HIV-sensitive social protection for unemployed and out-of-school young women in Botswana: An exploratory study of barriers and solutions.

Promotive social protection programs aim to increase income and capabilities and could help address structural drivers of HIV-vulnerability like poverty, lack of education and gender inequality. Unemployed and out-of-school young women bear the brunt of HIV infection in Botswana, but rarely benefit from such economic empowerment programs. Using a qualitative exploratory study design and a participatory research approach, we explored factors affecting perceived program benefit and potential solutions to barriers. Direct stakeholders (n = 146) included 87 unemployed and out-of-school young women and 59 program and technical officers in five intervention districts. Perceived barriers were identified in 20 semi-structured interviews (one intervention district) and 11 fuzzy cognitive maps. Co-constructed improvement recommendations were generated in deliberative dialogues. Analysis relied on Framework and the socioecological model. Overall, participants viewed existing programs in Botswana as ineffective and inadequate to empower vulnerable young women socially or economically. Factors affecting perceived program benefit related to programs, program officers, the young women, and their social and structural environment. Participants perceived barriers at every socioecological level. Young women's lack of life and job skills, unhelpful attitudes, and irresponsible behaviors were personal-level barriers. At an interpersonal level, competing care responsibilities, lack of support from boyfriends and family, and negative peer influence impeded program benefit. Traditional venues for information dissemination, poverty, inequitable gender norms, and lack of coordination were community- and structural-level barriers. Improvement recommendations focused on improved outreach and peer approaches to implement potential solutions. Unemployed and out-of-school young women face multidimensional, interacting barriers that prevent benefit from available promotive social protection programs in Botswana. To become HIV-sensitive, these socioeconomic empowerment programs would need to accommodate or preferentially attract this key population. This requires more generous and comprehensive programs, a more client-centered program delivery, and improved coordination. Such structural changes require a holistic, intersectoral approach to HIV-sensitive social protection.

Prevalence, molecular and phenotypic profiles of arboreal associated Cryptococcus neoformans in Botswana.

Mopane tree (Colophospermum mopane) is one of the main ecological niches of Cryptococcus neoformans, an opportunistic fungal pathogen that causes cryptococcosis primarily on immunocompromised hosts after inhalation of basidiospores from the environment. Hence, we investigated the prevalence, and phenotypically (antifungal resistance and biofilm formation capacity) and genotypically (mating type and genetic structure) characterized C. neoformans isolated from C. mopane, Acacia tortilis, Adansonia digitata and Ziziphus mucronata in Botswana. We report 7.1% and 2.9% prevalence of C. neoformans in C. mopane and other trees, respectively. All tested C. neoformans isolates were determined to be non-WT to fluconazole. Most isolates (65%) of C. neoformans isolates were biofilm producers. Mating type determination revealed a higher proportion of the globally rare MATa allele (53%) and a single MATα/MATa hybrid. The observed genotypeswere VNI (71%), VNB (23%) and VNB/VNB hybrids (6%). Native trees other than C. mopane are alternative ecological niches of antifungal resistant C. neoformans, and this represents a serious public health concern,and this represents a serious public health concern, especially for high-risk populations. Prevalence of C. neoformans on native trees and the observed emergence of hybrids (evidence of sexual recombination) highlight the need for increased surveillance and risk assessment within a One Health paradigm.

Improvement studies for equitable and evidence-based innovation: an overview of the 'IM-SEEN' model.

BACKGROUND: Health inequalities are ubiquitous, and as countries seek to expand service coverage, they are at risk of exacerbating existing inequalities unless they adopt equity-focused approaches to service delivery. MAIN TEXT: Our team has developed an equity-focused continuous improvement model that reconciles prioritisation of disadvantaged groups with the expansion of service coverage. Our new approach is based on the foundations of routinely collecting sociodemographic data; identifying left-behind groups; engaging with these service users to elicit barriers and potential solutions; and then rigorously testing these solutions with pragmatic, embedded trials. This paper presents the rationale for the model, a holistic overview of how the different elements fit together, and potential applications. Future work will present findings as the model is operationalised in eye-health programmes in Botswana, India, Kenya, and Nepal. CONCLUSION: There is a real paucity of approaches for operationalising equity. By bringing a series of steps together that force programme managers to focus on groups that are being left behind, we present a model that can be used in any service delivery setting to build equity into routine practice.

