The Impact of COVID-19 on the HIV Cascade of Care in Botswana – An Interrupted Time Series

Background: The Human Immunodeficiency Virus (HIV) remains a major infectious disease threat for Sub-Saharan Africa, with Botswana having one of the highest burdens of HIV. The COVID-19 pandemic may have impacted the cascade of care for HIV, although data are scarce.ObjectiveTo estimate the impact of the COVID-19 pandemic on the HIV cascade of care in an HIV high burden country in Sub-Saharan Africa.Method: We used an interrupted time series analysis of national-level summary data from the Botswana Ministry of Health for monthly numbers of HIV tests, numbers of positive HIV tests and numbers of ART initiations during the 24-month period from April 2019 until March 2021. Multivariable Poisson regression models were used to estimate the effect of the COVID-19 pandemic on each of the outcomes, with the break point of the model being April 2020, the month of the first lockdown. Primary outcome measures were the number of HIV tests, HIV-positive tests, and the number of ART initiations. Each model included month as a linear variable and COVID-19 as an intervention dummy variable.Findings: During the 12 months before the first national lockdown in Botswana, there were a total of 416,201 HIV tests, 13,808 HIV positive tests, and 15,939 ART initiations. During the 12 months after the lockdown, the total number of HIV tests decreased by 31% to 286,376, HIV positive tests decreased by 31% to 9,565, and ART initiations went down by 35% to 10, 324. Monthly numbers of HIV tests, positive tests and ART initiati286,376,went down during the first 12 months of the COVID-19 health emergency, compared to the period before COVID-19, there was a significantly lower median numbers of HIV tests (36,081.5, IQR 34,630-40021.5 vs 26932, IQR 22015-28056, respectively, p<0.001), lower median number of HIV positive tests (1205, IQR 1129-1280 vs 854, IQR 800.5-877.5, respectively, p<0.001) and lower median number of ART initiations (1235, IQR 1090-1400 vs 830.5, IQR 815-938.5, respectively, p<0.001). In multivariable Poisson regression, overall, the COVID-19 lockdown was associated with a 27% decrease in the monthly numbers of HIV tests (IRR 0.73, 95%CI 0.72-0.73), a 25% decrease in the monthly numbers of HIV positive tests (IRR 0.75, 95%CI 0.71-0.79), and a 43% reduction in the monthly numbers of ART initiations (IRR 0.57, 95%CI 0.55-0.60). The impact of the lockdown on all three outcomes appeared worse in males and people in the 50-59 years and ≥60 years age groups.Conclusions: In Botswana, COVID-19 had a strong negative impact on HIV screening, the detection of HIV-positive cases and the number of individuals initiated on ART. This impact is likely to have also occurred in other HIV high burden countries in Sub-Saharan Africa. These findings suggest a need to protect key existing health services in times of public health emergencies.Funding: No funding to report.Declaration of Interest: All authors declare no conflict of interest.Ethical Approval: The study received approval from the Botswana Ministry of Health: Health Research and Development Committee (HRDC), reference number: HPDME 13/18/1 and HPDME 6/13/1 as well as the Stellenbosch University Health Research Ethics Committee (SUHREC), reference number: S22/03/005_CIVID-19. A waiver of informed consent was requested from the ethics committees since data collected were not at individual/participant level and de-identified Permission to access and use the data was received from the Botswana Ministry of Health Department of Health Services Management.