Prevalence and Associated Risk Factors of Anemia Among Hospitalized Children in a Tertiary Level Hospital in Botswana.

Anemia is a global health concern and has been associated with long term cognitive and behavioral adverse effects. A cross sectional study was conducted to determine the prevalence of and risk factors for anemia in infants and children between 6 months to 5 years of age admitted to a tertiary hospital in Botswana. Baseline full blood count of every patient admitted during the study period was assessed to determine if anemia was present. Data were collected from patient's medical inpatient chart, electronic medical record (Integrated Patient Management System (IPMS)), and through interviewing parents and caregivers. Multivariate logistic regression model was used to identify risk factors of anemia. A total of 250 patients were included in the study. Prevalence of anemia in this cohort was 42.8%. There were 145 (58%) males. Of the patients with anemia, 56.1%, 39.2%, and 4.7% had mild, moderate, and severe anemia, respectively. Microcytic anemia consistent with iron deficiency was identified in 61 (57%) patients. Age was the only independent predictor of anemia. Children aged 24 months and more had a 50% lower risk of having anemia than their younger counterparts (odds ratio (OR) 0.52; 95% Confidence Interval (95% CI) 0.30 to 0.89). The findings of this study demonstrate anemia as a serious health concern in the pediatric population in Botswana.

Skin conditions among pediatric dermatology outpatients in Botswana.

BACKGROUND: An understanding of the prevalence patterns of skin diseases in children in Botswana is needed to guide national dermatological policy development, training, and resource allocation to improve patient care. OBJECTIVE: To describe local skin disease patterns in children aged 0-18 years presenting for dermatologic care in Botswana. METHODS: A retrospective review of records from 1st January 2011 to 31st December 2016 was conducted at the outpatient dermatology clinic of Princess Marina Hospital (PMH) in Gaborone, Botswana and outreach clinic sites. RESULTS: There were 4413 pediatric visits constituting 18.6% of all dermatology visits. There was a slight male predominance of 1.2:1. The majority of disorders were noninfectious 80.1% (3537/4413) versus infectious 14.6% (645/4413), with 5.2% (231/4413) unclassified. In the noninfectious category, two-thirds were inflammatory, followed by disorders of nails, skin appendages, and pigmentary disorders. Atopic dermatitis was the most common inflammatory disorder. Over half of infectious skin diseases were viral, followed by fungal and bacterial disorders. In the HIV-related disorders, the majority were verrucae 94% (108/115) followed by Kaposi sarcoma. The nine most common skin diagnoses accounted for close to 70% of all skin diseases seen at the clinic, and these included atopic dermatitis (almost half of all cases), followed by verruca, acne, and vitiligo. CONCLUSION: There is a high burden of skin disorders in children in Botswana. In our cohort, a small number of skin conditions made up the vast majority of pediatric diagnoses. This information can be used to guide dermatology training and resource allocation to better manage these common diseases.

Support for lowering cervical cancer screening age to 25 for women living with HIV: retrospective cross-sectional programmatic data from Botswana.

BACKGROUND: Women living with human immunodeficiency virus (HIV) tend to develop cervical cancer at a younger age than women without HIV. The World Health Organization's (WHO) 2021 guidelines for screening and treatment of cervical pre-cancer lesions for cervical cancer prevention include a conditional recommendation for initiating screening at age 25 for women living with HIV (WLWH). This recommendation is based on low-certainty evidence, and WHO calls for additional data. We describe the association of age and HIV status with visual inspection with acetic acid (VIA) positivity and cervical intraepithelial neoplasia grade two or higher (CIN2+) in Botswana. METHODS: This was a retrospective cross-sectional study of 5714 participants aged 25 to 49 years who underwent VIA screening in a clinic mainly serving WLWH. VIA-positive women received cryotherapy if eligible or were referred for colposcopy and excisional treatment. Known cervical cancer risk factors, screening outcome, and histological results were extracted from the program database. We compared the proportions and association of VIA positivity and CIN2+ by age and HIV status. RESULTS: The median age was 35 years [IQR 31-39], and 18% of the women were aged 25-29. Ninety percent were WLWH; median CD4 count was 250 cells/µL [IQR 150-428], and 34.2% were on anti-retroviral treatment (ART). VIA-positivity was associated with younger age (OR 1.48, CI 1.28, 1.72 for 25-29 years vs. 30-49 years), and HIV-positivity (OR 1.85, CI 1.51, 2.28). CIN2+ was only associated with HIV-positivity (OR 6.12, CI 3.39, 11.10), and proportions of CIN2+ were similar for both age groups in WLWH (69.1% vs. 68.3%). CONCLUSIONS: Younger WLWH in Botswana had a significant burden of CIN2+. This finding further supports lowering the screening age for WLWH from 30 to 25.