An ethnopharmacological survey of medicinal plants traditionally used by the BaKalanga people of the Tutume subdistrict in Central Botswana to manage HIV/AIDS, HIV-associated conditions, and other health conditions.

ETHNOPHARMACOLOGICAL RELEVANCE: While access to antiretroviral therapy (ART) continues to improve worldwide, HIV infection and AIDS persist as serious health challenges, particularly in sub-Saharan Africa. Complementary and Alternative Medicines (CAM), as part of indigenous and pluralistic medical systems, are important contributors to primary health care worldwide. However, this knowledge remains relatively undocumented in many parts of sub-Saharan Africa such as the Tutume subdistrict of Central Botswana, where CAM is widely used including potentially for HIV/AIDS and HIV-associated conditions. AIM OF THE STUDY: To explore the extent to which CAM is used by the BaKalanga Peoples of the Tutume subdistrict, we performed an exploratory community-based project to record medicinal plant use from this relatively undocumented region, with a particular focus on species used for management of HIV/AIDS and HIV-associated conditions. MATERIALS AND METHODS: Using the snowball sampling technique, we recruited 13 Traditional Health Practitioners (THPs) and conducted in-depth interviews to explore medicinal plant uses and treatment regimens. Plant specimens were collected and bio-authenticated. RESULTS: We documented 83 plant species used as CAM to treat or manage a variety of conditions including HIV/AIDS, HIV-associated conditions, and other health conditions. Plants from the family Leguminosae were most frequently reported, comprising 21 species (25.3%), followed by 5 from both Euphorbiaceae and Combretaceae families (6.0%). Four plants (4.8%) were used specifically to manage HIV (Lannea edulis (Sond.) Engl. root, Aloe zebrina Baker root, Myrothamnus flabellifolia Welw. whole plant, and Harpagophytum procumbens var. subulobatum (Engl.) tuber), while an additional 7 (8.4%) were reported specifically for treating combinations of HIV-related symptoms. Notably, 25 (30.1%) have not been reported previously as CAM and/or lack reported bioactivity data. CONCLUSIONS: To our knowledge, this is the first detailed ethnobotanical survey of CAM used by the BaKalanga Peoples of the Tutume subdistrict to manage HIV/AIDS and HIV-associated and other health conditions.

Psychometric properties of a clinical assessment tool in the postgraduate midwifery programme, Botswana.

BACKGROUND:  The psychometric properties of a clinical assessment tool used in the postgraduate midwifery programme in Botswana have not been evaluated. A lack of reliable and valid clinical assessment tools contributes to inconsistencies in clinical assessment in midwifery programmes. OBJECTIVES:  This study aimed to evaluate the internal consistency and content validity of a clinical assessment tool used in the postgraduate midwifery programme in Botswana. METHOD:  For internal consistency, we calculated the total-item correlation and Cronbach's alpha coefficient. For content validity, subject matter experts completed a checklist to evaluate the relevance and clarity of each competency in the clinical assessment tool. The checklist included questions with Likert-scale responses, indicating the level of agreement. RESULTS:  The clinical assessment tool had a good reliability, with a Cronbach's alpha of 0.837. The corrected item total correlation values ranged from -0.043 to 0.880 and the Cronbach's alpha (if item deleted) ranged from 0.079 to 0.865. Overall content validity ratio was 0.95, and content validity index was 0.97. Item content validity indices ranged from 0.8 to 1.0. The overall scale content validity index was 0.97 and the scale content validity index using universal agreement was 0.75. CONCLUSION:  The clinical assessment tool used in the postgraduate midwifery programme in Botswana has acceptable reliability. Most of the competencies included in the clinical assessment tool were relevant and clear. Certain competencies need to be reviewed to improve the reliability and validity of the clinical assessment tool.Contribution: The clinical assessment tool currently used in the postgraduate midwifery programme in Botswana had acceptable internal consistency reliability and validity.

