Modelling the impact of migrants on the success of the HIV care and treatment program in Botswana

Autoři: Tafireyi Marukutira aff001;  Nick Scott aff001;  Sherrie L. Kelly aff001;  Charles Birungi aff003;  Joseph M. Makhema aff005;  Suzanne Crowe aff001;  Mark Stoove aff001;  Margaret Hellard aff001
Působiště autorů: Burnet Institute, Melbourne, Australia aff001;  Monash University, Melbourne, Australia aff002;  UNAIDS, Gaborone, Botswana aff003;  University College London, London, England, United Kingdom aff004;  Botswana Harvard Partnership, Gaborone, Botswana aff005
Vyšlo v časopise: PLoS ONE 15(1)
Kategorie: Research Article



Botswana offers publicly financed HIV treatment to citizens, but not migrants, who comprised about 7% of the population in 2016. However, HIV incidence is not declining in proportion to Botswana’s HIV response. In 2018, Botswana had 86% of citizens living with HIV diagnosed, 95% of people diagnosed on treatment, and 95% viral suppression among those on treatment. We hypothesised that continued exclusion of migrants is hampering reduction of HIV incidence in Botswana. Hence, we modelled the impact of including migrants in Botswana’s HIV response on achieving 90-90-90 and 95-95-95 Fast-Track targets by 2020 and 2030, respectively.


The Optima HIV model, with demographic, epidemiological, and behavioural inputs, was applied to citizens of and migrants to Botswana. Projections of new HIV infections and HIV-related deaths were compared for three scenarios to the end of 2030: (1) continued status quo for HIV testing and treatment coverage, and maintenance of levels of linkage to care, loss to follow-up, and viral suppression among citizens and migrants (baseline); (2) with scaled-up budget, optimised to achieve 90-90-90 and 95-95-95 Fast-Track targets by 2020 and 2030, respectively, for citizens only; and (3) scaled-up optimised budget to achieve these targets for both citizens and migrants.


A baseline of 172,000 new HIV infections and 8,400 HIV-related deaths was projected over 2020–2030. Scaling up to achieve targets among citizens only averted an estimated 48,000 infections and 1,700 deaths. Achieving targets for both citizens and migrants averted 16,000 (34%) more infections and 442 (26%) more deaths. Scaling up for both populations reduced numbers of new HIV infections and deaths by 44% and 39% respectively compared with 2010 levels. Treating migrants when scaling up in both populations was estimated to cost USD 74 million over 2020–2030.


Providing HIV services to migrants in Botswana could lead to further reductions in HIV incidence and deaths. However, even with an increased, optimised budget that achieves 95-95-95 targets for both citizens and migrants by 2030, the 90% incidence reduction target for 2020 will be missed. Further efficiencies and innovations will be needed to meet HIV targets in Botswana.

Klíčová slova:

Antiretroviral therapy – Botswana – HIV – HIV diagnosis and management – HIV epidemiology – HIV infections – HIV prevention – Circumcision for HIV prevention


1. UNAIDS. Fast-track commitments to end AIDS by 2030. Geneva, Switzerland: UNAIDS; 2016. Available at

2. Ghys PD, Williams BG, Over M, Hallett TB, Godfrey-Faussett P. Epidemiological metrics and benchmarks for a transition in the HIV epidemic. PLoS Med. 2018;15(10):e1002678. doi: 10.1371/journal.pmed.1002678 30359372

3. International Organization for Migration (IOM). World Migration Report 2018. IOM, 2018. Available at

4. Vignier N, Dray Spira R, Pannetier J, Ravalihasy A, Gosselin A, Lert F, et al. Refusal to provide healthcare to sub-Saharan migrants in France: a comparison according to their HIV and HBV status. European Journal of Public Health, 28 (5): 1–7. 2018. doi: 10.1093/eurpub/cky118 29982518

5. Vearey J. Moving forward: why responding to migration, mobility and HIV in South(ern) Africa is a public health priority. J Int AIDS Soc. 2018;21 Suppl 4:e25137.

