Benchmarking of the Cervical Cancer Care Cascade and Survival Outcomes After Radiation Treatment in a Low- and Middle-Income Country Setting

PURPOSE

Timely radiation treatment (RT) is critical in cervical cancer treatment, but patients in low- and middle-income countries (LMICs) in sub-Saharan Africa often face barriers that delay care. Time to care was benchmarked in a multidisciplinary team (MDT) setting in Botswana.

METHODS

Time intervals between steps in care were recorded for 230 patients reviewed at MDT between January 2016 and July 2018. Associations between RT delay and overall survival (OS) were evaluated using Kaplan-Meier curves and multivariable Cox proportional hazards models.

RESULTS

For patients who received RT (n = 187; 81.3%), the median biopsy to pathology reporting interval was 25 (IQR, 19-36) days and was 57 (IQR, 28-68) days for patients who did not (P = .003). Intervals in care did not differ between patients who did and did not receive RT. Among treated patients, the uppermost quartile interval from pathology reporting to RT initiation was ≥111 days and that from RT simulation to initiation was ≥12 days. Among patients receiving a RT dose of ≥65 Gy (n = 100), the delay from RT simulation to initiation of >12 days was associated with worse median OS (2.0 v 4.6 years; P = .048); this association trended toward, although did not meet, statistical significance on multivariable analysis (hazard ratio, 2.35; 95% CI, 0.95 to 5.85; P = .07).

CONCLUSION

The MDT-coordinated care model allows for systematic benchmarking of the patient treatment cascade. Barriers to timely treatment exist for this cohort in Botswana, and RT delay may be associated with OS of patients receiving curative treatment. Interventions to accelerate the timing of the radiation oncology care cascade may improve clinical outcomes in this LMIC setting.

Attitudes, beliefs, and practices toward end-of-life care among physicians in sub-Saharan Africa

Introduction

as the opportunity to receive life-sustaining treatments expands in sub-Saharan Africa (SSA), so do potential ethical dilemmas. Little is known regarding the attitudes, beliefs, and practices of physicians in SSA regarding end-of-life care ethics.

Methods

we used validated survey items addressing physician end-of-life care views and added SSA-context specific items. We identified a convenience sample using the authors' existing African professional contacts and snowball recruitment. Participants were invited via email to an anonymous online survey.

Results

we contacted 78 physicians who practice critical care in Africa, and 68% (n=53) completed the survey. Of those, 66% were male, 55% were aged 36-45, 75% were Christian. They were from Kenya (30%), Zambia (28%), Rwanda (25%), Botswana (11%), and other countries (6%). Most (75%) agreed that competent patients can refuse even life-saving care. Only 32% agreed that their hospital had clear policies regarding withdrawing and withholding care, 11% agreed that their country had legal precedent for end-of-life care, and 43% believed that doctors could face legal or financial consequences for allowing patients to die by forgoing treatment. Pain control at the end of life, even if it may hasten death, was supported by 83%. However, 75% felt that clinicians undertreat pain due to fear of hastening death.

Conclusion

participants strongly supported patient autonomy and end-of-life pain control but expressed concern that inadequate policy and legal frameworks exist to guide care and that pain is undertreated. Humane and actionable end-of-life care frameworks are needed to guide decisions in SSA.

Potential facilitators and inhibitors to the implementation and sustainability of the community-based tuberculosis care interventions. A case study from Moshupa, Botswana

BACKGROUND

Eliminating Tuberculosis is one of the targets of Sustainable Development Goal Three. Decentralizing TB care beyond health facilities by leveraging community involvement is crucial for safeguarding effective tuberculosis care. In this study, we explored potential facilitators and inhibitors of the implementation and sustainability of community-based interventions for the prevention and treatment of TB in the Moshupa district, Botswana.

METHODS

This study adopted a qualitative approach using a collective case design. An interpretive paradigm based on relativist ontology and subjectivist epistemology along with abductive research logic was used. The study enrolled treatment supporters of tuberculosis patients diagnosed with drug-susceptible tuberculosis between January 2019 and December 2019 in Moshupa Village for semi-structured interviews, Health care professionals for in-depth interviews, and e community leaders for focus group discussions. Clinic-based observations in Mma-Seetsele clinic were also conducted to corroborate the participants' views. The data collected was analyzed using the NVivo version 12 software package, and statements of the participants were presented as quotes to substantiate the issues discussed.

RESULTS

This study highlighted effective partnerships between health services and external stakeholders, community empowerment, and the availability of policies and standard operating procedures as facilitators of community TB implementation and sustainability. However, Insufficient funding, low service provider training, policies not embracing age and educational eligibility for treatment supporters, shortage of equipment, medicines, and supplies, inadequate transport availability and incentives to meet clients' basic needs, paper-based systems, inadequate supervision, incomplete data reporting, and low service quality affected the Community TB program efficacy and sustainability in Moshupa. We also found that there was low service provider motivation and retention and that clients had low trust in treatment supporters.