Acceptance rate and risk perception towards the COVID-19 vaccine in Botswana.

BACKGROUND: The COVID-19 disease burden continues to be high worldwide and vaccines continue to be developed to help combat the pandemic. Acceptance and risk perception for COVID-19 vaccines is unknown in Botswana despite the government's decision to roll out the vaccine nationally. OBJECTIVES: This study aims to assess the acceptance rate and risk perception of COVID-19 vaccines amongst the general population in Botswana. METHODS: We interviewed 5300 adults in Botswana from 1-28 February 2021 using self-administered questionnaires. The main outcomes of the study were vaccine acceptance and hesitancy rates. Demographic, experiential and socio-cultural factors were explored for their association with outcome variables. RESULTS: Two-thirds of the participants were females (3199), with those aged 24-54 making the highest proportion (61%). The acceptance rate of COVID-19 vaccine was 73.4% (95% CI: 72.2%-74.6%) with vaccine hesitancy at 31.3% (95% CI: 30.0%-32.6%). When the dependent variable was vaccine acceptance, males had higher odds of accepting the vaccine compared to females (OR = 1.2, 95% CI: 1.0, 1.4). Individuals aged 55-64 had high odds of accepting the vaccine compared to those aged 65 and above (OR = 1.2, 95% CI: 0.6, 2.5). The odds of accepting the vaccine for someone with primary school education were about 2.5 times that of an individual with post graduate level of education. Finally, individuals with comorbidities had higher odds (OR = 1.2, 95% CI: 1.0, 1.5) of accepting the vaccine compared to those without any underlying conditions. CONCLUSION: This study demonstrated a high acceptance rate for the COVID-19 vaccine and a low risk perception in Botswana. In order to achieve a high vaccine coverage and ensure a successful vaccination process, there is need to target populations with high vaccine hesitancy rates. A qualitative study to assess the factors associated with vaccine acceptance and hesitancy is recommended to provide an in-depth analysis of the findings.

Mediation Analysis of a Theory-Based Culture and Age-Appropriate HIV/STI Prevention.

Few studies have investigated mediator effects of HIV prevention interventions on adolescents in sub-Saharan Africa. Herein, we report on a secondary analysis of an intervention that increased intentions to use condoms, abstain from sexual intercourse, and seek safe male circumcision among adolescents in Botswana. In a study conducted in Botswana, 806 grade 9 students from 21 public Junior Secondary Schools were randomly assigned to either the OWN THE FUTURE: Pulling Together We Will" ( PTWW) intervention group or a health promotion control group. Both conditions consisted of 12 1-h modules, with two modules delivered during each of the six sessions on six consecutive school days. The students in both groups completed confidential computer-based surveys at several time points: pre-, immediately post-, 3, 6, and 12 months post-intervention. Mediation was assessed using the product-of-coefficients approach in a generalized estimating equations (GEE) framework. The analyses showed that condom use beliefs were significant mediators of the intervention effect on the intention to consistently use condoms over time. Also, negative socio-cultural beliefs, prevention beliefs, and HIV/STI knowledge were significant mediators of the intervention's effects on the intention to abstain from sex. Additionally, normative beliefs, prevention beliefs, parental negotiation, and circumcision knowledge were significant mediators of the intervention's effect on intention to seek safe male circumcision. The mediation analysis delineated a theoretical model and isolated activities that positively impact condom use, abstinence from sex, and circumcision intentions of Batswana middle school adolescents.

Explicating factors that explain condom use intention among in-school adolescents in Botswana: a structural equation modelling approach.

Knowledge with respect to adolescents' intentions to engage in protective sexual behaviours is still deficient in numerous countries around the world, particularly in Sub-Saharan Africa (SSA) where HIV prevalence is the highest. Increasing cross-sectional research suggests that the theory of planned behaviour (TPB) is robust in predicting condom use intentions. This study used secondary, baseline data from a study involving 794 in-school adolescents. A structural equation model was applied to the data. Latent variables were used to validate the applicability of the TPB in HIV/AIDS prevention among adolescents in the Botswana context. The predictors of interest were all derived from the TPB. The results revealed that the TPB predictors, apart from affective and instrumental attitude, were predictive of condom use intention among Batswana adolescents. The independent variables explained 57% of the variance in the model. These results suggest that the TPB is recommended as a framework to establish the predictors of condom use intention among Batswana in-school adolescents. Policy makers working on developing HIV education programmes or interventions targeted at adolescents should improve the intention to use condoms via promotion of positive instrumental attitudes, subjective norms and perceived behavioural control beliefs of condom use.