Iron, folic acid, and multiple micronutrient supplementation strategies during pregnancy and adverse birth outcomes in Botswana.

BACKGROUND: Antenatal multiple micronutrient supplementation (MMS) with iron, folic acid, and other micronutrients might improve birth outcomes, but it is not currently universally recommended by WHO. METHODS: In this observational cohort study, we surveyed pregnancies for adverse birth outcomes at eight hospitals from July, 2014, to July, 2018, and 18 hospitals from August, 2018, to December, 2020, in Botswana to assess four routine supplementation strategies in women presenting before 24 weeks' gestation: folic acid only, iron only, iron and folic acid supplementation (IFAS), and MMS. Women with singleton pregnancies; a known HIV status, age, and delivery site; haemoglobin measured within 7 days of presenting to antenatal care; and weight measured within 31 days of presenting to care were included in our analysis. Data were abstracted from the maternity obstetric record (a record of antenatal care) at the time of birth from all women giving birth at selected hospitals throughout the country. We estimated risk differences overall and in key subgroups, adjusting for demographic and clinical factors. FINDINGS: Between July 6, 2014, and Dec 8, 2020, 96 341 eligible women (21 659 [22·5%] of whom had HIV) were included in the study. 36 334 (37·7%) women initiated iron only supplementation, 1133 (11·8%) initiated folic acid only supplementation, 23 101 (24·0%) initiated IFAS, and 31 588 (32·8%) women initiated MMS. Women who initiated iron only and folic acid only supplementation had higher risks of stillbirth, preterm birth, very preterm birth, low and very low birthweight, and neonatal death compared with women who received IFAS (adjusted risk differences for iron only supplementation vs IFAS ranged from 0·22% [95% CI 0·04 to 0·40] for neonatal death to 2·39% [1·78 to 3·00] for preterm birth; and adjusted risk differences for folic acid only supplementation vs IFAS ranged from 0·77% [-0·80 to 2·34] for neonatal death to 5·75% [1·38 to 10·13] for preterm birth), with greater difference in women with HIV and those aged 35 years and older. Compared with IFAS, women who initiated MMS had lower risks of preterm and very preterm births, and low and very low birthweight (adjusted risk differences ranged from -0·50% [-0·77 to 0·23] for very preterm birth to -1·06% [-1·69 to -0·42] for preterm birth). INTERPRETATION: Nationwide data from Botswana support improved birth outcomes with MMS compared with IFAS. FUNDING: National Institutes of Health, National Institute of Child Health and Human Development, and National Institute of Allergy and Infectious Diseases.

Provider Barriers and Facilitators of Breast Cancer Guideline-Concordant Therapy Delivery in Botswana: A Consolidated Framework for Implementation Research Analysis.

INTRODUCTION: Systemic treatment for breast cancer in sub-Saharan Africa (SSA) is cost effective. However, there are limited real-world data on the translation of breast cancer treatment guidelines into clinical practice in SSA. The study aimed to identify provider factors associated with adherence to breast cancer guideline-concordant care at Princess Marina Hospital (PMH) in Botswana. MATERIALS AND METHODS: The Consolidated Framework for Implementation Research was used to conduct one-on-one semistructured interviews with breast cancer providers at PMH. Purposive sampling was used, and sample size was determined by thematic saturation. Transcribed interviews were double-coded and analyzed in NVivo using an integrated analysis approach. RESULTS: Forty-one providers across eight departments were interviewed. There were variations in breast cancer guidelines used. Facilitators included a strong tension for change and a government-funded comprehensive cancer care plan. Common provider and health system barriers were lack of available resources, staff shortages and poor skills retention, lack of relative priority compared with HIV/AIDS, suboptimal interdepartmental communication, and lack of a clearly defined national cancer control policy. Community-level barriers included accessibility and associated transportation costs. Participants recommended the formal implementation of future guidelines that involved key stakeholders in all phases of planning and implementation, strategic government buy-in, expansion of multidisciplinary tumor boards, leveraging nongovernmental and academic partnerships, and setting up monitoring, evaluation, and feedback processes. DISCUSSION: The study identified complex, multilevel factors affecting breast cancer treatment delivery in Botswana. These results and recommendations will inform strategies to overcome specific barriers in order to promote standardized breast cancer care delivery and improve survival outcomes. IMPLICATIONS FOR PRACTICE: To address the increasing cancer burden in low- and middle-income countries, resource-stratified guidelines have been developed by multiple international organizations to promote high-quality guideline-concordant care. However, these guidelines still require adaptation in order to be successfully translated into clinical practice in the countries where they are intended to be used. This study highlights a systematic approach of evaluating important contextual factors associated with the successful adaptation and implementation of resource-stratified guidelines in sub-Saharan Africa. In Botswana, there is a critical need for local stakeholder input to inform country-level and facility-level resources, cancer care accessibility, and community-level barriers and facilitators.