6. UNAIDS. Global AIDS Update: Mile to go: Closing gaps, breaking barriers, righting injustices. Geneva, Switzerland: UNAIDS; 2018. Available at

7. Olawore O, Tobian AAR, Kagaayi J, Bazaale JM, Nantume B, Kigozi G, et al. Migration and risk of HIV acquisition in Rakai, Uganda: a population-based cohort study. The Lancet HIV. 2018;e181–189 doi: 10.1016/S2352-3018(18)30009-2 29490875

8. Fakoya I, Alvarez-del Arco D, Woode-Owusu M, Monge S, Rivero-Montesdeoca Y, Delpech V, et al. A systematic review of post-migration acquisition of HIV among migrants from countries with generalised HIV epidemics living in Europe: Implications for effectively managing HIV prevention programmes and policy. BMC Public Health. 2015;15:561. doi: 10.1186/s12889-015-1852-9 26085030

9. Alvarez-del Arco D, Fakoya I, Thomadakis C, Pantazis N, Touloumi G, Gennotte A-F, et al. High levels of postmigration HIV acquisition within nine European countries. AIDS. 2017;31(14):1979–88. doi: 10.1097/QAD.0000000000001571 28857779

10. Kenyon C, Colebunders R, Voeten H, Lurie M. Migration intensity has no effect on peak HIV prevalence: An ecological study. BMC Infectious Diseases. 2014;14(350).

11. Alvarez-Del Arco D, Fakoya I, Thomadakis C, Pantazis N, Touloumi G, Gennotte AF, et al. High levels of postmigration HIV acquisition within nine European countries. AIDS. 2017;31(14):1979–88. doi: 10.1097/QAD.0000000000001571 28857779

12. UNAIDS. Country factsheets Botswana 2017. Geneva, Switzerland UNAIDS; 2018. Available at

13. International Organization for Migration (IOM). Botswana Country Facts and Figures: IOM; 2016. Available from:

14. Marukutira T, Alwano M-G, Behel S, Jarvis JN, Chakalisa U, Powis K, et al. Immigrants and Botswana's ART Program: Potential Barriers to Epidemic Control. Conference on Retroviruses and Opportunistic Infections (CROI); 13–16 February 2017; Seattle, USA2017. Available at

15. Marukutira T, Stoové M, Lockman S, Mills LA, Gaolathe T, Lebelonyane R, et al. A tale of two countries: progress towards UNAIDS 90-90-90 targets in Botswana and Australia. Journal of the International AIDS Society. 2018;21(3):e25090.

16. National AIDS Coordinating Agency (NACA), Botswana. Progress Report of the national response to the 2011 declaration of commitments on HIV and AIDS. Gaborone, Botswana NACA; 2015. Available at

17. UNAIDS. UNAIDS Data 2018. Geneva, Switzerland: UNAIDS; 2018. Available at

18. Moyo S, Gaseitsiwe S, Mohammed T, Pretorius Holme M, Wang R, Kotokwe KP, et al. Cross-sectional estimates revealed high HIV incidence in Botswana rural communities in the era of successful ART scale-up in 2013–2015. Plos One. 2018;13(10).

19. Central Statistics Office (CSO), Botswana. Botswana AIDS Impact Survey 2013. Gaborone, Botswana, CSO; 2014. Available at

20. Gaolathe T, Wirth KE, Holme MP, Makhema J, Moyo S, Chakalisa U, et al. Botswana's progress toward achieving the 2020 UNAIDS 90-90-90 antiretroviral therapy and virological suppression goals: a population-based survey. Lancet HIV. 2016;3(5):e221–30. doi: 10.1016/S2352-3018(16)00037-0 27126489

21. Kerr Cliff C., Stuart Robyn M., Gray Richard T., Shattock Andrew J., Fraser-Hurt Nicole, Benedikt Clemens, et al. Optima: A Model for HIV Epidemic Analysis, Program Prioritization, and Resource Optimization. J Acquir Immune Defic Syndr. 2015;69:365–76. doi: 10.1097/QAI.0000000000000605 25803164

22. Kelly SL, Martin-Hughes R, Stuart RM, Yap XF, Kedziora DJ, Grantham KL, et al. The global Optima HIV allocative efficiency model: targeting resources in efforts to end AIDS. The Lancet HIV. 2018;5(4):e190–e8. doi: 10.1016/S2352-3018(18)30024-9 29540265

23. Statistics Botswana. Population and Housing Census 2011; Dissemination seminar report. 9-12th December 2013, Gaborone, Botswana: Statistics Botswana; 2014. Available at

24. AVERT. HIV and AIDS in Botswana 2018. Available from:

25. Farahani M, Price N, El-Halabi S, Mlaudzi N, Keapoletswe K, Lebelonyane R, et al. Trends and determinants of survival for over 200 000 patients on antiretroviral treatment in the Botswana National Program: 2002–2013. AIDS (London, England). 2016;30(3):477.