Prevalence and Factors Associated with Microalbuminuria in Pediatric Patients with Type 1 Diabetes Mellitus at a Large Tertiary-Level Hospital in Botswana.

INTRODUCTION: Microalbuminuria is considered the earliest sign of diabetic nephropathy among patients with type 1 diabetes mellitus (T1DM). The prevalence of microalbuminuria among African children with T1DM is reported to be high, yet its prevalence and population-specific risk factors in Botswana are not known. AIM: This study aimed to determine the prevalence of microalbuminuria among children and young adults with T1DM in Botswana and identify factors associated with microalbuminuria in this population. METHODS: A retrospective cross-sectional study was conducted on 127 T1DM patients aged <24 years followed at a pediatric endocrinology clinic in Botswana from 2010 to 2017. Clinical, laboratory, and demographic data were collected using chart review and patient surveys. Descriptive statistics were reported as mean and standard deviation for continuous variables, and frequency and percentage for categorical variables. Prevalence of microalbuminuria was calculated as a simple proportion. Group comparison was done using two-sample independent t-test, X 2-test, or Fisher's exact test and logistic regression to assess for associations. Level of significance was set at p<0.05. RESULTS: There were a total of 71 (55.9%) females. The mean age was 18.7 (±5) years and mean duration of T1DM was 6.6 (±4.6) years. Most study participants were of African descent. The prevalence of microalbuminuria was 28.3%. Group comparison revealed gender (p= 0.040), duration of diabetes (p= 0.002), systolic blood pressure (p=0.003), baseline glycated hemoglobin (HbA1c) (p=0.009) and Tanner's stage (p=008) to be significantly associated with microalbuminuria. On binary logistic regression, only gender (p=0.039) and baseline HbA1c (p=0.039) were independently associated with the presences of microalbuminuria. CONCLUSION: This study identified a high prevalence of microalbuminuria among children and young adults with T1DM in Botswana and reaffirms the importance of early detection, glycemic control, and regular screening to prevent diabetic nephropathy.

Lack of RH2 gene expression may have influenced the HIV pandemic in sub-Saharan Africa.

OBJECTIVE: To evaluate the association between the Rhesus system RH2-blood group expression and susceptibility to HIV infection, viral load, CD4+ cell count and rate of CD4+ decline. We also aimed to determine if a country's HIV prevalence may be predicted from its RH2 relative frequency. DESIGN: Our previous studies did not find any HIV-infected RH2 homozygotes. Therefore, the current cross-sectional study analysed a larger sample to determine whether HIV-infection also occurs in homozygotes. We also conducted a cross-sectional analysis of RH2 expression in an HIV natural history cohort in Botswana. Lastly, we analysed published data from 60 countries around the world to interrogate the link between RH2 frequency and HIV prevalence. METHODS: One thousand and six hundred anticoagulated blood samples (800 HIV-positive and 800 HIV-negative) were phenotyped for RH2 using serological methods. The proportion of RH2-positive samples was compared across categories of HIV status and odds ratios calculated. Mean viral load and CD4+ cell counts from a natural history cohort study were also compared across categories of RH2. Kaplan--Meier plots were generated for 4-year CD4+-decline to 350 cells/µl. RESULTS: No RH2 homozygotes were found among HIV-positives. Moreover, RH2-negatives were 1.37 times more likely to be HIV-positive than heterozygotes (P = 0.02) and 33 times more likely than RH2 homozygotes (P = 0.01). RH2-positive patients showed significantly higher mean CD4+ cell counts (P < 0.0001), lower viral load (P = 0.024) and slower CD4+ decline (P = 0.038). CONCLUSION: RH2 is potentially a critical host genetic factor determining susceptibility of any population to HIV infection, and probably transcends most other factors in importance for HIV risk of infection.

Efficient estimation of human immunodeficiency virus incidence rate using a pooled cross-sectional cohort study design.

