At approximately 18 percent, the prevalence of HIV in Botswana’s general population is one of the highest in the world. As a result, national HIV prevention efforts have focused more intensively on the general population than on other populations. Little is known about key populations, such as female sex workers and men who have sex with men, whose behaviors are both stigmatized and illegal in Botswana.
In 2012, the Botswana Ministry of Health used an integrated behavioral and biological surveillance survey to estimate population sizes and prevalence of HIV and sexually transmitted infections (STIs) among female sex workers and men who have sex with men. The study was historic. For the first time, it showed the HIV and STI burden among these two key populations and raised awareness about how they might have contributed to the generalized HIV epidemic.
The survey, carried out with technical assistance from FHI 360 through the Preventive Technologies Agreement (funded by the U.S. Agency for International Development), uncovered a population of more than 4,000 female sex workers in the three districts where the survey was conducted. Among these female sex workers, HIV prevalence was 61.9 percent, and the prevalence of gonorrhea and chlamydia were both higher than 10 percent. The female sex workers had a mean of more than seven partners per week, and condom failure, which includes condom breakage and being paid or forced not to use condoms, was common.
New insight into the HIV epidemic
Although the contribution of female sex workers to Botswana’s generalized HIV epidemic has yet to be confirmed, female sex workers likely played a role given their sizeable population, high HIV prevalence, average number of new sexual partners per day, and common experiences with condom failure. This important data helps us better understand the progression and severity of Botswana’s epidemic and contributes to the development of a more comprehensive response.
The survey also identified a population of almost 800 men who have sex with men in two of the three districts. Among this population, HIV prevalence was 13.1 percent, and chlamydia was the most prevalent STI (11.3 percent). Risk factors for HIV and STI acquisition and transmission included multiple concurrent partnerships, sex with both men and women, excessive alcohol consumption, limited access to water-based lubricants and a lack of awareness that anal sex increases HIV risk.
The findings among men who have sex with men have been important for raising awareness about this key population in Botswana, where many people are just beginning to accept that there are men who have this sexual identity. The findings have also been instrumental in paving the way for targeted services and programs for this group, which were largely nonexistent and were not endorsed by the government until the survey results were released.
Survey results were presented to the National AIDS Council and other high-level government officials and stakeholder groups, and in late 2013, the Ministry of Health updated Botswana’s national STI treatment guidelines. The new guidelines encourage clinicians to perform anal examinations and collect comprehensive sexual histories for men who have sex with men. The Ministry of Health has also appointed a local nongovernmental organization to provide HIV and STI services directly to key populations, likely to begin later this year.
Additional policy and programmatic changes based on the survey results are possible, as the government of Botswana remains committed to a long-term response to HIV and AIDS. And the top priority in the government’s response? Preventing new HIV infections. The results of the 2012 behavioral and biological surveillance survey are helping to reach that goal.