CONCLUSION

The findings of this study imply that the operational effectiveness of the community TB care approach to disease elimination is compromised; therefore, initiatives addressing the key components, including the availability of resources, governance arrangements and supportive systems for community health workers, are required for successful community TB implementation and sustainability.

"It's Better If I Die Because Even in the Hospital, There is a Stigma, People Still Gossip": Gossip as a Culturally Shaped Labeling Process and Its Implications for HIV-Related Stigma in Botswana

This study qualitatively explores HIV-related gossip as both a manifestation and driver of HIV-related stigma, which is a known barrier to HIV testing and treatment in Botswana. Data were elicited from 5 focus group discussions and 46 semi-structured in-depth interviews with individuals living with HIV and community members with undisclosed serostatus in Gaborone, Botswana in 2017 (n = 84). Directed content analysis using the 'What Matters Most' theoretical framework identified culturally salient manifestations of HIV-related stigma; simultaneous use of Modified Labeling Theory allowed interpretation and stepwise organization of how the social phenomenon of gossip leads to adverse HIV outcomes. Results indicated that HIV-related gossip can diminish community standing through culturally influenced mechanisms, in turn precipitating poor psychosocial well-being and worsened HIV-related outcomes. These harms may be offset by protective factors, such as appearing healthy, accepting one's HIV status, and community education about the harms of gossip.

Youth and healthcare workers' perspectives on the feasibility and acceptability of self-testing for HIV, Hepatitis and Syphilis among young people: Qualitative findings from a pilot study in Gaborone, Botswana

INTRODUCTION

Little is known regarding the attitudes and perspectives of young people and healthcare workers in Botswana about dual self-testing for HIV and STIs including its acceptability, or their perceptions of the opportunities and limitations of this approach.

METHODS

From July to November 2021, 25 young people and 6 healthcare workers were purposively sampled for in-depth telephone interviews conducted in English or Setswana. The interviews followed a semi-structured topic guide, were audio recorded, transcribed, and analysed thematically using deviant case and constant comparative techniques. The study was part of a pilot project evaluating dual self-testing for HIV and STIs among young people in Gaborone.

RESULTS

We found that most of the young people were already aware of their HIV status and were motivated to participate in self-testing mainly because they were interested in learning their STI status. Whilst most were excited about the autonomy and convenience offered by self-testing, some participants expressed nervousness particularly of the finger-prick process, and preferred healthcare worker-administered tests. Both young people and healthcare workers raised concerns about the potential negative mental health outcomes of unexpected test results and emphasized the importance of pre- and post-test counselling and seamless linkage to care.

CONCLUSION

Dual self-testing for HIV and STIs has the potential to empower young people to take control of their sexual health. However, it is crucial to ensure that proper support and counselling services are in place, along with effective mechanisms for linkage to care. This study emphasizes the importance of integrating pre- and post-test counselling into self-testing programs to ensure that young people feel adequately supported throughout the testing process. By doing so, self-testing can become a valuable tool for improving the sexual health outcomes of young people in Botswana.

Broadly neutralizing antibody treatment maintained HIV suppression in children with favorable reservoir characteristics in Botswana

Broadly neutralizing antibodies (bNAbs) may provide an alternative to standard antiretroviral treatment (ART) for controlling HIV-1 replication and may have immunotherapeutic effects against HIV-1 reservoirs. We conducted a prospective clinical trial with two HIV-1 bNAbs (VRC01LS and 10-1074) in children (n = 25) who had previously initiated small-molecule ART treatment before 7 days of age and who continued treatment for at least 96 weeks. Both bNAbs were dosed intravenously every 4 weeks, overlapping with ART for at least 8 weeks and then continued for up to 24 weeks or until detectable viremia of HIV-1 RNA rose above 400 copies per milliliter in the absence of ART. Eleven (44%) children maintained HIV-1 RNA below 400 copies per milliliter through 24 weeks of bNAb-only treatment; 14 (56%) had detectable viremia above 400 copies per milliliter at a median of 4 weeks. Archived HIV-1 provirus susceptible to 10-1074, lower birth HIV-1 DNA reservoir in peripheral blood mononuclear cells, sustained viral suppression throughout early life, and combined negative qualitative HIV-1 DNA polymerase chain reaction and negative HIV-1 serology at entry were associated with maintaining suppression on bNAbs alone. This proof-of-concept study suggests that bNAbs may represent a promising treatment modality for infants and children living with HIV-1. Future studies using newer bNAb combinations with greater breadth and potency are warranted.

