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In a population-based representative sample of adults residing in 22 communities in Botswana, a southern African country with high HIV prevalence, 1 in 4 individuals had high blood pressure. High blood pressure was less prevalent in adults with HIV than without HIV. Sixty percent of persons with high blood pressure had not previously been diagnosed. Among individuals with a prior diagnosis of high blood pressure who reported being prescribed anti-hypertension medications, almost half had elevated blood pressure, irrespective of HIV-status. One-third of adults in this setting (mainly men) declined free non-invasive blood pressure assessments in their households. In conclusion, our study highlights alarmingly high hypertension rates in the community, with low levels of awareness and control, emphasizing the urgent need for community level BP screening and active management to reach recommended targets.

Botswana is close to reaching the UNAIDS \"90-90-90\" HIV testing, antiretroviral treatment (ART), and viral suppression goals. We sought to determine HIV incidence in this setting with both high HIV prevalence and high ART coverage. We used a cross-sectional approach to assessing HIV incidence. A random, population-based sample of adults age 16-64 years was enrolled in 30 rural and peri-urban communities as part of the Botswana Combination Prevention Project (BCPP), from October 2013 -November 2015. Data and samples from the baseline household survey were used to estimate cross-sectional HIV incidence, following an algorithm that combined Limiting-Antigen Avidity Assay (LAg-Avidity EIA), ART status (documented or by testing ARV drugs in plasma) and HIV-1 RNA load. The LAg-Avidity EIA cut-off normalized optical density (ODn) was set at 1.5. The HIV-1 RNA cut-off was set at 400 copies/mL. For estimation purposes, the Mean Duration of Recent Infection was 130 days and the False Recent Rate (FRR) was evaluated at values of either 0 or 0.39%. Among 12,610 individuals participating in the baseline household survey, HIV status was available for 12,570 participants and 3,596 of them were HIV positive. LAg-Avidity EIA data was generated for 3,581 (99.6%) of HIV-positive participants. Of 326 participants with ODn ≤1.5, 278 individuals were receiving ART verified through documentation and were considered to represent longstanding HIV infections. Among the remaining 48 participants who reported no use of ART, 14 had an HIV-1 RNA load ≤400 copies/mL (including 3 participants with ARVs in plasma) and were excluded, as potential elite/viremic controllers or undisclosed ART. Thus, 34 LAg-Avidity-EIA-recent, ARV-naïve individuals with detectable HIV-1 RNA (>400 copies/mL) were classified as individuals with recent HIV infections. The annualized HIV incidence among 16-64 year old adults was estimated at 1.06% (95% CI 0.68-1.45%) with zero FRR, and at 0.64% (95% CI 0.24-1.04%) using a previously defined FRR of 0.39%. Within a subset of younger individuals 16-49 years old, the annualized HIV incidence was estimated at 1.29% (95% CI 0.82-1.77%) with zero FRR, and at 0.90% (95% CI 0.42-1.38%) with FRR set to 0.39%. Using a cross-sectional estimate of HIV incidence from 2013-2015, we found that at the time of near achievement of the UNAIDS 90-90-90 targets, ~1% of adults (age 16-64 years) in Botswana's rural and peri-urban communities became HIV infected annually.

Randomized trials have shown that voluntary medical male circumcision (VMMC) significantly reduces the risk of HIV acquisition in men. However, the rate of complications associated with the surgical procedure varies from 0.7% to 37.4% in real-world settings. We assessed the frequency, type and severity of adverse events following VMMC among 427 adult men surgically circumcised in southeastern Botswana; 97% completed ≥1 follow-up visit within seven days post-circumcision. Thirty moderate AEs were observed in 28 men resulting in an overall AE rate of 6.7%. Patient satisfaction was high: >95% were very or somewhat satisfied with the procedure and subsequent follow-up care.

