Lessons from Botswana's HIV/AIDS treatment programme
Authors: John Stover
Journal: The Lancet Global Health (2013)

The report by Mansour Farahani and colleagues1Farahani M Vable A Lebelonyane R et al.Outcomes of the Botswana national HIV/AIDS treatment programme from 2002 to 2010: a longitudinal analysis.Lancet Glob Health. 2013; (published online Dec 11.)http://dx.doi.org/10.1016/S2214-109X(13)70149-9Google Scholar in The Lancet Global Health of 9-year outcomes of the antiretroviral therapy (ART) programme in Botswana is a welcome addition to the scientific literature on ART programmes. It provides national-level data for more than 126 000 patients who initiated ART from 2002 to 2010. Botswana was the first country in sub-Saharan Africa to make a strong national commitment to scaling up treatment to the entire eligible population. There was early commitment from the commercial sector and the national government to provide resources for treatment. Donor support quickly followed. As a result, Botswana achieved very high coverage, 80–90%, of those eligible for treatment as early as 2005. The effect of this high coverage was an estimated decrease in AIDS deaths of more 50% from 2002 to 2006.2Stover J Fidazni B Molomo BC Moeti T Musuka G Estimated HIV trends and programme effects in Botswana.PLoS One. 2008; 3: e3829Crossref PubMed Scopus (54) Google Scholar The programme has maintained high coverage even as eligibility has expanded. Confirmation of this high coverage comes from data presented by Farahani and colleagues showing that the median CD4 cell count at treatment initiation rose from 101 cells/μL (IQR 44–156) in 2002, to 191 cells/μL (115–239) by 2010. The increase in CD4 count at initiation contributed to the decrease in overall mortality of those in their first year of treatment from 29% (51 of 171) of patients in the first year of the programme to 3% (349 of 11 679) in 2009.Farahani and colleagues report that mortality for patients receiving ART was highest in the first few months of treatment and then declined sharply with longer time on treatment. This finding is consistent with patterns shown by the International Epidemiologic Databases to Evaluate AIDS (IeDEA) Consortium reporting on mortality among 123 000 patients in treatment cohorts in several different countries.3Yiannoutsos CT Johnson LF Boulle A et al.Estimated mortality of adult HIV-infected patients starting treatment with combination antiretroviral therapy.Sex Trans Infect. 2012; 88: i33-i43Crossref PubMed Scopus (46) Google Scholar For southern Africa the IeDEA Consortium estimates that mortality in the first year of treatment is more than double the rate for those on treatment for more than 2 years.3Yiannoutsos CT Johnson LF Boulle A et al.Estimated mortality of adult HIV-infected patients starting treatment with combination antiretroviral therapy.Sex Trans Infect. 2012; 88: i33-i43Crossref PubMed Scopus (46) Google Scholar The Botswana data show an even steeper gradient in mortality with 12·8 deaths per 100 person-years (95% CI 12·4–13·2) in the first 3 months of treatment, 3·46 deaths per 100 person-years (3·25–3·69) after 6 months of treatment, and only 1·16 deaths per 100 person-years (1·12–1·20) in the second year of treatment. This finding provides strong justification for earlier treatment initiation.As with most analyses of this type, the results are affected by assumptions about what happened to patients who were lost to follow-up, who constituted 12% (15 270 of 126 263) of the patients in the database. The reported mortality is based on documented deaths of patients receiving ART and patient-years of follow-up and thus is likely to underestimate total mortality. Farahani and colleagues estimate that if 60% of those who were lost to follow-up had died, then the overall mortality would increase from 8% (10 230 of 126 263) to 11–13%.Botswana has been a leader in showing that high-quality treatment and programmes to prevent mother-to-child transmission (95% coverage in 20124UNAIDSGlobal Report: UNAIDS report on the global AIDS epidemic 2013. UNAIDS, Geneva2013Google Scholar) can be implemented at scale by national programmes in sub-Saharan Africa. Sustaining this success will require meeting new challenges, particularly meeting the rising costs of the programme with even larger contributions from the national government and identifying and initiating people on treatment earlier, at CD4 counts of up to 500 cells/μL. Meeting these challenges will provide substantial benefits in terms of reduced mortality, fewer new HIV infections, fewer orphaned children, and future savings from averting infections (saving future treatment costs) and productivity losses.I declare that I have no conflicts of interest. The report by Mansour Farahani and colleagues1Farahani M Vable A Lebelonyane R et al.Outcomes of the Botswana national HIV/AIDS treatment programme from 2002 to 2010: a longitudinal analysis.Lancet Glob Health. 