Post-COVID symptom profiles and duration in a global convalescent COVID-19 observational cohort: Correlations with demographics, medical history, acute COVID-19 severity and global region

Background

Post-COVID conditions are characterised by persistent symptoms that negatively impact quality of life after SARS-CoV-2 diagnosis. While post-COVID risk factors and symptoms have been extensively described in localised regions, especially in the global north, post-COVID conditions remain poorly understood globally. The global, observational cohort study HVTN 405/HPTN 1901 characterises the convalescent course of SARS-CoV-2 infection among adults in North and South America and Africa.

Methods

We categorised the cohort by infection severity (asymptomatic, symptomatic, no oxygen requirement (NOR), non-invasive oxygen requirement (NIOR), invasive oxygen requirement (IOR)). We applied a regression model to assess correlations of demographics, co-morbidities, disease severity, and concomitant medications with COVID-19 symptom persistence and duration across global regions.

Results

We enrolled 759 participants from Botswana, Malawi, South Africa, Zambia, Zimbabwe, Peru, and the USA a median of 51 (interquartile range (IQR) = 35-66) days post-diagnosis, from May 2020 to March 2021. 53.8% were female, 69.8% were 18-55 years old (median (md) = 44 years old, IQR = 33-58). Comorbidities included obesity (42.8%), hypertension (24%), diabetes (14%), human immunodeficiency virus (HIV) infection (11.6%) and lung disease (7.5%). 76.2% were symptomatic (NOR = 47.4%; NIOR = 22.9%; IOR = 5.8%). Median COVID-19 duration among symptomatic participants was 20 days (IQR = 11-35); 43.4% reported symptoms after COVID-19 resolution, 33.6% reported symptoms ≥30 days, 9.9% reported symptoms ≥60 days. Symptom duration correlated with disease severity (P < 0.001, NIOR vs NOR; P = 0.003, IOR vs NOR), lung disease (P = 0.001), race (P < 0.05, non-Hispanic Black vs White), and global region (P < 0.001). Prolonged viral shedding correlated with persistent abdominal pain (odds ratio (OR) = 5.51, P < 0.05) and persistent diarrhoea (OR = 6.64, P < 0.01).

Conclusions

Post-COVID duration varied with infection severity, race, lung disease, and region. Better understanding post-COVID conditions, including regionally-diverse symptom profiles, may improve clinical assessment and management globally.

Registration

Clinicaltrials.gov (#NCT04403880).

Improvement studies for equitable and evidence-based innovation: an overview of the 'IM-SEEN' model

BACKGROUND

Health inequalities are ubiquitous, and as countries seek to expand service coverage, they are at risk of exacerbating existing inequalities unless they adopt equity-focused approaches to service delivery.

MAIN TEXT

Our team has developed an equity-focused continuous improvement model that reconciles prioritisation of disadvantaged groups with the expansion of service coverage. Our new approach is based on the foundations of routinely collecting sociodemographic data; identifying left-behind groups; engaging with these service users to elicit barriers and potential solutions; and then rigorously testing these solutions with pragmatic, embedded trials. This paper presents the rationale for the model, a holistic overview of how the different elements fit together, and potential applications. Future work will present findings as the model is operationalised in eye-health programmes in Botswana, India, Kenya, and Nepal.

CONCLUSION

There is a real paucity of approaches for operationalising equity. By bringing a series of steps together that force programme managers to focus on groups that are being left behind, we present a model that can be used in any service delivery setting to build equity into routine practice.

Feeding back of individual genetic results in Botswana: mapping opportunities and challenges

PURPOSE

We explored the views of Botswana stakeholders involved in developing, implementing and applying ethical standards for return of individual study results from genomic research. This allowed for mapping opportunities and challenges regarding actionability requirements that determine whether individual genomic research results should be fed back.

METHODS

Using in-depth interviews, this study explored the views of sixteen (16) stakeholders about the extent, nature and timing of feedback of individual genomic research findings, including incidental findings that arise in the context of African genomics research. Coded data was analyzed through an iterative process of analytic induction to document and interpret themes.

RESULTS

Overall, respondents were of the view that feedback of actionable individual genomic results was an important outcome that could benefit participants. However, a number of themes surfaced that pointed to opportunities and challenges that exist in Botswana that could help in planning for feeding back of individual genomic results that were mapped. Some of the opportunities cited by the respondents included the existence of good governance; democracy and humanitarianism; universal healthcare system; national commitment to science; research and innovation to transform Botswana into a knowledge-based economy; and applicable standard of care which could promote actionability. On the other hand, contextual issues like the requirement for validation of genomic research results in accredited laboratories, high cost of validation of genomic results, and linkage to care, as well as lack of experts like genomic scientists and counselors were considered as challenges for return of individual results.

