The Botswana HIV/AIDS epidemic started in the early 1990s, with the proportion
of the overall population infected with HIV (prevalence) rapidly escalating to 28.2% by
the year 2000. Today, HIV prevalence has decreased to 23%, yet Botswana has the third
highest percentage of HIV infected population in the world. The HIV epidemic in
Botswana is in need of attention, but prevalence alone does not represent the full picture.
HIV incidence (the rate of new infections and a critical indicator of success of HIV
prevention programs) peaked in Botswana around 1996 at 5.7% and has declined to about
2.72% today. Botswana’s two most effective programs in its response to the epidemic
have been provision of universal HIV treatment and prevention of mother-to-childtransmission
(PMTCT) programs, which have achieved over 95% coverage for all
eligible patients. These two programs largely account for Botswana’s rapid decline in
HIV prevalence and incidence rates. However, females have continually had higher rates
of prevalence and incidence than males throughout the course of Botswana’s epidemic.
In order to continue these declining rates of infection, Botswana may consider
redoubling its efforts around HIV prevention. Women and young adolescent girls have
not been the main beneficiaries of prevention programs. Women are more susceptible to
HIV infection biologically and more vulnerable to infection due to social determinants,
most notably their lack of empowerment and control in sexual partnerships. The main
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social drivers of the HIV epidemic in Botswana have been concurrent partnerships,
sexual assault, cross-generational sex, and transactional sex. These drivers increase risk
of HIV infection particularly for women.
Botswana has implemented promising national prevention programs focused on
HIV counseling and testing, consistent condom use, decreased concurrent partnerships,
and male circumcision. However, the Botswana legal system reinforces gender
inequalities, further increasing women’s risk for HIV infection. In Botswana’s law,
martial rape, domestic violence, and intimate partner violence are not criminalized.
Further, sex with minors and sexual assault are not strictly enforced. Sex work is illegal
and stigmatized, and thus sex workers are not receiving appropriate support in HIV
prevention. This high-risk population accounts for only 1.65% of the general population
but will account for 6.38% of new HIV infections.
The HIV treatment and PMTCT programs have decreased HIV incidence, but
Botswana may consider increasing its behavioral prevention programs to regard gender
norms and reforming legislation to protect women and young girls. This paper
recommends behavioral prevention programs through increased youth education
programs, women empowerment programs, access to sexual and reproductive health care,
and male involvement in sexual and reproductive health. Further, it is recommended that
policy makers focus on reforming civil legislation and bolstering enforcement of existing
laws that protect women from violence. The key to successful scale-up of behavioral
prevention in Botswana will be community-driven HIV initiatives and strong leadership
from community leaders and members of parliament, including women.