Improving Care for Criminalized Populations at Risk for HIV in Botswana

Botswana penal code 164 criminalizes same-sex relations, while penal code 167 criminalizes sex work, creating barriers to HIV prevention and care service access among key populations.

Penal code 164 is of contentious legal status, as Botswana’s High Court overturned it in June 2019, but the attorney general announced that the government would appeal the decision in July. Sex work remains unambiguously criminalized in the country.

Previous research has shown that female sex workers had HIV prevalence of 61.9% and incidence of 12.5%. Additionally, men who have sex with men had HIV prevalence of 13.1% and incidence of 3.6%. These key populations face barriers to service access, criminalization, negative provider attitudes, discrimination, and stigma.

A poster presentation at the Association of Nurses in AIDS Care Conference (ANAC 2019) detailed the Botswana Family Welfare Association’s (BOFWA) efforts to increase service access to HIV care and related co-morbid conditions for key populations. Efforts by BOFWA included raising nurse capacities through training to prescribe and dispense antiretroviral therapy.

BOFWA engages in nurse-led and user-responsive integrated HIV services. Programs allowed antiretroviral nurse prescribers to provide new HIV testing, counseling, and treatment. Nurses also provided treatment and screening for tuberculosis, gonorrhea, and chlamydia.

A program called “BOFWA in a box” provided confidential safe space services, drop in centers, and home visits. Key population participants on antiretroviral therapy subsequently increased from 33 in 2016 to 526 in 2018, with a 95% viral load suppression rate.

Providers reported adherence issues, costly follow up, and resistance to continuing care through government facilities. Despite these challenges, more members of key populations accessed HIV and related services through BOFWA. Government providers were trained in key population compliant approaches and stigma transformation.

Successes were attributed in part to confidentiality, safe spaces, and intensive follow up creating retention of care. Abstract authors expressed hope that their methods could be replicated in similar contexts to the benefit of criminalized communities.

The abstract, Caring for HIV positive key populations & those at risk for HIV acquisition in a criminalized environment — A case of Botswana Family Welfare Association (BOFWA), was presented in a poster session at ANAC 2019 in Portland, Oregon.