CONCLUSION

We propose that decisions whether and which genomic results to return take into consideration contextual opportunities and challenges for actionability for return of results in a research setting. This is likely to avoid or minimize ethical issues of justice, equity and harm regarding actionability decisions.

Brief Report: Long-Term Clinical, Immunologic, and Virologic Outcomes Among Early-Treated Children With HIV in Botswana: A Nonrandomized Controlled Clinical Trial

BACKGROUND

Early antiretroviral treatment (ART) improves outcomes in children, but few studies have comprehensively evaluated the impact of ART started from the first week of life.

METHODS

Children diagnosed with HIV within 96 hours of life were enrolled into the Early Infant Treatment Study in Botswana and followed on ART for 96 weeks. Nevirapine, zidovudine, and lamivudine were initiated; nevirapine was switched to lopinavir/ritonavir between weeks 2-5 in accordance with gestational age. Clinical and laboratory evaluations occurred at weeks 1, 2, 4, 8, 12, 24, 36, 48, 60, 72, 84, and 96.

FINDINGS

Forty children initiated ART at a median of 2 (IQR 2, 3) days of life; 38 (95%) completed follow-up through 96 weeks, and 2 (5%) died between 12 and 24 weeks. ART was well tolerated; 9 children (24%) experienced a grade 3 or 4 hematologic event, and 2 (5%) required treatment modification for anemia. The median 96-week CD4 count was 1625 (IQR 1179, 2493) cells/mm 3 with only 5/38 (13%) having absolute counts <1000 cells/mm 3 . Although 23 (61%) had at least one visit with HIV-1 RNA ≥40 copies/mL at or after 24 weeks, 28 (74%) had HIV-1 RNA <40 copies/mL at the 96-week visit. Median cell-associated HIV-1 DNA at 84/96-week PBMCs was 1.9 (IQR 1.0, 2.6) log 10 copies/10 6 cells. Pre-ART reservoir size at birth was predictive of the viral reservoir at 84/96 weeks.

INTERPRETATION

Initiation of ART in the first week of life led to favorable clinical outcomes, preserved CD4 cell counts, and low viral reservoir through 96 weeks of life.

Perceptions and attitudes of patients and healthcare workers towards the use of telemedicine in Botswana: An exploratory study

INTRODUCTION

In March 2020, the Botswana Ministry of Health and Wellness approved a National eHealth Strategy. Although a milestone, the strategy does not mention telemedicine. There is need to address this by developing an evidence-based adjunct strategy for telemedicine to facilitate its introduction and adoption. To do so, several stages of a published eHealth Strategy Development Framework were mimicked. This allowed situational awareness to be created through exploring behavioural factors and perceptions that might influence the adoption of telemedicine in Botswana. The study aim was to explore current issues, concerns, perceptions, attitudes, views, and knowledge of patients and healthcare professionals regarding health-related issues and telemedicine that might influence implementation of telemedicine in Botswana and thereby inform future development of a telemedicine strategy.

METHODS

An exploratory survey study was conducted using different survey questionnaires for patients and healthcare professionals, each using a mix of open- and closed-ended questions. These questionnaires were administered to convenience samples of healthcare professionals and patients at 12 public healthcare facilities in Botswana; seven clinics (three rural; four urban), and five hospitals (two primary, two district, and one tertiary), selected to align with the country's decentralised healthcare structure.

RESULTS

Fifty-three healthcare professionals and 89 patients participated. Few healthcare professionals had actively used telemedicine for clinical consults and self-education using telephone calls, cell phone apps, or video conferencing (doctors 42%, nurses 10%). Only a few health facilities had telemedicine installations. Healthcare professional preference for future telemedicine uses were e-learning (98%), clinical services (92%), and health informatics (electronic records (87%). All healthcare professionals (100%) and most patients (94%) were willing to use and participate in telemedicine programmes. Open-ended responses showed additional perspective. Resource shortages (health human resources and infrastructure) were key to both groups. Convenience, cost effectiveness, and increased remote patient access to specialists were identified as enablers to telemedicine use. However inhibitors were cultural and traditional beliefs, although privacy, security and confidentiality were also identified. Results were consistent with findings from other developing countries.

CONCLUSION

Although use, knowledge, and awareness of telemedicine are low, general acceptance, willingness to use, and understanding of benefits are high. These findings bode well for development of a telemedicine-specific strategy for Botswana, complementary to the National eHealth Strategy, to guide more systematic adoption and application of telemedicine in the future.