Clinical and sociodemographic factors associated with late stage cervical cancer diagnosis in Botswana.

BACKGROUND: Cervical cancer is the leading cause of female cancer mortality in Botswana with the majority of cervical cancer patients presenting with late-stage disease. The identification of factors associated with late-stage disease could reduce the cervical cancer burden. This study aims to identify potential patient level clinical and sociodemographic factors associated with a late-stage diagnosis of cervical cancer in Botswana in order to help inform future interventions at the community and individual levels to decrease cervical cancer morbidity and mortality. RESULTS: There were 984 women diagnosed with cervical cancer from January 2015 to March 2020 at two tertiary hospitals in Gaborone, Botswana. Four hundred forty women (44.7%) presented with late-stage cervical cancer, and 674 women (69.7%) were living with HIV. The mean age at diagnosis was 50.5 years. The association between late-stage (III/IV) cervical cancer at diagnosis and patient clinical and sociodemographic factors was evaluated using multivariable logistic regression with multiple imputation. Women who reported undergoing cervical cancer screening had lower odds of late-stage disease at diagnosis (OR: 0.63, 95% CI 0.47-0.84) compared to those who did not report screening. Women who had never been married had increased odds of late-stage disease at diagnosis (OR: 1.35, 95% CI 1.02-1.86) compared to women who had been married. Women with abnormal vaginal bleeding had higher odds of late-stage disease at diagnosis (OR: 2.32, 95% CI 1.70-3.16) compared to those without abnormal vaginal bleeding. HIV was not associated with a diagnosis of late-stage cervical cancer. Rural women who consulted a traditional healer had increased odds of late-stage disease at diagnosis compared to rural women who had never consulted a traditional healer (OR: 1.61, 95% CI 1.02-2.55). CONCLUSION: Increasing education and awareness among women, regardless of their HIV status, and among providers, including traditional healers, about the benefits of cervical cancer screening and about the importance of seeking prompt medical care for abnormal vaginal bleeding, while also developing support systems for unmarried women, may help reduce cervical cancer morbidity and mortality in Botswana.

Identifying anthropogenic features at Seoke (Botswana) using pXRF: Expanding the record of southern African Stone Walled Sites.

Numerous and extensive 'Stone Walled Sites' have been identified in southern African Iron Age landscapes. Appearing from around 1200 CE, and showing considerable variability in size and form, these settlements are named after the dry-stone wall structures that characterize them. Stone Walled Sites were occupied by various Bantu-speaking agropastoral communities. In this paper we test the use of pXRF (portable X-ray fluorescence analysis) to generate a 'supplementary' archaeological record where evident stratigraphy is lacking, survey conditions may be uneven, and excavations limited, due to the overall site size. We propose herein the application of portable X-ray fluorescence analysis (pXRF) coupled with multivariate exploratory analysis and geostatistical modelling at Seoke, a southern African SWS of historical age (18th century CE). The aim of the paper is twofold: to explore the potential of the application of a low cost, quick, and minimally invasive technique to detect chemical markers in anthropogenic sediments from a Stone Walled Site, and to propose a way to analyse the results in order to improve our understanding of the use of space at non-generalized scales in such sites.

Prevalence and correlates of multimorbidity among adults in Botswana: A cross-sectional study.

