Free antiretroviral therapy for non-citizens in Botswana: a further step towards the elimination of HIV

Following the expansion of antiretroviral therapy to migrants and non-citizens in Botswana, gaps have narrowed in the uptake of antenatal care and antiretroviral therapy during pregnancy between citizens and non-citizens living with HIV. Disparities in adverse birth outcomes were no longer observed after the change in policy, according to a report in the Journal of the International AIDS Society.

In Botswana, approximately 25% of female citizens aged 15 to 49 are living with HIV. Back in 2002, the government of Botswana launched a free universal antiretroviral therapy programme, which has proven to be very successful, including by improving birth outcomes of infants born to women with HIV. However, access to this programme was restricted to citizens of Botswana only, although non-Botswanan citizens represent as high as 7% of the country’s total population. Many are migrants from neighbouring countries with large HIV epidemics, such as Zimbabwe, Zambia and South Africa, with 13%, 11% and 19% HIV prevalence, respectively.

Only 29% of migrants in Botswana had personal health insurance or could afford to pay for HIV care, and research has shown that migrants had worse health outcomes than citizens of Botswana. Evidence has also shown that stigmatisation by healthcare and security staff in medical facilities were barriers to receiving care. Furthermore, pregnant non-citizens were less likely to receive antenatal care and more likely to receive care later in pregnancy, deliver at home and experience adverse birth outcomes than pregnant citizens of Botswana.

At the end of 2019, the government of Botswana drastically shifted its policy by authorising the free distribution of antiretroviral therapy to non-citizens living with HIV.

Dr Christina Fennel from Harvard University, with colleagues in Botswana and the US, evaluated the impact of this major policy change on antenatal care, antiretroviral therapy use and adverse birth outcomes among infants. For this, they compared outcomes in infants born to citizens and non-citizens living with HV, before (2014-2019) and after (2019-2021) the policy change. They used data from the Tsepamo Surveillance Study, a large birth outcomes surveillance programme that collects data from maternity sites in Botswana, including about 72% of all births in the country.

More specifically, the impact analysis was based on data from maternal records. Adverse birth outcomes analysed were preterm delivery, very preterm delivery, stillbirth, neonatal death, small for gestational age (babies smaller than usual for the number of weeks of pregnancy) and very small for gestational age. Because multiple births may be associated with adverse birth outcomes, only singleton births were included in the analyses of adverse birth outcomes.

Results

During the entire analysis period – 2014 to 2021 – there were 47,576 live deliveries and stillbirths among pregnant women with HIV recorded in the Tsepamo study, including 47,443 with known citizenship status – 45,917 (97%) Botswanan citizens and 1,516 (3%) non-citizens.

The proportion of non-citizens with unknown HIV status decreased significantly in the post-expansion period, from 6% to 1% (p < 0.001), whereas it remained the same (0.5% vs 0.4%; p = 0.02) for citizens.

The proportion of non-citizens with HIV attending antenatal care increased from 79% in the pre-expansion period to 87% following expansion, whereas attendance among citizens with HIV remained constant through both periods at approximately 96%. (Non-citizens can attend antenatal care by paying a modest fee, which did not change through the study period).

In the pre-expansion period, 65% of non-citizens received antiretroviral therapy, of whom only 7% had a dolutegravir-based regimen. After 2019, the proportion on antiretroviral therapy increased significantly to 90%, narrowing the gap with citizens (97%). Also, the proportion of non-citizens and citizens receiving dolutegravir almost equalised (42% vs 44%), showing a decrease in the use of old antiretrovirals such as nevirapine, which have a higher risk of adverse birth outcomes.

Regarding adverse birth outcomes, in the pre-expansion period infants born to non-citizens with HIV had significantly greater risks of preterm delivery (aRR = 1.28; 95% CI: 1.11, 1.46), very preterm delivery (aRR = 1.89; 95% CI: 1.43, 2.44) and neonatal death (aRR = 1.69; 95% CI: 1.03, 2.60) when compared with infants born to citizens with HIV. For reasons that are not clear, non-citizens had a reduced risk of having an infant who was small for gestational age (aRR = 0.75; 95% CI: 0.62, 0.89).

After the expansion of antiretroviral therapy, none of the adverse birth outcomes were significantly higher among infants born to non-citizens with HIV than infants born to citizens with HIV.  Also, there were declines in adverse birth outcomes among infants born to non-citizens, including preterm delivery (23% in 2014-2019 vs 14% in 2019-2021) and stillbirth (4% vs 3%). At the same time, no changes in birth outcomes for HIV-negative non-citizens were observed.

According to Fennel and colleagues, their findings suggest that greater access to antiretroviral therapy – including modern regimens – may have reduced adverse birth outcomes. They also underscore the substantial decrease of the proportion of pregnant non-citizens with unknown HIV status, as well as increased linkage to HIV therapy and antenatal care after the policy change.

In 2022, Botswana was praised for reaching, ahead of the 2025 target, the UNAIDS goals of 95% of all people living with HIV to be aware of their status, 95% of those aware of their status to receive sustained antiretroviral therapy, and 95% of people receiving this therapy to achieve viral load suppression. The results of this study further confirm that Botswana has become a model for other countries that may still hesitate to scale-up access to antiretroviral therapy and HIV care for all minorities, including migrants, not to mention those countries that might be tempted to introduce new restrictions.