This is the first study to our knowledge to assess knowledge, attitudes, and experiences surrounding the new policy of routine testing in Botswana. We found that 11 months after the introduction of routine testing in Botswana, there was widespread support for this policy in a population-based survey, with 81% of participants reporting that they were either extremely or very much in favor of routine testing and an additional 8% reporting that they were somewhat in favor of this policy. A majority of respondents felt that routine testing would decrease barriers to testing, HIV-related stigma, and violence toward women, and would increase uptake of ARVs through the Botswana National Treatment Program. These results, in conjunction with data showing a significant increase in testing and treatment uptake since the introduction of this policy [
], suggest that this policy is beneficial in improving access to testing and life-saving treatment. Consistent with this, a study of several prenatal clinics in Botswana found that routine prenatal HIV testing was associated with a 15% increase in the proportion of pregnant women undergoing HIV testing between February and April 2004 (after routine testing was introduced) when compared with the last few months of 2003 [
]. Figures also indicate a more than 2-fold increase in treatment enrollment since the introduction of this policy, with 42,000 individuals enrolled in treatment as of March 2005 [
Evaluating our findings in the context of potential human rights burdens, we found that few individuals reported violence (1%), discrimination (2%), or a breach of confidentiality by healthcare workers (5%) associated with VCT or routine testing. Highlighting some potential problems with routine testing, 43% believed that routine testing would lead to avoidance of doctor visits for fear of being tested, and 14% felt that this policy could lead to increased violence against women. In addition, approximately two-thirds of participants who were tested by either routine testing or VCT felt that they could not refuse the HIV test, suggesting that the voluntary nature of both routine testing and VCT is not fully understood. These findings underscore the importance of implementing HIV testing policies with measures in place to ensure informed consent, protection of confidentiality, and protection of women from gender-based violence related to testing. Careful monitoring and evaluation of Botswana's routine testing program will help to ensure that the significant benefits of this program in terms of linkage to care and prevention of HIV transmission are not associated with potential adverse impacts.
Detailed guidelines for the implementation of routine testing were not introduced until February 2004, and the training of healthcare practitioners and the development of training materials were still ongoing in early 2005 [
]. Consequently, at the time of our study, there was still some confusion surrounding the details of implementation of this policy, including the extent to which routine testing should be provided as opt-out (all patients are automatically tested unless they refuse) or as routine-offer (all patients are offered a test, and they must provide explicit informed consent). The current policy has moved toward routine-offer HIV testing in accordance with the recommendations of WHO and UNAIDS; both organizations emphasize that the central principles of testing should include confidentiality, counseling, and informed consent [
]. As counseling has been found to account for some of the benefits of VCT in terms of reduced HIV transmission risk behavior [
] and linkage to subsequent medical care, reinforcing the importance of counseling in routine testing programs may help ensure that these programs help to maximize sexual-risk reduction and access to care. Additional conditions should be considered when implementing routine testing policies elsewhere, including the need to increase human resources and to expand the use of rapid testing.
Consistent with the documented role of HIV-related stigma as an impediment to testing in studies in Africa and elsewhere [
], we found that HIV-related stigma was associated with decreased odds of having been tested for HIV, of getting routine testing, and of planning to test among people not previously tested. In addition, respondents with more stigmatizing views about HIV and a greater number of fears related to HIV stigma were significantly less likely to have heard of routine testing after adjusting for possible confounders, attesting to the association between poor information and HIV-related stigma. Addressing HIV-related stigma should comprise an integral part of ongoing HIV testing programs and policies in Botswana, including measures to protect people with HIV/AIDS from discrimination in healthcare, work, and other settings. Policies that target HIV-related stigma may also prevent a reduction of clinical visits related to people's fears of being tested. Increasing testing and decreasing stigma will likely work together to reinforce one another, with more testing leading to a reduction in HIV-related stigma, which in turn will work to further increase testing. Botswana already has several innovative programs in place aimed to address stigma directly, including media campaigns, the public testing of President Festus Mogae and other national leaders, and the annual “Miss HIV Stigma Free” competition [
]. Additional progress toward stigma reduction will require a deeper understanding of the structural dimensions of HIV-related stigma, and the mechanisms by which stigma reinforces and generates social inequalities related to gender, ethnicity, and class [
We found a relatively high prevalence of self-reported HIV testing in Botswana in the era of routine testing, compared with its neighboring countries. While 48% of our sample reported having been tested for HIV, results from Zimbabwe suggest that only 10%–12% of people are aware of their HIV status [
], and a nationwide community based–survey in South Africa in 2002 found that only 20% of people aware of VCT services had been tested for HIV [
]. In addition to the policy of routine testing, universal access to ARVs and to HIV testing likely contributes to the relatively high prevalence of testing in Botswana. Consistent with this, perceived access to testing was associated with 60% higher odds of having received an HIV test among respondents in our study, and the availability of ART was cited as a leading facilitator to testing. In addition, a national survey from Botswana in 2001 showed that fewer than 20% of individuals ages 15–49 had ever received an HIV test [
], suggesting a more than 2-fold increase in testing prevalence since the introduction of both universal ART access and routine testing. On the other hand, because over 50% of our sample had not yet been tested, our results reinforce the fact that availability of testing facilities and ART, while essential, may not be sufficient to guarantee HIV testing for many [
Study results should be interpreted in the context of a number of limitations. First, as this study was cross-sectional, causality cannot be determined from our findings. Second, while we interviewed individuals from both rural and urban areas, and covered the five most populated districts in Botswana, because we did not interview individuals in all districts of Botswana, our results may not be generalizable to the entire Botswana population. In addition, Botswana has a number of unique features that may limit generalizability to neighboring African countries, such as its relatively high per capita income, comparatively extensive healthcare infrastructure, strong donor involvement, and strong government commitment to combating HIV. Third, as the policy of routine testing was not yet implemented in a uniform way across all medical facilities in Botswana, and different facilities were at different stages of implementation, it was impossible to conduct a more systematic evaluation of the impacts of this policy. Moreover, since routine testing is a relatively new policy in Botswana, only a small proportion of those tested (15%) had been tested by routine testing at the time of our study. Finally, self-report can introduce misclassification and bias. To maximize validity we did not ask about HIV status, assured confidentiality and privacy, and asked survey questions in a culturally sensitive, nonjudgmental manner. To reduce social desirability bias, interviewers were not informed of key research hypotheses, and study aims were presented to participants in general terms.
In the face of a devastating epidemic that has already infected nearly half of its adult population, the government of Botswana has taken strong steps to improve access to testing and to ensure the right to life-sustaining treatment for all of its citizens. Early evidence of widespread support for the policy of routine testing in this study holds significant promise for the prevention and treatment of HIV/AIDS in Botswana and elsewhere. Concerted efforts to scale up HIV testing, however, must also be accompanied by appropriate monitoring of testing practices to ensure that they are implemented in accordance with international guidelines on human rights and HIV/AIDS [