26. Marukutira T, Yin D, Cressman L, Kariuki R, Malone B, Spelman T, et al. Clinical outcomes of a cohort of migrants and citizens living with human immunodeficiency virus in Botswana: implications for Joint United Nation Program on HIV and AIDS 90-90-90 targets. Medicine (Baltimore). 2019;98(23):e15994.

27. Optima Consortium for Decision Science. Optima HIV User Guide Vol. VI: Parameter Data Sources. 2019. Available from:

28. UNAIDS. Country factsheets: Botswana 2016. Geneva, Switzerland: UNAIDS; 2017. Available at

29. Williams BG, Gupta S, Wollmers M, Granich R. The impact and cost of ending AIDS in Botswana. The Lancet HIV. 2016;3(9):e409. doi: 10.1016/S2352-3018(16)30116-3 27562741

30. UNAIDS. 90-90-90 An ambitious treatment target to help end the AIDS epidemic. Geneva, Switzerland: UNAIDS; 2014. Available at

31. Kibona I, Yang C. HIV Model Enhancing UNAIDS Goal to End AIDS: Simulations in Botswana. Journal of Scientific Research and Reports. 2018;19(6):1–19.

32. Stegman P, Keapoletsw K, Ramaabya D, Petlo C, Mkhweli B, Bogosing L et al. New Investment Framework for HIV/AIDS: Making the Case in Botswana. 20th International AIDS Conference; Melbourne, Australia: 2014. Available from

33. Scott N, Stoové M, Kelly SL, Wilson DP, Hellard ME. Achieving 90-90-90 HIV targets will not be enough to achieve the HIV incidence reduction target in Australia. Clinical Infectious Diseases. 2018;66(7):1019–26. doi: 10.1093/cid/cix939 29099920

34. Williams BG, Gupta S, Wollmers M, Granich R. Progress and prospects for the control of HIV and tuberculosis in South Africa: a dynamical modelling study. The Lancet Public Health. 2017;2(5):e223–e30. doi: 10.1016/S2468-2667(17)30066-X 29253488

35. Maddali MV, Gupta A, Shah M. Epidemiological impact of achieving UNAIDS 90-90-90 targets for HIV care in India: a modelling study. BMJ Open. 2016;6(7):e011914. doi: 10.1136/bmjopen-2016-011914 27388363

36. Kelly KL and Wilson DP. HIV Cascade Monitoring and Simple Modelling Reveal Potential for Reductions in HIV Incidence. Journal of Acquired Immune Deficiency Syndrome. 2015;69:257–63.

37. Assefa Y, Gilks CF, Dean J, Tekle B, Lera M, Balcha TT, et al. Towards achieving the fast-track targets and ending the epidemic of HIV/AIDS in Ethiopia: Successes and challenges. Int J Infect Dis. 2018;78:57–64. doi: 10.1016/j.ijid.2018.10.022 30391417

38. Keetile M. High-risk behaviors among adult men and women in Botswana: implications for HIV/AIDS prevention efforts. SAHARA J. 2014;11:158–66. doi: 10.1080/17290376.2014.960948 25293869

39. Klein DJ, Eckhoff PA, Bershteyn A. Targeting HIV services to male migrant workers in southern Africa would not reverse generalized HIV epidemics in their home communities: a mathematical modeling analysis. Int Health. 2015;7(2):107–13. doi: 10.1093/inthealth/ihv011 25733560

40. White Peter J., Ward Helen, GP Garnett. Is HIV out of control in the UK? An example of analysing patterns of HIV spreading using incidence-to-prevalence ratios. AIDS. 2006;20:1898–901. doi: 10.1097/01.aids.0000244213.23574.fa 16954735

41. UNAIDS. Prevention gap report. 2016. Geneva, Switzerland: UNAIDS; 2016.

Článek vyšel v časopise


2020 Číslo 1
Nejčtenější tento týden