The highest incidence of childhood acute lower respiratory tract infection (ALRI) is in low- and middle-income countries. Few studies examined whether detection of respiratory viruses predicts ALRI outcomes in these settings. We conducted prospective cohort and case-control studies of children 1-23 months of age in Botswana. Cases met clinical criteria for pneumonia and were recruited within six hours of presentation to a referral hospital. Controls were children without pneumonia matched to cases by primary care clinic and date of enrollment. Nasopharyngeal specimens were tested for respiratory viruses using polymerase chain reaction. We compared detection rates of specific viruses in matched case-control pairs. We examined the effect of respiratory syncytial virus (RSV) and other respiratory viruses on pneumonia outcomes. Between April 2012 and August 2014, we enrolled 310 cases, of which 133 had matched controls. Median ages of cases and controls were 6.1 and 6.4 months, respectively. One or more viruses were detected from 75% of cases and 34% of controls. RSV and human metapneumovirus were more frequent among cases than controls, but only enterovirus/rhinovirus was detected from asymptomatic controls. Compared with non-RSV viruses, RSV was associated with an increased risk of treatment failure at 48 hours [risk ratio (RR): 1.85; 95% confidence interval (CI): 1.20, 2.84], more days of respiratory support [mean difference (MD): 1.26 days; 95% CI: 0.30, 2.22 days], and longer duration of hospitalization [MD: 1.35 days; 95% CI: 0.20, 2.50 days], but lower in-hospital mortality [RR: 0.09; 95% CI: 0.01, 0.80] in children with pneumonia. Respiratory viruses were detected from most children hospitalized with ALRI in Botswana, but only RSV and human metapneumovirus were more frequent than among children without ALRI. Detection of RSV from children with ALRI predicted a protracted illness course but lower mortality compared with non-RSV viruses.

Background HIV-1 is endemic in Botswana. The country’s primary challenge is identifying people living with HIV who are unaware of their status. We evaluated factors associated with undiagnosed HIV infection using HIV-1 phylogenetic, behavioural, and demographic data. Methods As part of the Botswana Combination Prevention Project, 20% of households in 30 villages were tested for HIV and followed from 2013 to 2018. A total of 12,610 participants were enrolled, 3596 tested HIV-positive at enrolment, and 147 participants acquired HIV during the trial. Extensive socio-demographic and behavioural data were collected from participants and next-generation sequences were generated for HIV-positive cases. We compared three groups of participants: (1) those previously known to be HIV-positive at enrolment (n = 2995); (2) those newly diagnosed at enrolment (n = 601) and (3) those who tested HIV-negative at enrolment but tested HIV-positive during follow-up (n = 147). We searched for differences in demographic and behavioural factors between known and newly diagnosed group using logistic regression. We also compared the topology of each group in HIV-1 phylogenies and used a genetic diversity-based algorithm to classify infections as recent (< 1 year) or chronic (≥ 1 year). Results Being male (aOR = 2.23) and younger than 35 years old (aOR = 8.08) was associated with undiagnosed HIV infection ( p  < 0.001), as was inconsistent condom use (aOR = 1.76). Women were more likely to have undiagnosed infections if they were married, educated, and tested frequently. For men, being divorced increased their risk. The genetic diversity-based algorithm classified most incident infections as recent (75.0%), but almost none of known infections (2.0%). The estimated proportion of recent infections among new diagnoses was 37.0% ( p  < 0.001). Conclusion Our results indicate that those with undiagnosed infections are likely to be young men and women who do not use condoms consistently. Among women, several factors were predictive: being married, educated, and testing frequently increased risk. Men at risk were more difficult to delineate. A sizeable proportion of undiagnosed infections were recent based on a genetic diversity-based classifier. In the era of “test and treat all”, pre-exposure prophylaxis may be prioritized towards individuals who self-identify or who can be identified using these predictors in order to halt onward transmission in time.