Test-Retest Reliability of a Computerized Neurocognitive Battery in School-Age Children with HIV in Botswana

Human immunodeficiency virus (HIV) infection is prevalent among children and adolescents in Botswana, but standardized neurocognitive testing is limited. The Penn Computerized Neurocognitive Battery (PennCNB) attempts to streamline evaluation of neurocognitive functioning and has been culturally adapted for use among youth in this high-burden, low-resource setting. However, its reliability across measurements (i.e., test-retest reliability) is unknown. This study examined the test-retest reliability of the culturally adapted PennCNB in 65 school-age children (age 7-17) living with HIV in Botswana. Intraclass correlation coefficients (ICCs) for PennCNB summary scores (ICCs > 0.80) and domain scores (ICCs = 0.66-0.88) were higher than those for individual tests, which exhibited more variability (ICCs = 0.50-0.82), with the lowest reliability on memory tests. Practice effects were apparent on some measures, especially within memory and complex cognition domains. Taken together, the adapted PennCNB exhibited adequate test-retest reliability at the domain level but variable reliability for individual tests. Differences in reliability should be considered in implementation of these tests.

Incident HIV acquisition among pregnant women in Botswana: findings from the Tsepamo birth outcomes surveillance study

INTRODUCTION

In Botswana, where almost all pregnant women known to have HIV receive antiretroviral therapy, a large proportion of vertical HIV transmission may occur among women with incident undiagnosed HIV infection during pregnancy. Botswana guidelines recommend repeat HIV testing every 3 months in pregnancy, with at least one test in the third trimester. We evaluated the rate of repeat HIV testing, calculated HIV incidence during pregnancy and estimated missed seroconversions.

METHODS

In the Botswana Tsepamo Study, we abstracted HIV test dates and results from obstetric records of all women who delivered at maternity wards in 18 communities between 7th May 2017 and 20th August 2021. We defined seroconversion as an initial negative/indeterminate HIV test in pregnancy followed by a positive test during pregnancy/at delivery. The incidence rate (IR) of seroconversion was calculated among women with > = 2 known test dates. Missed seroconversions were estimated among women without a test in the third trimester by applying the IR to the time after the last HIV test until delivery.

RESULTS

Among 103,529 women delivering in the study period testing negative at the first test and with known conception and HIV test dates, 29,085 (28%) were tested in one trimester of pregnancy, 73,156 (71%) were tested in ≥ 2 trimesters of pregnancy and 9628 (9%) had a test in all trimesters. A total of 78,162 (75%) women had a third-trimester test. There were 223 seroconversions (2.58/1000 pregnancies, 0.26%) among those with ≥ 2 known HIV test dates, yielding an IR of 0.69/100 person-years. Among 25,289 women who did not have a test in the third trimester, we estimate approximately 58 seroconversions may have been missed during pregnancy due to a lack of repeat testing. Factors associated with seroconversion during pregnancy included younger age, less education and not being married.

CONCLUSIONS

More than two-thirds of women had repeat HIV testing in pregnancy and HIV incidence was low. However, an estimated 21% of seroconversions in pregnancy were likely missed due to a lack of re-testing. To reach the goal of zero new paediatric HIV infections, Botswana will need to intensify repeat HIV testing in the third trimester of pregnancy.

Orb-web spider Argiope (Araneidae) as indigenous arrow poison of G/ui and G//ana San hunters in the Kalahari

Hunting has been crucial in early human evolution. Some San (Bushmen) of southern Africa still practice their indigenous hunting. The use of poisons is one remarkable aspect of their bow-and-arrow hunting but the sources, taxonomic identifications of species used, and recipes, are not well documented. This study reports on fieldwork to investigate recent indigenous hunting practices of G/ui and G//ana San communities in the Central Kalahari Game Reserve (CKGR), Botswana. Here we discuss their use of spider poison. The hunters use the contents of the opisthosoma ('abdomen') of a spider as sole ingredient of the arrow poison and discard the prosoma that contains the venom-glands. Using taxonomic keys, we identified the spider as the garden orb-web spider Argiope australis (Walckenaer 1805) (Araneidae). The hunters' choice of this species is remarkable given the scientific perception that A. australis is of little medical importance. The species choice raises questions about how the spider fluids could kill game, particularly when the prosoma, which contains the venom glands, is not used. Possibilities include trauma, as a source of pathogens, or abdomen-containing toxins. Based on characteristics of Argiope Audouin 1826, we hypothesize that the choice of this species for arrow poisons might have evolved from the recognition of aposematic signalling or spiritual symbolism. Indigenous knowledge (IK) is an important source for advances in biotechnology but is in decline worldwide. The study contributes to the documentation of the San people, and their ancient IK, which is threatened by marginalization, political pressures, and climate change.

