Low-Level Viremia among Adults Living with HIV on Dolutegravir-Based First-Line Antiretroviral Therapy Is a Predictor of Virological Failure in Botswana.

We evaluated subsequent virologic outcomes in individuals experiencing low-level virem ia (LLV) on dolutegravir (DTG)-based first-line antiretroviral therapy (ART) in Botswana. We used a national dataset from 50,742 adults who initiated on DTG-based first-line ART from June 2016-December 2022. Individuals with at least two viral load (VL) measurements post three months on DTG-based first-line ART were evaluated for first and subsequent episodes of LLV (VL:51-999 copies/mL). LLV was sub-categorized as low-LLV (51-200 copies/mL), medium-LLV (201-400 copies/mL) and high-LLV (401-999 copies/mL). The study outcome was virologic failure (VF) (VL ≥ 1000 copies/mL): virologic non-suppression defined as single-VF and confirmed-VF defined as two-consecutive VF measurements after an initial VL < 1000 copies/mL. Cox regression analysis identified predictive factors of subsequent VF. The prevalence of LLV was only statistically different at timepoints >6-12 (2.8%) and >12-24 (3.9%) (p-value < 0.01). LLV was strongly associated with both virologic non-suppression (adjusted hazards ratio [aHR] = 2.6; 95% CI: 2.2-3.3, p-value ≤ 0.001) and confirmed VF (aHR = 2.5; 95% CI: 2.4-2.7, p-value ≤ 0.001) compared to initially virally suppressed PLWH. High-LLV (HR = 3.3; 95% CI: 2.9-3.6) and persistent-LLV (HR = 6.6; 95% CI: 4.9-8.9) were associated with an increased hazard for virologic non-suppression than low-LLV and a single-LLV episode, respectively. In a national cohort of PLWH on DTG-based first-line ART, LLV > 400 copies/mL and persistent-LLV had a stronger association with VF. Frequent VL testing and adherence support are warranted for individuals with VL > 50 copies/mL.

Testing modality associated with fast-track ART initiation in Botswana.

OBJECTIVES: The aim of this study was to identify community testing modalities associated with fast-track ART initiation in Botswana. METHODS: We conducted a retrospective cohort study that included all Botswana citizens 15 years or older who were newly identified as HIV-positive from 1 May 2017 to 31 January 2019, in Mahalapye and Southern districts. We used Poisson regression with robust error variance and generalised linear mixed models to control for cluster effects to model risk of ART initiation within 7 and 30 days of HIV diagnosis, testing modality factors. RESULTS: A total of 1436 individuals were newly identified HIV-positive, with men accounting for 60% across all testing modalities. 22% of all HIV-positive individuals were initiated on ART within 7 days. Clients diagnosed through index testing were more likely to be started on ART within 7 days (adjusted risk ratio [aRR] = 1.38, 95% CI 1.37-1.38) and 30 days (aRR = 1.17, 95% CI 1.09-1.26) than those diagnosed through mobile/outreach testing. CONCLUSIONS: Community HIV testing can complement facility-based testing by reaching individuals who may be less likely to seek HIV services at a facility, such as men. Monitoring ART initiation by testing modalities is critical to identify the optimal ones and to guide continuous programme improvement.

Improving same-day antiretroviral therapy in Botswana: effects of a multifaceted national intervention.

BACKGROUND: In 2019, the Botswana Ministry of Health and Wellness (MOHW) implemented an HIV national Reboot program, which was needed for refocusing and intensifying efforts for achieving epidemic control. The strategies deployed as part of Reboot were reviewed and evaluated for their effect on same-day and within-seven-days (fast-track initiation) antiretroviral therapy (ART) initiation among adults newly identified with HIV. METHODS: We conducted a retrospective cohort analysis of patients aged 18 years or older who were newly diagnosed with HIV from October 2018 to September 2019 across 41 health facilities. We used generalized linear mixed models, adjusting for clustering by facility, to assess the association of the Reboot with same-day or within-seven-days ART initiation (fast-track initiation). RESULTS: From October 2018 to January 2019, 28% (636/2269) of newly diagnosed HIV patients were initiated the same day of diagnosis, and 56% (1260/2269) were initiated within seven days. Following the launch of Reboot (February to September 2019), 59% (2092/3553) were initiated the same day of diagnosis, and 77% (2752/3553) were initiated within seven days. Clients were 2.08 (adjusted risk ratio 95% confidence interval 1.79-2.43) times more likely to be initiated the same day of diagnosis and 1.39 (adjusted risk ratio 95% confidence interval 1.28-1.52) times more likely to be initiated within seven days than before Reboot after adjusting for sex and age. CONCLUSION: In Botswana, a multifaceted national intervention improved timely ART initiation. Identifying and implementing different client-centered strategies to facilitate ART initiation is critical to preventing AIDS-related complications and prevent ongoing transmission.

