and above

32.7

38.4

47.0

37.7

28.9 40.9

43.349.3

40.4

45.8

52.2

27.9

44.832.4

31.9

28.4

25.7

27.030.6

37.4

32.1

0

10

20

30

40

50

1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

15-19 20-25 25-49

YEAR

HIV

PR

EVA

LEN

CE

Trend in HIV prevalence amongpregnant women, Botswana, 1992-2003

Age specific HIV seroprevalenceamong pregnant women, 2003

botswana 2003 second generation hiv/aids surveillance

Documents

Transcript of botswana 2003 second generation hiv/aids surveillance