The HIV epidemic in Botswana and gender inequalities: a way forward
Kim, Diane Mi-Ae
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The Botswana HIV/AIDS epidemic started in the early 1990s, with the proportion of the overall population infected with HIV (prevalence) rapidly escalating to 28.2% by the year 2000. Today, HIV prevalence has decreased to 23%, yet Botswana has the third highest percentage of HIV infected population in the world. The HIV epidemic in Botswana is in need of attention, but prevalence alone does not represent the full picture. HIV incidence (the rate of new infections and a critical indicator of success of HIV prevention programs) peaked in Botswana around 1996 at 5.7% and has declined to about 2.72% today. Botswana's two most effective programs in its response to the epidemic have been provision of universal HIV treatment and prevention of mother-to-child-transmission (PMTCT) programs, which have achieved over 95% coverage for all eligible patients. These two programs largely account for Botswana's rapid decline in HIV prevalence and incidence rates. However, females have continually had higher rates of prevalence and incidence than males throughout the course of Botswana's epidemic. In order to continue these declining rates of infection, Botswana may consider redoubling its efforts around HIV prevention. Women and young adolescent girls have not been the main beneficiaries of prevention programs. Women are more susceptible to HIV infection biologically and more vulnerable to infection due to social determinants, most notably their lack of empowerment and control in sexual partnerships. The main social drivers of the HIV epidemic in Botswana have been concurrent partnerships, sexual assault, cross-generational sex, and transactional sex. These drivers increase risk of HIV infection particularly for women. Botswana has implemented promising national prevention programs focused on HIV counseling and testing, consistent condom use, decreased concurrent partnerships, and male circumcision. However, the Botswana legal system reinforces gender inequalities, further increasing women's risk for HIV infection. In Botswana's law, martial rape, domestic violence, and intimate partner violence are not criminalized. Further, sex with minors and sexual assault are not strictly enforced. Sex work is illegal and stigmatized, and thus sex workers are not receiving appropriate support in HIV prevention. This high-risk population accounts for only 1.65% of the general population but will account for 6.38% of new HIV infections. The HIV treatment and PMTCT programs have decreased HIV incidence, but Botswana may consider increasing its behavioral prevention programs to regard gender norms and reforming legislation to protect women and young girls. This paper recommends behavioral prevention programs through increased youth education programs, women empowerment programs, access to sexual and reproductive health care, and male involvement in sexual and reproductive health. Further, it is recommended that policy makers focus on reforming civil legislation and bolstering enforcement of existing laws that protect women from violence. The key to successful scale-up of behavioral prevention in Botswana will be community-driven HIV initiatives and strong leadership from community leaders and members of parliament, including women.