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Annex 1: Country and sector or program background.

BOTSWANA: Botswana National HIV/AIDS Prevention Support Project

Brief Country Profile

1. Botswana is a small land-locked country in Southern Africa, bordered by Zambia and Angola to the north, Namibia to the west, and Zimbabwe and South Africa to the east and south respectively. The administrative structure is composed of 9 districts (Central, Ghanzi, Kgalagadi, Kgatleng, Kweneng, North East, North West, South East and Southern), 5 urban districts, 28 sub-districts, and 24 health districts.

2. Since independence from the United Kingdom in 1966, its economic indices have appreciated significantly. Its GDP per capita has risen from US$304 at independence in 1966 to US$4,423 in 2006 (measured in constant 2000 US$). Diamond mining, which has been the largest GDP contributor for the past thirty years accounts for 38 percent of GDP and for 70-80 percent of export earnings. Tourism, financial services, subsistence farming, and cattle farming are other key economic sub-sectors. In contrast to these indicators, the country continues to face significant development challenges including high inequality (as measured by the Gini coefficient), high unemployment at an estimated 20 percent (unofficial estimates place this figure closer to 40 percent) and limited economic diversification, and the world's second most severe HIV/AIDS epidemic.

Demographic and Health Profile

3. Botswana has a population of 1.8 million with an annual growth rate of 1.5 percent. It has a contraceptive prevalence rate of 40.4 percent, a total fertility rate of 3.1 children per woman and a crude death rate of 27.7 percent. About 50 percent of its population lives in the rural areas with sparse population settlements in the villages along the westward located Kalahari Desert. Its education indicators are impressive with an adult literacy rate of 81.2 percent and a female primary school enrolment rate of 83 percent.

4. However, some social indicators are weaker than those of other middle income economies. In 2006 Botswana ranked 131 out of 177 countries on the Human Development Index as the HTV/AIDS pandemic continues to jeopardize the social gains of recent decades with key health indicators on decline. Life expectancy has quickly fallen from 60 to 35 years. Infant mortality is up from 45 (per 1,000 births) in 1990 to 85 in 2005. Tuberculosis is up from 236.2 (per 100,000) in 1990 to 670.2 in 2005 and made up approximately 38 percent of AIDS deaths. Malaria is not endemic in Botswana, with seasonal occurrences during the rains in the northern districts of Central, Chobe, Ghanzi, Ngamiland, and the Okavango Delta area.

5. Botswana has 24 health districts, each with a health team. It has 3 referral hospitals, 12 district hospitals, 17 primary hospitals, 222 clinics, 220 health posts and 740 mobile stops. Towards strengthening its HAART delivery system, the Ministry of Health is constructing 250 additional clinics so as to increase access to ARVs. Total expenditure on health is 5.6 percent of GDP, with general government spending making up 58.2 percent and private spending making up 41.2 percent. It has 0.4 physicians, 2.65 nurses, and 0.19 pharmacists per 1000.


6. It is estimated that in 2008, 283,000 adults (over 15 years of age) were living with HIV/AIDS in Botswana. This indicates a national adult (15-49 years) prevalence of approximately 23.8 percent (5). As noted earlier, key factors fueling the HIV/AIDS epidemic include the incidence of multiple concurrent sexual partnerships, the incidence of unprotected sex, the vulnerability of women, persistent inequality and poverty, and high levels of population mobility, including cross-border challenges.

7. The number of new infections rose rapidly during the early 1990s, peaking in the mid-1990s. The number of AIDS deaths started to grow rapidly about 10 years later than the rise in new infections, peaking in 2003, just before the expansion of the national AIDS treatment program. Around 2003, the number of new infection was approximately equal to the number of AIDS deaths, with respect to the adult population of Botswana. The successful expansion of the treatment program has reduced the number of AIDS deaths by half. The most significant challenge for the national program, currently, is to strengthen efforts to reduce the number of new infections still occurring each year. During 2008, it is projected that there will be 14,100 new adult infections, 690 new child infections, and 7,700 AIDS deaths in Botswana. Despite continued challenges in expanding prevention efforts, some pockets of improvement have become evident.


