Many individuals who tested HIV-positive using Botswana’s Tebelopele voluntary testing and counselling (VCT) service were in a monogamous sexual relationship, according to a study published in the October 1st edition of the Journal of Acquired Immune Deficiency Syndromes. The study also revealed that demand for HIV testing increased significantly after Botswana introduced an antiretroviral treatment programme.
Botswana is a politically stable, middle-income country with one of the highest HIV prevalences in the world. The government of Botswana has a stated commitment to HIV-related health programmes and introduced the first free programme designed to prevent mother-to-child transmission of HIV in Africa in 2001, and a year later, Botswana was the first country in Africa to develop a public antiretroviral treatment programme. By late 2004, over 25,000 individuals were receiving anti-HIV therapy in Botswana.
Despite these advances in the provision of HIV treatment, the rate of HIV testing in Botswana has been low, with fewer than half of pregnant women tested for HIV in 2002, and only 6% of tuberculosis patients are on record as having had an HIV test.
Since 2000, providing voluntary HIV testing and counselling outside the healthcare system has been a high priority in Botswana, and to this end the government launched testing and counselling facilities called Tebelopele (“to look into the future”). By 2003, there were 16 Tebelopele centres offering free anonymous HIV testing and counselling.
Investigators wished to describe the social and demographic characteristics of Tebelopele’s clients and the factors associated with HIV infection. Information obtained from 157,000 visits between April 2000 and September 2004 were available for analysis.
Of the 117,000 individuals testing at a Tebelopele facility for the first time, 37% were HIV-positive. The number of individuals seeking HIV testing increased dramatically after Botswana introduced its antiretroviral treatment programme in 2002, with a marked increase in the number of clients seeking an HIV test because of illness (8% sought HIV testing because of illness before antiretroviral therapy was available, this increased to 20% after the treatment programme was launched). There was also an increase in the proportion of clients testing HIV-positive following the launch of the treatment programme from 26% to 39%. The investigators also found that 78% of individuals who sought an HIV test for health reasons were HIV-positive.
When the investigators analysed the details of Tebelopele’s clients, they found that 88% of men and 96% of women had had one or no sexual partners in the three months preceding their HIV test. In multivariate analysis, marriage, a higher level of education, and consistent condom use, were all found to be associated with a lower risk of HIV infection.
For women, factors significantly associated with an increased risk of HIV infection were increasing age, being unmarried or widowed, low educational attainment, being a labourer or a business person, sexual abstinence, inconsistent condom use, and seeking an HIV test for health reasons (all p < 0.001). The same factors were also significantly associated with testing HIV-positive for men, as was having only one sexual partner in the previous three months and being in the uniformed services.
Overall, 44% of sexually active individuals reported using condoms all the time, 28% to using them sometimes and 23% said they never used condoms. Unmarried individuals with only one sexual partner in the previous three months were more likely to report never using condoms than were individuals with multiple sexual partners (19% vs. 9%, p < 0.001), and had an HIV prevalence rate of 51%.
Repeat HIV tests were performed on 33,500 individuals and 1,100 of these (4%) tested HIV-positive. Individuals who had used Tebelopele for testing and counselling before were more likely to report consistent condom use than first-time clients (67% vs. 50%, < 0.001).
The investigators are enthusiastic about Tebelopele, noting that in its first five years, it tested 11% of Botswana’s adult population for HIV. However, they note the high HIV prevalence and low levels of condom use amongst clients reporting that they were unmarried and only had one recent sexual partner. The investigators believe that there is a need to “emphasize strongly that short-term monogamy does not equal protection from HIV.” The future marketing of Tebelopele should, they write, “emphasize testing for those who are not ill, continue to encourage testing for couples, and focus on normalizing HIV testing at pivotal points in interpersonal relationships, including before having sex for the first time, before ceasing condom use, before marriage, and before pregnancy”
Creek TL et al. Botswana’s Tebelopele voluntary HIV counselling and testing network: use of client and risk factors for HIV infection, 2000 – 2004. J Acquir Immune Defic Syndr 43: 210 – 218, 2006.