Accuracy of point-of-care HIV and CD4 field testing by lay healthcare workers in the Botswana Combination Prevention Project

Accurate HIV and CD4 testing are critical in program implementation, with HIV misdiagnosis having serious consequences at both the client and/or community level. We implemented a comprehensive training and Quality Assurance (QA) program to ensure accuracy of point-of-care HIV and CD4 count testing by lay counsellors during the Botswana Combination Prevention Project (BCPP). We compared the performance of field testing by lay counsellors to results from an accredited laboratory to ascertain accuracy of testing. All trained lay counsellors passed competency assessments and performed satisfactorily in proficiency testing panel evaluations in 2013, 2014, and 2015. There was excellent agreement (99.6 %) between field and laboratory-based HIV test results; of the 3002 samples tested, 960 and 2030 were concordantly positive and negative respectively, with 12 misclassifications (kappa score 0.99, p < 0.0001). Of the 149 HIV-positive samples enumerated for CD4 count in the field using PIMA at a threshold of ≤ 350 cells/µl; there was 86 % agreement with laboratory testing, with only 21 misclassified. The mean difference between field and lab CD4 testing was - 16.16 cells/µl (95 % CI -5.4 to 26.9). Overall, there was excellent agreement between field and laboratory results for both HIV rapid test and PIMA CD4 results. A standard training package to train lay counsellors to accurately perform HIV and CD4 point-of-care testing in field settings was feasible, with point-of-care results obtained by lay counsellors comparable to laboratory-based testing.

Toward Meaningful Cultural Adaptation Across Implementation Stages: Lessons Learned From a Culturally Based HIV Stigma Intervention in Gaborone, Botswana

A culturally based stigma intervention for pregnant women living with HIV in Gaborone, Botswana highlights the importance of conceptualizing and formalizing cultural adaptation across all stages of implementation.

Doravirine-associated resistance mutations in antiretroviral therapy naïve and experienced adults with HIV-1 subtype C infection in Botswana

OBJECTIVES

There are limited data on the prevalence of doravirine (DOR)-associated drug resistance mutations in people with HIV (PWH) in Botswana. This cross-sectional, retrospective study aimed to explore the prevalence of DOR-associated resistance mutations among ART-naïve and -experienced PWH in Botswana enrolled in the population-based Botswana Combination Prevention Project (BCPP).

METHODS

A total of 6078 HIV-1C pol sequences were analysed for DOR-associated resistance mutations using the Stanford HIV drug resistance database, and their levels were predicted according to the Stanford DRM penalty scores and resistance interpretation. Virologic failure was defined as HIV-1 RNA load (VL) >400 copies/mL.

RESULTS

Among 6078 PWH, 5999 (99%) had known ART status, and 4529/5999 (79%) were on ART at time of sampling. The suppression rate among ART-experienced was 4517/4729 (96%). The overall prevalence of any DOR-associated resistance mutations was 181/1473 (12.3% [95% confidence interval {CI}: 10.7-14.1]); by ART status: 42/212 (19.8% [95% CI: 14.7-25.4]) among ART-failing individuals (VL ≥400 copies/mL) and 139/1261 (11.0% [95% CI: 9.3-12.9]) among ART-naïve individuals (P < 0.01). Intermediate DOR-associated resistance mutations were observed in 106/1261 (7.8% [95% CI: 6.9-10.1]) in ART-naïve individuals and 29/212 (13.7% [95% CI: 9.4-8.5]) among ART-experienced participants (P < 0.01). High-level DOR-associated resistance mutations were observed in 33/1261 (2.6% [95% CI: 1.8-3.7]) among ART-naïve and 13/212 (6.1% [95% CI: 3.6-10.8]) among ART-failing PWH (P < 0.01). PWH failing ART with at least one EFV/NVP-associated resistance mutation had high prevalence 13/67 (19.4%) of high-level DOR-associated resistance mutations.

CONCLUSION

DOR-associated mutations were rare (11.0%) among ART-naive PWH but present in 62.7% of Botswana individuals who failed NNRTI-based ART with at least one EFV/NVP-associated resistance mutation. Testing for HIV drug resistance should underpin the use of DOR in PWH who have taken first-generation NNRTIs.

Medical stakeholder perspectives on implementing a computerized battery to identify neurocognitive impairments among youth in Botswana

HIV infection and in utero exposure, common in Sub-Saharan Africa, are associated with pediatric neurocognitive impairment. Cognitive screening can identify impairments, but it is rarely used in this setting. The Penn Computerized Neurocognitive Battery (PennCNB), an evidence-based cognitive screening tool, was adapted for use in Botswana. To facilitate future implementation, 20 semi-structured interviews were conducted to elicit key stakeholders' perspectives on factors likely to be related to successful uptake of the PennCNB in clinical settings. An integrated analytic approach combining constructs from the Consolidated Framework for Implementation Research and modified grounded theory was used. Results underscore the need for cognitive screening in Botswana and the acceptability of the PennCNB. Implementation barriers include limited time and resources, whereas facilitators include standard procedures for introducing new tools into medical settings and for training implementers. Recommended implementation strategies include integrating screening into the existing workflow, implementing the tool in the medical and educational sectors, and targeting selection of children for assessment. This research addresses the research-to-practice gap by engaging in pre-implementation inquiry and designing for implementation. Results will inform the development of strategies to maximize the likelihood of successful implementation of the PennCNB to identify neurocognitive impairment in children in this high-need setting.

