HIV prevalence among young women in Botswana falls to lowest level since early 1990s, but still high

HIV prevalence among women in Botswana between the ages of 15-19 and 20-24 has fallen to 17.8% and 30.6%, respectively, the lowest levels since 1992 and 1993, according to the 2005 Botswana HIV/AIDS Sentinel Surveillance Technical Report, which was distributed at the Botswana International HIV Conference earlier this month in Gaborone. The decline in prevalence among young women also powered a slight decline in the adjusted HIV prevalence among pregnant women in Botswana from 37.4% in 2003 down to 33.4%.

“We pray that this truly signifies that the prevention efforts that have been put in place are starting to bear fruit and we hope that with time that it will be sustained,” Botswana’s President Festus Mogae said at the Conference opening.

Nevertheless, “the figures are of course still unacceptably high,” said the Minister of Health Professor Sheila Tloe. According to the Minister, the national response has been stymied by an “inadequate change in desired behaviour.”

“We are hoping we can go well beyond that if we are really going to have an HIV-free generation by 2016 and to meet our Millennium Development goals.”

The sentinel survey

The survey involved 7,391 pregnant women between the ages of 15-49 years old attending antenatal clinics in Botswana’s 24 health districts. Although some of the districts fell short of the sample sizes needed to reliably calculate their local prevalence (two significantly), the survey was well powered to calculate the national prevalence.

In addition to monitoring national and regional trends in HIV prevalence (and estimating the current number of people living with HIV), it also explored behaviours that could explain the current epidemiological patterns within the country.

As might be expected, most of the pregnant women participating in the survey were under the age of 29. About 15% were between the ages of 15-19. The vast majority, 80.5%, were also single — only 10.7% were married — and 8.3% were living with a partner. For 32.9% of the women, this was their first pregnancy, 46.2% had had between two to three pregnancies while 21% had borne more than three children.

Results

Although the overall adjusted national HIV prevalence was 33.4%, it varied substantially among the districts, from a low of 20.8% in the Goodhope district in the south of the country up to 46.5% in Selebi-Phikwe (a densely populated mining community in the eastern part of the country). Two other districts, Francistown and Tutume (both in the northeast) had an HIV prevalence over 40%.

While the percentage of younger women who are HIV infected is lower than in previous years (see below), a growing number will become infected over time. In this survey, almost half of the women (49.2%) between the ages of 30-34 were HIV-positive, compared to 44.5% of those between the ages of 25-29, 40.2% of those aged 35-39 and 30.4% between the ages of 40-49.

Married women seemed to have a somewhat lower HIV prevalence rate nationally (27.9%) while 35.7% of the single women and 39.9% of the women living with partners were HIV-infected. However, in the two districts with the highest prevalence rates, Francistown and Selebi/Phikwe, or in Gaborone, there seemed to be no protective effect associated with marriage. All three of these districts are urban centres.

HIV prevalence tended to be highest among those with primary education (44.2%) than those with secondary or above (or no education). There was no clear trend in risk by current employment status. Domestic workers and store workers (41.9% and 41.2% respectively) tended to have the highest prevalence while students and office workers/professionals tended to have the lowest (19.8% and 30.4% respectively). Another analysis suggested that HIV prevalence increased with the number of pregnancies (which may be related partly to increasing age).

Although HIV prevalence was slightly higher in women attending urban facilities, there was no statistically significant difference between urban or rural facilities in any age group.

Trends and total estimated infected population

“We are seeing a reduction in HIV prevalence in Botswana in 2005... In pregnant women for the past four years, it was sort of stabilised, but in 2005, there was a significant reduction of about 4%,” said Dr. Khumo Seipone, who is the Director of Department of HIV/AIDS Prevention and Care of the Ministry of Health.

She again stressed that the reduction was powered by a lower prevalence rate in young women, down from a peak of 32.4% for 15-19 years olds in 1995 (24.7% in 2001) and a peak of 42.8% for 20-24 year olds in 1998 (and 38.7% in 2001).

“We are convinced that this is a real reduction, not due to high mortality or something like that. But we are crossing our fingers that the 2006 sentinel surveillance will confirm if this is a real trend,” Dr. Seipone said.

Data from the Botswana AIDS Impact Survey II (BAIS II) published last year were used to estimate that there are 256,206 HIV-infected Batswana (male: 98,423, and female: 157,783) between the ages of 15-49. It is interesting to note that over 42,000 people between the ages of 40-49 are HIV-infected, and as the HIV-infected population has been ageing, there must be a substantial number of persons over the age of 50 who are HIV-infected as well.

Association of prevalence with behaviour and HIV knowledge

The lower prevalence among young women is associated with an increased likelihood of using condoms — particularly with casual partners. However, data from BAIS II suggest that many Batswana still hold mistaken beliefs about HIV. For example, 30% believe that AIDS can be acquired by supernatural means (such as a curse), and over 50% think it can be acquired by mosquito bites.

Very few Batswana are aware that having multiple sexual partnerships is associated with a much higher risk of HIV (~21%). This is troubling considering that many Batswana have multiple partnerships. According to Dr. Molly Smit of BOTUSA (a partnership between the US CDC and Botswana), most of the households are headed by women, and “each child has a different father.”

When opening the conference, Dr. Kgosi Mompati, President of the Botswana Branch of the Southern Africa HIV Clinicians Society, said that there is a persistent carelessness around sex.

He conducted focus groups examining sexual attitudes among Batswana youth two years ago and was struck by language that seemed “aimed at getting youth to abandon the use of condoms” and engage in multiple partnerships.

For example, “among men,” Dr. Mompati said: “ ‘jumping out of the plane without a parachute’ means having sex without a condom, and when you do that you are a brave man and many others must follow you. ‘First in command’ is the wife with an unfaithful husband, and everything must be kept secret, and among them there is no condom use. Second in command is the stable girlfriend, well supported by a married man. Short range: Casual female sex partner met in night clubs and sex without condom. Handing over, means recommending your casual sex partner to a friend, giving him liberty to sleep with her and often without a condom.

“It's not just carelessness among men, there’s also carelessness among women. This language “I feel you” is what a girl will say to a boy indicating she wants to have sex with him without any commitment whatsoever and often without a condom.”

Professor Tlou pointed out there are gender-related age discrepancies in HIV serostatus, with many HIV-infected young women but few HIV-infected young men. However, with increasing age, there is increasing parity between men and women. She believes this may be evidence of intergenerational sex.

According to Dr. Mompati, there is often a transactional nature to these relationships. In his focus groups, young women gave these “clients” titles.

“The ‘Minister of Education’ is the client of a girl who buys books and stationery; the ‘minister of telecommunications’ is the man who is responsible for buying her mobile phone and airtime, the ‘minister of commerce’ buys clothes and the ‘minister of transport’ provides taxi fares. These honourable ministers do not use condoms because they pay more,” he said.

Information, education and communication (IEC) programmes in Botswana are increasingly trying to tackle intergenerational sex and promote fidelity. “I think it is an issue we need to confront to a larger extent than we have so far, by targeted interventions for both men and the youth,” she wrote in the Technical Report’s preface. However, she also alluded to a quote recently made by President Mogae.

“We have reached a crossroads in which there is a genuine opportunity to begin to move toward significant and sustainable reduction in new infections, but people will first have to embrace this prospect in their own lives.”