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Analytical summary - Tuberculosis

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Botswana has one of the world’s highest burdens of tuberculosis (TB) per capita, with a notification rate of 470 per 100 000 population (see table). TB is one of the most common opportunistic infections in those infected with HIV, with 75% of TB patients being HIV positive. TB rates started rising with increasing prevalence of HIV/AIDS in the 1990s, with an increase of 200 cases per 100 000 population in 1990 to 620 cases per 100 000 in 2002.

TB notification per 100 000 population and HIV prevalence (%) in pregnant women aged 15–19 years. Source: Botswana national TB programme annual reports and antenatal care sentinel surveillance reports
Botswana’s response to TB has been influenced by both national commitment and regional and international resolutions and targets for controlling TB. The country has also had strong support from development partners. The development of the current strategic plan document was also informed by the global Stop TB Partnership strategy that empowers people living with TB and their communities and devolves responsibility to them. The TB control guidelines provide a framework for guiding implementation of the TB control strategy and define responsibilities of the different players.

During the past few years, a TB reference laboratory and a computerized TB register have been established, leading to improvement in diagnostic and surveillance capacity. Botswana has had four multidrug-resistant TB (MDR-TB) surveys since 1995. These have shown a steady increase in MDR-TB and an increasing prevalence of mono-resistance to rifampicin and ethambutol.

The prevalence of MDR-TB has increased from 0.2% in 1996 to 2.5% in 1998. In addition, there has emerged an extensively drug resistant-TB (XDR-TB) in Botswana with three cases confirmed in 2007. The current MDR-TB national guidelines advocate for a comprehensive approach to management of MDR-TB with emphasis on TB/HIV coinfected persons and the paediatric population. Surveillance and management of TB/HIV have been improving over the past few years.

A national TB/HIV advisory committee was formed in 2005 and isoniazid preventive therapy was expanded to prevention of mother-to-child transmission, voluntary testing and counselling and antiretroviral programmes. All doctors administering antiretroviral therapy are trained in TB/HIV coinfection diagnosis and management. Botswana's TB/HIV policy guidelines were launched in 2011. However, the process of sharing TB/HIV surveillance data between TB and HIV programmes has not been well established. By 2008, only 65% of TB patients had been tested for HIV against the target of 90% and only 34% of TB patients were receiving highly active antiretroviral therapy.

The poor outcomes may be due to poor monitoring and evaluation and weak patient referral tracking. Challenges withstanding, a strong political commitment to combat AIDS combined with resource allocation provides Botswana with a strong platform for building collaborative TB/HIV activities.