Lower Insulin Sensitivity in Newborns With In Utero HIV and Antiretroviral Exposure Who Are Uninfected in Botswana

BACKGROUND

Few data exist on early-life metabolic perturbations in newborns with perinatal HIV and antiretroviral (ARV) exposure but uninfected (HEU) compared to those perinatally HIV unexposed and uninfected (HUU).

METHODS

We enrolled pregnant persons with HIV (PWH) receiving tenofovir (TDF)/emtricitabine or lamivudine (XTC) plus dolutegravir (DTG) or efavirenz (EFV), and pregnant individuals without HIV, as well as their liveborn infants. Newborns were randomized to receive either zidovudine (AZT) or nevirapine (NVP) postnatal prophylaxis. Preprandial homeostasis model assessment for insulin resistance (HOMA-IR) was assessed at birth and 1 month. Linear mixed models were fit to assess the association between in utero HIV/ARV exposure and average HOMA-IR from birth to 1 month, adjusting for confounders.

RESULTS

Of 450 newborns, 306 were HEU. HOMA-IR was higher in newborns HEU versus HUU after adjusting for confounders (mean difference of 0.068 in log HOMA-IR, P = .037). Among newborns HEU, HOMA-IR was not significantly different between TDF/XTC/DTG versus TDF/XTC/EFV in utero ARV exposure and between AZT versus NVP newborn postnatal prophylaxis arms.

CONCLUSIONS

Newborns HEU versus HUU had lower insulin sensitivity at birth and at 1 month of life, raising potential concern for obesity and other metabolic perturbations later in life for newborns HEU.

CLINICAL TRIALS REGISTRATION

NCT03088410.

Community Knowledge, Perceptions and Experiences on Healthcare Services for Malaria Prevention and Treatment in the Okavango Delta, Botswana

This paper analyses community knowledge, perceptions, and experiences of effectiveness of healthcare service provision on malaria prevention/treatment in two disease-endemic villages of the Okavango Delta panhandle in northern Botswana. A stratified random sampling of 355 households was conducted in October-November 2015. Follow-up retrospective cohort interviews were undertaken in August 2016 from 79 households that reported malaria incidences during the household survey. Data were also collected from 16 key informant interviews and 2 focus group discussions participants. Descriptive statistics and content analyses were used to summarise quantitative and qualitative data, respectively. Results indicate that communities in the study sites had positive perceptions about efficiency of health services based on availability, accessibility and utilization, adequacy of prevention and treatment interventions. Local health clinics were crucial information channels used by respondents. Additionally, factors related to acceptability, availability and accessibility are likely to contribute to perceived effectiveness of the interventions provided by healthcare service providers. Affirmation of efficiency health service provision against malaria has public health implications for adherence to treatment/prevention and participation in community health education campaigns and program implementation in the Okavango Delta region.

Services as a Determinant of Botswana's Economic Sustainability

In 2015, the services sector contributed about 58 percent to the gross domestic product (GDP) in Sub-Saharan Africa (SSA), which was a significant increase from the 47.6 percent observed in 2005, and a shift from the mining, agriculture, and manufacturing sector. This increase calls to support services as the catalyst for sustained economic development as indicated by the structural transformation and modernization theories. The main objective of this paper was to examine the relationship between and the impact of services on the economic development in Botswana and make recommendations on how Botswana can apply well-directed policies to improve its services sector and diversify its impact on other sectors and GDP, making it less reliant on mining which is vulnerable to price volatilities. The paper applied econometric modeling and results of the Autoregressive-Distributed Lag (ARDL) Bounds test for cointegration indicate that services and other industries services, agriculture, industry, mining, and investment impact GDP over the short and long run. These variables impacted GDP and converged to equilibrium at the speed of 46.89 percent, with a percent change in services in the short and long run impacting GDP by 0.328 and 0.241 percentages, respectively, and the outcome of the Wald test indicated causality from services to GDP growth. The services sectors have contributed over 40 percent to the country's GDP from 1995 to the present, though the sectors have not gone without challenges with limitations such as limited infrastructure development; poverty and inequality; unemployment of over 20 percent; disease, which has dampened productivity; and lack of proper governance and accountability, which has created a habitat for an increase in cases of corruption in state and private entities. The findings of the study with the lessons learned from other studies with similar findings recommend that the government of Botswana should formulate suitable policies and strategies for services diversification. This is by expanding the market for the sector in areas such as tourism that were impacted by the COVID-19 pandemic, escalating investments by instituting strategies to attract and grow domestic and foreign investments, and improve on management of institutions and resources.