Development of methods to accurately estimate human immunodeficiency virus (HIV) incidence rate remains a challenge. Ideally, one would follow a random sample of HIV-negative individuals under a longitudinal study design and identify incident cases as they arise. Such designs can be prohibitively resource intensive and therefore alternative designs may be preferable. We propose such a simple, less resource-intensive study design and develop a weighted log likelihood approach which simultaneously accounts for selection bias and outcome misclassification error. The design is based on a cross-sectional survey which queries individuals' time since last HIV-negative test, validates their test results with formal documentation whenever possible, and tests all persons who do not have documentation of being HIV-positive. To gain efficiency, we update the weighted log likelihood function with potentially misclassified self-reports from individuals who could not produce documentation of a prior HIV-negative test and investigate large sample properties of validated sub-sample only versus pooled sample estimators through extensive Monte Carlo simulations. We illustrate our method by estimating incidence rate for individuals who tested HIV-negative within 1.5 and 5 years prior to Botswana Combination Prevention Project enrolment. This article establishes that accurate estimates of HIV incidence rate can be obtained from individuals' history of testing in a cross-sectional cohort study design by appropriately accounting for selection bias and misclassification error. Moreover, this approach is notably less resource-intensive compared to longitudinal and laboratory-based methods.

Socioeconomic and behavioural determinants of overweight/obesity among adults in Botswana: a cross-sectional study.

OBJECTIVE: To undertake a comprehensive assessment of socioeconomic and behavioural determinants of overweight/obesity among adult population in Botswana. DESIGN: The study adopted a cross-sectional design by selecting adult respondents in 3 cities and towns, 15 urban villages and 15 rural areas across Botswana using a multistage probability sampling technique. SETTING: The study was conducted in selected rural and urban areas of Botswana. PARTICIPANTS: The study sample consisted of 1178 adult males and females aged 15 years and above. PRIMARY OUTCOME MEASURES: Objectively measured overweight/obesity. RESULTS: Prevalence of overweight/obesity in the study population was estimated at 41%. The adjusted OR (AOR) of overweight/obesity were highest among women (AOR=2.74, 95% CI 1.92 to 3.90), in ages 55-64 years (AOR=5.53, 95% CI 2.62 to 11.6), among individuals with secondary (AOR=1.70, 95% CI 1.11 to 2.61) and tertiary education (AOR=1.99, 95% CI 1.16 to 3.38), smokers (AOR=2.16, 95% CI 1.22 to 3.83) and people with poor physically activity (AOR=1.46, 95% CI 1.03 to 3.24). These were statistically significant at 5% level. CONCLUSION: Women, older adults, people with high education level, smokers and people who reported poor physical activity were found to have higher odds of being overweight/obesity. These findings suggest the need for broad based strategies encouraging physical activity among different socioeconomic groups.

Revealing a safer sex option to reduce HIV risk: a cluster-randomized trial in Botswana.

BACKGROUND: 1.8 million new HIV infections occur every year, disproportionately affecting adolescent girls and young women. Abstinence-only risk avoidance approaches have had limited impact on reducing new infections. This cluster-randomized trial examines a risk reduction approach to curbing risky sex for school-going girls in Botswana. METHODS: The unit of randomization was the school (n = 229). Intervention participants received a 1-h intervention revealing a safer sex option: dating same-age partners which have 5-9x lower HIV prevalence than older partners. Primary outcomes were pregnancy as a proxy for unprotected sex and HIV. Secondary outcomes included self-reported sexual behavior. Generalized linear multilevel models with school-level robust variance for adjusted relative risk ratios were used in an intention-to-treat analysis. RESULTS: At a 12-month follow up, the intervention reduced pregnancy with an adjusted Relative Risk Ratio (aRRR) of .657 [95% CI .433-.997] significant at the 5% level. Effects were largest at junior school (aRRR = .575 [95% CI .394-.841]) and in rural areas (aRRR = .518 [95% CI .323-.831]), significant at the 1% level. There were no significant effects for primary school students, suggesting age of sexual debut and related mechanisms are critical factors in the intervention's effectiveness. Moreover, baseline beliefs of which partner is riskiest mediate the magnitude of effects. CONCLUSIONS: Information on safe sex options can change sexual behavior. The success of the intervention working across contexts will depend on various factors, such as age of sexual debut and baseline beliefs. TRIAL REGISTRATION: Pan African Clinical Trials Registry PACTR201901837047199 . Registered 31 December 2018. Retrospectively registered. This study adheres to CONSORT guidelines.

Building research capacity through programme development and research implementation in resource-limited settings - the Ipabalele study protocol: observational cohort studies determining the effect of HIV on the natural history of cervical cancer in Botswana.