BACKGROUND: Botswana is currently undergoing rapid epidemiological transition indicated by a decline in infectious diseases and an increase in chronic non-communicable diseases and their associated risk factors. The main aim of this study was to assess prevalence and correlates of multimorbidity among the adult population in Botswana. METHODS: A cross-sectional study called Chronic Non-Communicable Diseases Study (NCDs study) was conducted in March, 2016. Using multistage cross sectional sampling design, 1178 male and female respondents aged 15 years and above were interviewed across 3 cities and towns, 15 urban villages and 15 rural villages. Participants were interviewed face-to-face using a structured questionnaire. Adjusted multinomial logistic regression analysis was used to assess covariates of multimorbidity. The statistical significant level was fixed at p <0 .05. RESULTS: Prevalence of multimorbidity in the sampled population was estimated at 5.4%. Multivariate results indicate that the odds of multimobridty were significantly high among women (AOR = 3.34, 95% C.I. = 1.22-21.3) than men. On the other hand, the odds of multimorbidity were significantly low among young people aged below 24 years (AOR = 0.01, 95% C.I. = 0.00-0.07), currently married people (AOR = 0.24, 95% C.I. = 0.07-0.80) and individuals in the 2nd wealth quintile (AOR = 0.20, 95% C.I. = 0.05-0.75) compared to their counterparts. For behavioural risk factors, alcohol consumption (AOR = 4.80, 95% C.I. = 1.16-19.8) and overweight/obesity (AOR = 1.44, 95% CI = 1.12-2.61) were significantly associated with high multimorbidity prevalence. CONCLUSION: Multimorbidity was found to be more prevalent among women, alcohol consumers and overweight/obese people. There is need to strengthen interventions encouraging healthy lifestyles such as non-consumption of alcohol, physical activity and healthy diets. Moreover, there is need for a holistic approach of health care services to meet the needs of those suffering from multimorbidity.

A role for traditional doctors in health promotion: experience from a trial of HIV prevention in Botswana.

Traditional doctors have been largely ignored in HIV prevention, particularly primary prevention. As part of a structural intervention programme to reduce HIV risk among young women in Botswana, we trained 147 traditional doctors in four districts as well as government health education assistants (HEAs) and teachers to run discussion groups in the community and schools, using an evidence-based eight-episode audio-drama, covering gender roles, gender violence, and how these are related to HIV risk. One year later, we contacted 43 of the 87 trained traditional doctors in two districts. Most (32) were running discussion groups with men and women, with links to the local HEAs and teachers. They were adept at recruiting men to their groups, often a challenge with community interventions, and reported positive changes in attitudes and behaviour of group participants. Traditional doctors can play an important role in primary prevention of gender violence and HIV.

Utility of Targeted, Amplicon-Based Deep Sequencing To Detect Resistance to First-Line Tuberculosis Drugs in Botswana.

Multidrug-resistant tuberculosis (TB) is an alarming threat, and targeted deep sequencing (DS) may be an effective method for rapid identification of drug-resistant profiles, including detection of heteroresistance. We evaluated the sensitivity and specificity of targeted DS versus phenotypic drug susceptibility testing (pDST) among patients starting first-line anti-TB therapy in Botswana. Overall, we found high concordance between DS and pDST. Lower sensitivity of DS, which targets established high-confidence resistance variants, was observed for detecting isoniazid resistance among HIV-infected patients.

A standardized low-cost peer role-playing training intervention improves medical student competency in communicating bad news to patients in Botswana.

