Botswana’s HIV Triumph and Cure Quest
By Darius Spearman (africanelements)
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A Nation’s Fight Against HIV
At the dawn of the 21st century, Botswana faced a grave crisis. HIV was rampant, threatening the very existence of the nation. Reports indicated that one in eight infants were infected with HIV at birth, and the rates of mother-to-child transmission, whether during pregnancy, childbirth, or breastfeeding, soared between 20 percent and 40 percent (The Guardian). This devastating reality led to a near doubling of mortality among children under five due to HIV between 1990 and 2000. With a population of only 1.7 million and the second-highest HIV prevalence globally, then-President Festus Mogae declared in 2001, “We are threatened with extinction” (The Guardian).
The situation was indeed dire. Dr. Loeto Mazhani, a retired pediatrician and public health official, recalled the profound despair, stating that if the entire population was infected in utero, at birth, or during early infancy, with the majority either dying or living with significant disability, there seemed to be no future (The Guardian). However, from this profound crisis emerged one of the world’s most successful HIV elimination programs. Led by Dr. Mazhani and supported by President Mogae, a series of groundbreaking interventions were introduced. Over two decades, these efforts dramatically reduced mother-to-child transmission rates to below one percent (The Guardian).
Achieving Gold Tier Status
Earlier this year, Botswana achieved a remarkable milestone. It became the first country with a high HIV burden to reach the World Health Organization’s (WHO) Gold Tier status for eliminating mother-to-child HIV transmission as a public health threat (The Guardian). This “Gold Tier status” signifies that Botswana has successfully reduced mother-to-child HIV transmission rates to a level that no longer poses a significant public health problem. The criteria for this status include a transmission rate of less than 5 percent, a high coverage of antiretroviral therapy for pregnant women, and robust surveillance systems. Dr. Ava Avalos, an HIV specialist and technical adviser to Botswana’s health ministry, noted that the transformation was so drastic that the WHO initially doubted the country’s reported figures (The Guardian). They would report low numbers of HIV infections at birth, and the WHO would respond with skepticism, suggesting that there must be thousands of HIV-positive children. This went on for years until they had to accept the strength of Botswana’s program (The Guardian).
Today, new pediatric HIV infections are exceedingly rare in Botswana, with fewer than 100 HIV-positive infants born annually (The Guardian). Each new case is thoroughly investigated to understand how the transmission occurred. This achievement required significant political will, substantial investment in scientific infrastructure, and a sustained public health education program to ensure that the latest science-backed strategies reached those most at risk (The Guardian). One of the major challenges was convincing HIV-positive mothers to use formula milk instead of breastfeeding, due to the risk of transmission (The Guardian). This went against traditional infant nutrition practices and could lead to social stigma, as community members would know a woman had HIV if she used formula. However, over time, the stigma associated with formula feeding gradually diminished (The Guardian).
Mother-to-Child HIV Transmission Rate Reduction in Botswana
This chart illustrates the dramatic reduction in mother-to-child HIV transmission rates in Botswana. Source: The Guardian
Pioneering Interventions and Strategies
A significant turning point in Botswana’s fight against HIV was the decision in 2013 to implement the WHO’s Option B+ strategy (The Guardian). This strategy made antiretroviral therapy (ART) that combined three drugs freely available to all pregnant and breastfeeding women living with HIV. Option B+ is a public health approach where all pregnant and breastfeeding women diagnosed with HIV are immediately started on lifelong ART, regardless of their CD4 count or clinical stage. This approach simplifies treatment, reduces the risk of mother-to-child transmission, and improves the health of the mother. At the time, Botswana was one of the first countries globally to fund Option B+ on a national scale (The Guardian). Professor Roger Shapiro, who has led an HIV research program in Botswana since the 1990s, explained that it became clear that three-drug therapy was by far the best way to treat mothers for their health and essentially halt vertical transmission (The Guardian).
However, research indicated that these steps alone were not enough to completely prevent pediatric infections. Studies showed that a significant number of mother-to-child transmissions occurred when mothers unknowingly contracted HIV during pregnancy, with the unborn child becoming infected in the third trimester (The Guardian). To address these cases, Botswana’s health ministry invested in two laboratories capable of analyzing thousands of PCR tests and began offering repeat HIV testing to all pregnant women (The Guardian) This enabled women who tested positive to be swiftly placed on antiretrovirals and post-exposure prophylaxis drugs, limiting the possibility of transmission to the baby (The Guardian) While other sub-Saharan African countries also offer widespread HIV testing for pregnant women, Botswana’s program is particularly effective due to its near-universal antenatal coverage, with most women accessing services and giving birth in hospitals rather than at home (The Guardian). This also allows all babies born to HIV-positive women to be immediately tested, and if infected, started on treatment as early as possible (The Guardian).
The Promise of Early Treatment and Cure Research
The success of Botswana’s testing regime has led to a unique group of children and adolescents with HIV who have suppressed the virus to nearly negligible levels due to being on antiretroviral medications since birth (The Guardian). These children are considered ideal candidates for experimental trials that aim to use emerging treatments to cure them completely of HIV (The Guardian). Starting antiretroviral therapy (ART) early in life for HIV-infected children is crucial because it can limit the establishment of viral reservoirs, reduce inflammation, and preserve immune function, potentially leading to long-term remission or even a functional cure. Viral suppression refers to the reduction of HIV to undetectable levels in the blood, often measured by “viral load.” HIV reservoirs are hidden populations of infected cells that persist even with effective treatment, making a cure challenging. “Reservoir characteristics” refer to the nature and size of these hidden viral populations. Researchers believe that treating children early, before the virus has deeply seeded in body tissues or infected memory cells, could make a cure easier to achieve (The Guardian).