Retrospective analysis of SARS-CoV-2 omicron invasion over delta in French regions in 2021-22: a status-based multi-variant model

BACKGROUND

SARS-CoV-2 is a rapidly spreading disease affecting human life and the economy on a global scale. The disease has caused so far more then 5.5 million deaths. The omicron outbreak that emerged in Botswana in the south of Africa spread around the globe at further increased rates, and caused unprecedented SARS-CoV-2 infection incidences in several countries. At the start of December 2021 the first omicron cases were reported in France.

METHODS

In this paper we investigate the spreading potential of this novel variant relatively to the delta variant that was also in circulation in France at that time. Using a dynamic multi-variant model accounting for cross-immunity through a status-based approach, we analyze screening data reported by Santé Publique France over 13 metropolitan French regions between 1st of December 2021 and the 30th of January 2022. During the investigated period, the delta variant was replaced by omicron in all metropolitan regions in approximately three weeks. The analysis conducted retrospectively allows us to consider the whole replacement time window and compare regions with different times of omicron introduction and baseline levels of variants' transmission potential. As large uncertainties regarding cross-immunity among variants persist, uncertainty analyses were carried out to assess its impact on our estimations.

RESULTS

Assuming that 80% of the population was immunized against delta, a cross delta/omicron cross-immunity of 25% and an omicron generation time of 3.5 days, the relative strength of omicron to delta, expressed as the ratio of their respective reproduction rates, [Formula: see text], was found to range between 1.51 and 1.86 across regions. Uncertainty analysis on epidemiological parameters led to [Formula: see text] ranging from 1.57 to 2.34 on average over the metropolitan French regions, weighted by population size.

CONCLUSIONS

Upon introduction, omicron spread rapidly through the French territory and showed a high fitness relative to delta. We documented considerable geographical heterogeneities on the spreading dynamics. The historical reconstruction of variant emergence dynamics provide valuable ground knowledge to face future variant emergence events.

A Review of the User Fees Policy for Primary Healthcare Consultations in Botswana: Problems With Effective Planning, Implementation and Evaluation

BACKGROUND

The Government of Botswana introduced user-fees for primary healthcare consultations in 1975. The policy has remained in place since then, although the fee has remained largely unaltered despite rising inflation. Early reviews of the policy pointed to problems in its implementation, but there has been no evaluation in the past 20 years. The aim of this study was to review the policy to assess whether documented issues with its implementation have been addressed.

METHODS

This qualitative study involved interviews with 32 key informants: 18 policy-makers and 14 front-line revenue collectors. Data were analysed thematically using a template approach with constructs from an established organizational capacity assessment framework used as predetermined categories to guide data collection and analysis.

RESULTS

Limited administrative and management capacity has been a major hindrance to effective implementation of the policy. The lack of infrastructure for effective revenue collection led to misappropriation of funds. Lack of clear guidelines for health facilities on how to implement the policy generated interdepartmental conflicts. Study participants believed the current policy was unlikely to be cost-effective since the cost of collecting fees probably exceeded the revenue it generated.

CONCLUSION

If the Botswana Government persists with the policy then it needs to improve organizational capacity to collect and manage revenues efficiently. However, policy thinking since the turn of the century has turned away from user-charges in healthcare as they impede the move towards universal access. It is timely therefore to consider alternative financing approaches that are more effective and a more equitable means of paying for healthcare.

Acceptability and accessibility of HIV testing and treatment among men who have sex with men in Botswana

Background: Although HIV testing and treatment are the cornerstones of a comprehensive prevention strategy, their acceptability and accessibility are complex within the healthcare system.Methods: We used Aday and Andersen's conceptual framework of access to healthcare services to explore factors influencing acceptability and accessibility of HIV testing and treatment among men who have sex with men (MSM) in Botswana. A qualitative descriptive study was conducted, using purposive sampling to recruit 20 MSM. Semi-structured interviews were conducted in Setswana and English. All data were audio-recorded, transcribed, translated into English, where necessary, and analysed using thematic analysis.Findings: This study found that acceptance of HIV testing and treatment was largely positive among MSM. Motivators were the expansion of HIV services, free healthcare services and the perceived risk of contracting HIV. Although perceptions of accessibility to HIV testing and treatment were positive, there were some concerns about privacy and confidentiality, perceived barriers and fear of positive diagnosis, making MSM reluctant to access HIV testing and treatment.Conclusion: This study highlights the need for novel approaches to increase the acceptability and accessibility of HIV testing and treatment. Barriers to accessing HIV services should be addressed to achieve satisfactory health outcomes, and sustainable HIV prevention barriers to accessing HIV should be addressed among MSM.