OBJECTIVE: The purpose of this study was to demonstrate effectiveness of an educational training workshop using role-playing to teach medical students in Botswana to deliver bad news. METHOD: A 3-hour small group workshop for University of Botswana medical students rotating at the Princess Marina Hospital in Gaborone was developed. The curriculum included an overview of communication basics and introduction of the validated (SPIKES) protocol for breaking bad news. Education strategies included didactic lecture, handouts, role-playing cases, and open forum discussion. Pre- and posttraining surveys assessed prior exposure and approach to breaking bad news using multiple-choice questions and perception of skill about breaking bad news using a 5-point Likert scale. An objective structured clinical examination (OSCE) with a standardized breaking bad news skills assessment was conducted; scores compared two medical student classes before and after the workshop was implemented.ResultForty-two medical students attended the workshop and 83% (35/42) completed the survey. Medical students reported exposure to delivering bad news on average 6.9 (SD = 13.7) times monthly, with 71% (25/35) having delivered bad news themselves without supervision. Self-perceived skill and confidence increased from 23% (8/35) to 86% (30/35) of those who reported feeling "good" or "very good" with their ability to break bad news after the workshop. Feedback after the workshop demonstrated that 100% found the SPIKES approach helpful and planned to use it in clinical practice, found role-playing helpful, and requested more sessions. Competency for delivering bad news increased from a mean score of 14/25 (56%, SD = 3.3) at baseline to 18/25 (72%, SD = 3.6) after the workshop (p = 0.0002).Significance of resultsThis workshop was effective in increasing medical student skill and confidence in delivering bad news. Standardized role-playing communication workshops integrated into medical school curricula could be a low-cost, effective, and easily implementable strategy to improve communication skills of doctors.

A retrospective review of patients with Kaposi's sarcoma in Botswana.

BACKGROUND: Despite widespread antiretroviral coverage in Botswana, Kaposi's sarcoma (KS) remains among the most common malignancies. To date, adult KS in Botswana is not well characterized. The diagnosis relies on clinical suspicion that is often confirmed by histopathology given the implications of treatment; however, this poses a significant resource burden. METHODS: We conducted a retrospective review of the cohort of patients biopsied for possible KS at Princess Marina Hospital, the main dermatology referral site in Botswana, from September 2008 through June 2015 to describe the demographics, human immunodeficiency virus (HIV) characteristics, and clinical presentations of these patients. Histopathologic diagnoses were reviewed, and positive predictive value (PPV) was used to characterize the accuracy of clinical suspicion of KS. RESULTS: A total of 441 patients received 450 biopsies where KS was on the differential diagnosis, and 239 patients (54%) were ultimately diagnosed with KS. The KS cohort was more likely to be male (58% vs. 37%, P < 0.001), HIV positive (94% vs. 85%, P < 0.05), and have lower CD4 counts at the time of biopsy (274 cells/µl vs. 362 cells/µl, P < 0.05). The PPV of clinical suspicion of KS was 58%. When KS was not histopathologically diagnosed, clinically benign diseases were found in 17%, medically significant conditions requiring alternative therapies in 78%, and life-threatening diseases in 5%. DISCUSSION: Our study reinforces the risk factors in development of KS. The poor PPV supports the important role of histology in KS diagnosis to both ensure appropriate treatment and prevent overtreatment. Improved accessibility to biopsy and augmentation of local dermatopathologic services would likely improve diagnostic accuracy and treatment.

Palliative care in Botswana: current state and challenges to further development.

BACKGROUND: A rising tide of cancers and other chronic diseases, alongside the ongoing HIV/AIDS epidemic, has created an increasing demand for palliative care in Africa. Yet, few African nations have established effective palliative care programs. In Botswana, the escalating HIV/AIDS crisis revealed an unmet need for holistic care, prompting efforts to expand palliative care education and policy, and target curricular and health system integration in the years that followed. Despite numerous successes, Botswana continues to face barriers to palliative care development. In this paper, we examine the country's current state of palliative care and the challenges it must still overcome. METHODS: Data was collected from June to July of 2015, and includes interviews of physicians, nurses and hospice staff. RESULTS: Palliative care delivery in Botswana is primarily concentrated in the south, where the country's first palliative care clinic and three hospices are located. While 157 health care workers, students and lecturers received palliative care training from 2013 to 2014, 100% of participants felt that education remains a significant obstacle for palliative care expansion. Sixty-four percent commented on the need for increased palliative care understanding and awareness, while 91% noted the difficulty of achieving adequate access to pain medication. CONCLUSIONS: Several targets were identified that have persistently hampered efforts to advance palliative care in Botswana, including: infrastructural challenges such as access to pain medications, the strained size of the palliative care workforce, and a need for increased palliative care education and understanding. However, recent achievements in national strategy and policy offer promising avenues for moving past these historical barriers. With implementation of action plans already underway, Botswana may ultimately provide a model for successful palliative care implementation in continuing to strengthen palliative care services throughout the country.