Unprotected sexual intercourse after undergoing voluntary medical male circumcision but prior to complete wound healing can lead to major adverse events including HIV acquisition. To better understand perceptions related to early resumption of sex prior to wound healing, 27 focus group discussions were conducted among 238 adult men, women, and community leaders in Botswana. Median age among all participants was 31 years of whom 60% were male and 51% were either employed and receiving salary or self-employed. Only 12% reported being currently married. Pain, not risk of HIV acquisition, was perceived as the main adverse consequence of early resumption of sex. In fact, no participant mentioned that early resumption of sex could lead to an increase in HIV risk. Demonstrating masculinity and virility, fear of losing female partners, and misperception about post-operative wound healing also played key roles in the decision to resume sex prior to complete wound healing. Findings from this study highlight a potentially widespread lack of awareness of the increased risk of HIV acquisition during the wound healing period. Strengthening post-operative counseling and identifying strategies to discourage the early resumption of sex will be increasingly important as older men and HIV-positive men seek voluntary medical male circumcision services.

In this community-randomized trial in 30 communities in Botswana, a bundle of services (community-wide HIV testing, linkage to care, antiretroviral treatment in participants with a higher CD4 count, and male circumcision) were compared with standard care. A numerical decrease in incident HIV infection and a significant decrease in HIV viral load were observed in the communities receiving the bundle of services.

Background: Circumcised men may increase sexual risk-taking following voluntary medical male circumcision (VMMC) because of decreased perceptions of risk, which may negate the beneficial impact of VMMC in preventing new human immunodeficiency virus (HIV) infections.Objectives: We evaluated changes in sexual behaviour following VMMC.Method: We conducted a prospective cohort study amongst sexually active, HIV-negative adult men undergoing VMMC in Gaborone, Botswana, during 2013–2015. Risky sexual behaviour, defined as the number of sexual partners in the previous month and ≥ 1 concurrent sexual partnerships during the previous 3 months, was assessed at baseline (prior to VMMC) and 3 months post-VMMC. Change over time was assessed by using inverse probability weighted linear and conditional logistic regression models.Results: We enrolled 523 men; 509 (97%) provided sexual behaviour information at baseline. At 3 months post-VMMC, 368 (72%) completed the follow-up questionnaire. At baseline, the mean (95% confidence interval) number of sexual partners was 1.60 (1.48, 1.65), and 111 (31% of 353 with data) men reported engaging in concurrent partnerships. At 3 months post-VMMC, 70 (23% of 311 with data) reported fewer partners and 19% had more partners. Amongst 111 men with a concurrent partnership at baseline, 52% reported none post-VMMC. Amongst the 242 (69%) without a concurrent partnership at baseline, 19% reported initiating one post-VMMC. After adjustment for loss to follow-up, risky sexual behaviour post-VMMC (measured as mean changes in a number of partners and proportion engaging in concurrency) was similar to baseline levels.Conclusion: We found no evidence of sexual risk compensation in the 3 months following VMMC.

The instrumental variable (IV) design is a well-known approach for unbiased evaluation of causal effects in the presence of unobserved confounding. In this article, we study the IV approach to account for selection bias in regression analysis with outcome missing not at random. In such a setting, a valid IV is a variable which (i) predicts the nonresponse process, and (ii) is independent of the outcome in the underlying population. We show that under the additional assumption (iii) that the IV is independent of the magnitude of selection bias due to nonresponse, the population regression in view is nonparametrically identified. For point estimation under (i)-(iii), we propose a simple complete-case analysis which modifies the regression of primary interest by carefully incorporating the IV to account for selection bias. The approach is developed for the identity, log and logit link functions. For inferences about the marginal mean of a binary outcome assuming (i) and (ii) only, we describe novel and approximately sharp bounds which unlike Robins-Manski bounds, are smooth in model parameters, therefore allowing for a straightforward approach to account for uncertainty due to sampling variability. These bounds provide a more honest account of uncertainty and allows one to assess the extent to which a violation of the key identifying condition (iii) might affect inferences. For illustration, the methods are used to account for selection bias induced by HIV testing nonparticipation in the evaluation of HIV prevalence in the Zambian Demographic and Health Surveys.

[...]no results are reported for associations between HIV prevalence and other risk factors for HIV acquisition.