Bring-your-own-device in medical schools and healthcare facilities: A review of the literature.

BACKGROUND: Enabling personal mobile device use through a bring-your-own device (BYOD) policy can potentially save significant costs for medical schools and healthcare facilities, as they would not always have to acquire facility-owned devices. The BYOD policy is also perceived as a driver for balancing user needs for convenience with institutional needs for security. However, there seems to be a paucity in the literature on BYOD policy development, policy evaluation, and evaluation of mobile device implementation projects. OBJECTIVE: This review explored the literature to identify BYOD policy components (issues, interventions, and guidelines) that could potentially inform BYOD policy development and implementation in medical schools and healthcare facilities. METHODS: A literature search on PubMed, Web of Science, and Ebscohost (Academic Search Premier, ERIC, CINAHL, and MEDLINE) was conducted using the following search terms and their synonyms: healthcare facilities, mobile devices, BYOD, privacy and confidentiality, and health records. We developed a review matrix to capture the main aspects of each article and coded the matrix for emerging themes. The database and hand search yielded 1 594 articles, 14 of which were deemed as meeting the inclusion criteria. RESULTS: Several themes emerging from the analysis include: device management, data security, medical applications, information technology, education and/or curriculum, policy, and guidelines. The guidelines theme seems to provide a direction for BYOD policy development and implementation while the policy theme seems to be the comprehensive solution that synergizes BYOD implementation. CONCLUSION: Rather than an approach of 'chasing' issues with interventions, a more feasible approach towards achieving a safe mobile device use environment is through the development of comprehensive BYOD policies that would balance users' need for convenience with organizational security and patient privacy. The paucity in peer-reviewed literature calls for robust research that uses socio-technical approaches to development and evaluation of BYOD policies in medical schools and healthcare facilities.

Rural exposure during medical education and student preference for future practice location - a case of Botswana.

BACKGROUND: Botswana's medical school graduated its first class in 2014. Given the importance of attracting doctors to rural areas the school incorporated rural exposure throughout its curriculum. AIM: This study explored the impact of rural training on students' attitudes towards rural practice. SETTING: The University of Botswana family medicine rural training sites, Maun and Mahalapye. METHODS: The study used a mixed-methods design. After rural family medicine rotations, third- and fifth-year students were invited to complete a questionnaire and semi-structured interview. Data were analysed using descriptive statistics and thematic analysis. RESULTS: The thirty-six participants' age averaged 23 years and 48.6% were male. Thirtythree desired urban practice in a public institution or university. Rural training did not influence preferred future practice location. Most desired specialty training outside Botswana but planned to practice in Botswana. Professional stagnation, isolation, poorly functioning health facilities, dysfunctional referral systems, and perceived lack of learning opportunities were barriers to rural practice. Lack of recreation and poor infrastructure were personal barriers. Many appreciated the diversity of practice and supportive staff seen in rural practice. Several considered monetary compensation as an enticement for rural practice. Only those with a rural background perceived proximity to family as an incentive to rural practice. CONCLUSION: The majority of those interviewed plan to practice in urban Botswana, however, they did identify factors that, if addressed, may increase rural practice in the future. Establishing systems to facilitate professional development, strengthening specialists support, and deploying doctors near their home towns are strategies that may improve retention of doctors in rural areas.Keyords: rural health, student perceptions.