This theory is currently being tested in a landmark clinical trial in Botswana, where approximately 30 children will receive regular infusions of broadly neutralizing antibodies (bNAbs) over 11 months (The Guardian). Broadly neutralizing antibodies (bNAbs) are a type of antibody that can neutralize a wide range of HIV strains. They are being investigated for their potential in HIV treatment and prevention, including maintaining viral suppression in children (science.org). These new drugs can attack different strains of HIV and stimulate the immune system to recognize them (The Guardian) The hope is that after this period, a certain number of children will be able to live long-term without needing any daily medication, effectively achieving a cure (The Guardian). Professor Shapiro, leading the trial, believes there are two potential ways for a cure: either no intact virus remains, or the children’s immune systems can handle the small amount that does (The Guardian).
Why Children Are Key to HIV Cure Research
Early Treatment Benefits
Starting ART early in life can limit the establishment of viral reservoirs and preserve immune function, making a cure more achievable.
Reduced Viral Reservoirs
Children treated early may have smaller, less entrenched HIV reservoirs, which are hidden populations of infected cells that persist despite treatment.
Immune System Development
Their developing immune systems may respond differently to treatment, potentially leading to long-term remission or functional cure.
Ideal Candidates for Trials
A unique group of children in Botswana with suppressed viral loads are ideal for experimental trials using new treatments like bNAbs.
This infographic highlights the reasons why children are considered crucial in the quest for an HIV cure. Source: The Guardian, science.org
Challenges and the Path Forward
While there have been isolated cases of children controlling HIV without medication, these instances are not yet widespread or easily replicable (science.org). The challenge in translating these rare cases into a general cure lies in understanding the precise biological mechanisms that allow these individuals to achieve long-term remission and then developing therapies that can induce similar responses in a broader population. For example, the “Mississippi baby” was thought to be cured in 2013, but HIV returned strongly after 27 months off treatment (science.org). Similarly, a French woman, the first documented HIV-infected child to go off treatment and remain in remission for a long time, was found to have strong signals of HIV DNA, indicating she is not cured (science.org). Scientists do not yet know why this long-term remission occurred in her case (science.org).
Funding challenges for pediatric HIV research are significant, impacting the ability to conduct crucial clinical trials. These challenges can lead to the withdrawal of previously committed support, potentially delaying or halting promising research. For instance, an HIV scientist named Martins faced recent funding challenges for a novel therapy (wired.com). A previous commitment from the National Institutes of Health to support a clinical trial in HIV-infected children was withdrawn (wired.com). Martins is now in discussions with the Gates Foundation to see if they can sponsor the trial (arstechnica.com). Despite these challenges, the importance of such trials has gained even greater weight in Botswana and across sub-Saharan Africa, especially in the wake of foreign aid cuts and economic turmoil (The Guardian). While Botswana’s HIV program has been more resilient than most, with treatment and testing largely government-funded, the country is experiencing an economic downturn (The Guardian). This makes it all the more urgent to identify a strategy for curing infected individuals (The Guardian).
Botswana’s Unique Position in Cure Research
Botswana’s success in virtually eliminating mother-to-child HIV transmissions, combined with its established infrastructure for clinical trials and a suitable population of children with the best chance of being cured, positions the country as a potential leader in finding a widespread cure for HIV (The Guardian). The country’s near-universal antenatal care coverage and hospital births ensure that most women access services and that babies born to HIV-positive mothers are tested and treated early (The Guardian). This robust public health system provides an ideal environment for conducting advanced research. The availability of infrastructure for clinical trials and a suitable population of children make Botswana an ideal location for cure research (The Guardian).
Key Factors in Botswana's HIV Success and Cure Potential
Political Will
Strong government commitment and leadership were crucial in implementing widespread HIV prevention and treatment programs.
Scientific Infrastructure
Investment in laboratories and research capabilities supported effective testing and program monitoring.
Public Health Education
Sustained efforts to educate the public on prevention, treatment adherence, and reducing stigma were vital.
Early ART Access
Widespread availability of antiretroviral therapy for pregnant women and early treatment for infants significantly reduced transmission.
Universal Antenatal Care
High rates of antenatal coverage and hospital births ensured early detection and intervention for mothers and babies.
Unique Pediatric Cohort
A population of children with suppressed viral loads from early treatment provides ideal candidates for cure trials.
This infographic outlines the key factors contributing to Botswana's success in HIV elimination and its potential in cure research. Source: The Guardian
The development of broadly neutralizing antibodies (bNAbs) and advancements in vaccine research, aiming to induce such antibodies, offer promising avenues for future HIV treatment and prevention (science.org). The hope is that if a breakthrough in HIV cure research can be achieved anywhere, it is most likely to happen in Botswana (The Guardian). Dr. Avalos expressed this sentiment powerfully, stating, “If we can’t manage it here, I do not know where we could do it” (The Guardian) This optimism underscores the critical role Botswana plays in the global effort to find a widespread cure for HIV, building on its remarkable success in preventing mother-to-child transmission.
ABOUT THE AUTHOR
Darius Spearman has been a professor of Black Studies at San Diego City College since 2007. He is the author of several books, including Between The Color Lines: A History of African Americans on the California Frontier Through 1890. You can visit Darius online at africanelements.org.