Prevalence of Rilpivirine and Etravirine Resistance Mutations in HIV-1 Subtype C-Infected Patients Failing Nevirapine or Efavirenz-Based Combination Antiretroviral Therapy in Botswana.

Rilpivirine (RPV) and Etravirine (ETR) are approved second-generation non-nucleoside reverse transcriptase inhibitors (NNRTIs) for HIV treatment. There is a cross-resistance HIV mutation profile between first- and second-generation NNRTI drugs. We determined the prevalence of HIV-1 drug resistance mutations (DRMs) to RPV and ETR in Botswana. A total of 168 HIV-1 polymerase gene sequences from participants failing nevirapine (NVP)- or efavirenz (EFV)-containing regimens were analyzed for DRMs using the Stanford University HIV drug resistance database. Forty-one sequences were from an adult antiretroviral therapy (ART) study, the Tshepo study, and 127 from a prevention of mother-to-child transmission (PMTCT) study, the Mashi study, all conducted in Botswana. Prevalence of RPV and ETR highest DRM in the adult ART study (n = 41) were K101E (26.2%), E138A (23.8%), and Y181C (26.2%). The PMTCT cohort's (n = 127) high prevalence mutations were Y181C (15.7%), E138A (15%), and K101E (11%). A total of 42.9% and 3.2% of patients in the adult ART study and PMTCT study, respectively, had three or more NNRTI mutations at virologic failure. We identified HIV-1 mutations conferring resistance to RPV and ETR even though they have not been used in Botswana. Of concern was the high proportion of sequences from the adult ART study that displayed multiple DRMs; as the number of NNRTI mutations increases, the level of cross-resistance increases. It is plausible that patients displaying such profiles maybe at increased risk of failing second-generation NNRTI drugs, hence, calls for genotyping in patients with prior NVP or efavirenz exposure before prescription of RPV- or ETR-containing cART.

Palliative Care in South Africa.

The Hospice Palliative Care Association (HPCA) was established in 1987 by hospices in South Africa who felt the need for a national body to share best practices and to promote palliative care services in South Africa. HPCA supports member hospices in providing palliative care to people of any age with a life-limiting condition. HPCA has the further aim to ensure access to palliative care in settings other than member hospices. Many projects were launched over the years to influence policy, and to educate medical practitioners, nurses, social workers, theologians, and community caregiver; and to develop services. A key initiative was the development of a mentorship program to assist organizations to develop accredited palliative care services in South Africa. This article highlights some of the HPCA projects funded over the years by the Open Society Foundations' International Palliative Care Initiative.

Development of Family Medicine training in Botswana: Views of key stakeholders in Ngamiland.

BACKGROUND: Family Medicine training commenced in Botswana in 2011, and Maun was one of the two sites chosen as a training complex. If it is to be successful there has to be investment in the training programme by all stakeholders in healthcare delivery in the district. AIM: The aim of the study was to explore the attitudes of stakeholders to initiation of Family Medicine training and their perspectives on the future roles of family physicians in Ngami district, Botswana. SETTING: Maun and the surrounding Ngami subdistrict of Botswana. METHODS: Thirteen in-depth interviews were conducted with purposively selected key stakeholders in the district health services. Data were recorded, transcribed and analysed using the framework method. RESULTS: Participants welcomed the development of Family Medicine training in Maun and expect that this will result in improved quality of primary care. Participants expect the registrars and family physicians to provide holistic health care that is of higher quality and expertise than currently experienced, relevant research into the health needs of the community, and reduced need for referrals. Inadequate personal welfare facilities, erratic ancillary support services and an inadequate complement of mentors and supervisors for the programme were some of the gaps and challenges highlighted by participants. CONCLUSION: Family Medicine training is welcomed by stakeholders in Ngamiland. With proper planning introduction of the family physician in the district is expected to result in improvement of primary care.