2013; (published online Dec 11.)http://dx.doi.org/10.1016/S2214-109X(13)70149-9Google Scholar in The Lancet Global Health of 9-year outcomes of the antiretroviral therapy (ART) programme in Botswana is a welcome addition to the scientific literature on ART programmes. It provides national-level data for more than 126 000 patients who initiated ART from 2002 to 2010. Botswana was the first country in sub-Saharan Africa to make a strong national commitment to scaling up treatment to the entire eligible population. There was early commitment from the commercial sector and the national government to provide resources for treatment. Donor support quickly followed. As a result, Botswana achieved very high coverage, 80–90%, of those eligible for treatment as early as 2005. The effect of this high coverage was an estimated decrease in AIDS deaths of more 50% from 2002 to 2006.2Stover J Fidazni B Molomo BC Moeti T Musuka G Estimated HIV trends and programme effects in Botswana.PLoS One. 2008; 3: e3829Crossref PubMed Scopus (54) Google Scholar The programme has maintained high coverage even as eligibility has expanded. Confirmation of this high coverage comes from data presented by Farahani and colleagues showing that the median CD4 cell count at treatment initiation rose from 101 cells/μL (IQR 44–156) in 2002, to 191 cells/μL (115–239) by 2010. The increase in CD4 count at initiation contributed to the decrease in overall mortality of those in their first year of treatment from 29% (51 of 171) of patients in the first year of the programme to 3% (349 of 11 679) in 2009. Farahani and colleagues report that mortality for patients receiving ART was highest in the first few months of treatment and then declined sharply with longer time on treatment. This finding is consistent with patterns shown by the International Epidemiologic Databases to Evaluate AIDS (IeDEA) Consortium reporting on mortality among 123 000 patients in treatment cohorts in several different countries.3Yiannoutsos CT Johnson LF Boulle A et al.Estimated mortality of adult HIV-infected patients starting treatment with combination antiretroviral therapy.Sex Trans Infect. 2012; 88: i33-i43Crossref PubMed Scopus (46) Google Scholar For southern Africa the IeDEA Consortium estimates that mortality in the first year of treatment is more than double the rate for those on treatment for more than 2 years.3Yiannoutsos CT Johnson LF Boulle A et al.Estimated mortality of adult HIV-infected patients starting treatment with combination antiretroviral therapy.Sex Trans Infect. 2012; 88: i33-i43Crossref PubMed Scopus (46) Google Scholar The Botswana data show an even steeper gradient in mortality with 12·8 deaths per 100 person-years (95% CI 12·4–13·2) in the first 3 months of treatment, 3·46 deaths per 100 person-years (3·25–3·69) after 6 months of treatment, and only 1·16 deaths per 100 person-years (1·12–1·20) in the second year of treatment. This finding provides strong justification for earlier treatment initiation. As with most analyses of this type, the results are affected by assumptions about what happened to patients who were lost to follow-up, who constituted 12% (15 270 of 126 263) of the patients in the database. The reported mortality is based on documented deaths of patients receiving ART and patient-years of follow-up and thus is likely to underestimate total mortality. Farahani and colleagues estimate that if 60% of those who were lost to follow-up had died, then the overall mortality would increase from 8% (10 230 of 126 263) to 11–13%. Botswana has been a leader in showing that high-quality treatment and programmes to prevent mother-to-child transmission (95% coverage in 20124UNAIDSGlobal Report: UNAIDS report on the global AIDS epidemic 2013. UNAIDS, Geneva2013Google Scholar) can be implemented at scale by national programmes in sub-Saharan Africa. Sustaining this success will require meeting new challenges, particularly meeting the rising costs of the programme with even larger contributions from the national government and identifying and initiating people on treatment earlier, at CD4 counts of up to 500 cells/μL. Meeting these challenges will provide substantial benefits in terms of reduced mortality, fewer new HIV infections, fewer orphaned children, and future savings from averting infections (saving future treatment costs) and productivity losses. I declare that I have no conflicts of interest. Outcomes of the Botswana national HIV/AIDS treatment programme from 2002 to 2010: a longitudinal analysisThe Botswana national HIV/AIDS treatment programme reduced mortality among adults with HIV to levels much the same as in other low-income or middle-income countries. Full-Text PDF Open Access