National HIV prevalence in Botswana has shown a steady decline fallen, most prominently amongst the most vulnerable age groups; 15-19 year olds (22.8 percent in 2003 to 17.5 percent in 2006) as well as the 20-24 year olds (38.6 percent to 29.4 percent in 2006) (6), as is demonstrated in Figure 1. There has been a increase in the reported condom use with non-regular partners in the last 12 months among ages 15-24, from 82 percent in 2001 to 87.5 percent in 2005. Other positive responses include that fact that testing increased to 25.4 percent of 10-64 year olds in 2004 from 8.9 percent in 2001 (7). There also has been an increase in the proportion of pregnant women attending antenatal clinics accepting HIV testing, from 71 percent in early-2004 to 80 percent in early- 2007. In parallel, there has been an increase in the number of HIV-seropositive pregnant women receiving a complete course of antiretroviral prophylaxis to reduce the risk of mother-to-child transmission, from 34.3 percent in 2001 to 89 percent in 2007. This has yielded a dramatic decline in the proportion of infants born to HIV+ mothers who are infected at 18 months, from 40 percent in 2001 to 7 percent (at 6 weeks) in 2007.



8. HIV incidence increased from 6 percent to 8.7 percent between 2001/2002 and 2006, for pregnant women attending ANC. This can be partially explained by the following data:

* An increase in proportion of males between 15 and 24 years old who have ever had sex from 39 percent (2001) to 56.1 percent (2005), and females in the same age group increased from 42.2 percent to 57.9 percent in the same time frame (8).

* An increase in the proportion of people aged 15-24 years old reporting unprotected sex in the last month after consuming alcohol, from 5 percent in 2001/2 to 14.7 percent in 2007 (9) (a 200 percent increase).

* Increase in the percentage of young people 15-19 who had sex with more than one partner during the last 12 months from 0.3 percent in 2001(BAIS I) to 17.1 percent in 2005 (BAIS II).

* A reduction of 15 percent in the proportion of people aged between 15 and 24 who know all three ways of preventing sexual transmission, from 36.3 percent in 2001/2 to 17.35 percent in 2005. Further segregated, only 15.5 percent of 15-19 year olds and 19.2 percent of 20-24 year olds know all three ways of preventing HIV transmission. 10.65 percent of 15-24 year olds didn't know any way of preventing HIV transmission.

9. The effect of HIV/AIDS has been nothing short of devastating and

threatens the long-term socio-economic development of Botswana. In 2002, the Government of Botswana commenced its national treatment program, via which it offered free ART treatment to all infected Botswana citizens with CD4 levels<200, presence of an AIDS defining illness or any child under the age of 13 years. Following this, ART sites were rolled out in a phased manner and by December 2005, 32 ART sites covered all 24 districts in the country. As of March 2008, national treatment coverage is estimated to be 88.4 percent. Patient follow-up and adherence to treatment has been estimated at over 90 percent.

10. It is of significant economic concern that national HIV/AIDS-related investments have displaced other budget priorities, especially given the paucity of donors active in Botswana. It should be noted that the Government of Botswana finances over 90 percent of the national HIV/AIDS program. The cost of this disease-specific government allocation has increased dramatically from US$69.8 million in 2000-2001, to US$165 million in 2004-2005.

11. The government agency in charge of coordinating the national response is the National AIDS Coordinating Agency (NACA), which serves as the secretariat of the National AIDS Council (NAC) which up March 31, 2008 chaired by the President of the country, now chaired by the former President. NACA has the primary responsibility of overseeing the multi-sectoral implementation of the national response as stipulated in the National Strategic Framework (NSF). However its efforts have yet to realize their full potential due to weak operating systems and inadequate human resources. International donors have also played a significant part in the response to HIV/AIDS in Botswana, though compared to other high prevalence countries, they are few in number. Notable among these are the US government (CDC, PEPFAR, and BOTUSA), ACHAP (partnership between the Bill and Melinda Gates foundation, Merck and the Government of Botswana) as well as the key UN agencies.

12. The Civil Society Organizations (NGOs, FBOs, PLWHA Groups, and the Private Sector) response is quite extensive in Botswana. They are the primary implementers of HIV/AIDS related activities at the community level. Majority of them are local, while only a few international NGOs (e.g. Population Services International) are represented. They are primarily funded by the Government of Botswana, but also receive funding from the International donors. However poor coordination, inconsistent funding and weak implementation and monitoring capacity have blunted the potential effect of the CSOs.
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Publication:Botswana - National HIV/AIDS Prevention Support Project
Date:Jan 1, 2008
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