INTRODUCTION: The global burden of cancer continues to increase in low- and middle-income countries, particularly in sub-Saharan Africa (SSA). Botswana, a middle-income country in SSA, has the second highest prevalence of HIV worldwide and has seen an increase in human papillomavirus (HPV)-associated cervical cancer over the last decade in the setting of improved survival of HIV-infected women. There is an urgent need to understand more clearly the causes and consequences of HPV-associated cervical cancer in the setting of HIV infection. We initiated the Ipabalele ('take care of yourself' in Setswana) programme to address this need for new knowledge and to initiate long-term research programme capacity building in the region. In this manuscript, we describe the components of the programme, including three main research projects as well as a number of essential cores to support the activities of the programme. METHODS AND PROCEDURES: Our multidisciplinary approach aims to further current understanding of the problem by implementing three complementary studies aimed at identifying its molecular, behavioural and clinical determinants. Three participant cohorts were designed to represent the early, intermediate and late stages of the natural history of cervical cancer.The functional structure of the programme is coordinated through programmatic cores. These allow for integration of each of the studies within the cohorts while providing support for pilot studies led by local junior investigators. Each project of the Ipabalele programme includes a built-in capacity building component, promoting the establishment of long-lasting infrastructure for future research activities. ETHICS AND DISSEMINATION: Institutional review board approvals were granted by the University of Pennsylvania, University of Botswana and Ministry of Health and wellness of Botswana. Results will be disseminated via the participating institutions and with the help of the Community Advisory Committee, the project's Botswana advisory group.

Prevalence of G6PD deficiency and associated haematological parameters in children from Botswana.

Glucose-6-Phosphate Dehydrogenase (G6PD) deficiency is commonly seen in malaria endemic areas as it is known to confer a selective advantage against malaria. Recently, we reported a high proportion of asymptomatic reservoir of Plasmodium vivax in Botswana, that calls for intervention with primaquine to achieve radical cure of vivax malaria. Considering that individuals with this enzyme deficiency are at risk of haemolysis following primaquine treatment, assessment of the population for the relative frequency of G6PD deficiency is imperative. Samples from 3019 children from all the districts of Botswana were successfully genotyped for polymorphisms at positions 202 and 376 of the G6PD gene. Haematological parameters were also measured. The overall population allele frequency (based on the hemizygous male frequency) was 2.30% (95% CI, 1.77-2.83), while the overall frequency of G6PD-deficient genotypes A- (hemizygote and homozygote genotypes only) was 1.26% (95% CI, 0.86-1.66). G6PD deficiency is spread in Botswana according to the historical prevalence of malaria with a North-West to South-East decreasing gradient trend. There was no association between G6PD status and P. vivax infection. G6PD A- form was found to be associated with decreased RBC count and haemoglobin levels without a known cause or illness. In conclusion, we report for the first time the prevalence of G6PD deficiency in Botswana which is relevant for strategies in the malaria elimination campaign. Further work to examine the activities of the enzyme in the Botswana population at risk for malaria is warranted.

Orphans' perspectives on grief and loss in Botswana.

This paper seeks to examine orphaned children's experiences on grief and loss in Botswana, and its impact on their well-being and make policy recommendations. A cross sectional design which utilized survey questionnaires was employed. Data were collected from 11 districts (3 urban and 8 rural) among orphan children aged 10-18 years. Chi-squared test was used to identify variables believed to be associated with loss and grief. Unadjusted (simple) and adjusted multiple logistic regression was used to investigate factors associated with loss. Of the 732 participants (53.1%) were females and mean age was 13.5 years (SD = 2.7); and 44.6% of these children had experienced death of a close family member in the past year which had been communicated. Children had access to education, lower primary (19.5%), upper primary (39.1%), junior secondary (32.5%), senior secondary school (6.6%), and (0.3%) in tertiary institutions. Most children (88.6%) had not experienced stigma and discrimination at school; 55.2% lived with grandparents, aunts (23.4%), siblings (11.8%), uncles (4.0%), other relatives (3.5%) and non-relatives (0.1%). Unadjusted logistic regression indicated that loss was significantly associated with having someone to talk to (OR = 0.72, 95% CI, 0.53-0.98, p = 0.03), change of residence (OR = 3.08, 95% CI, 1.94-4.90, p < 0.01), having siblings (OR = 2.06, 95% CI, 1.38-3.07, p < 0.01) and being from urban areas (OR = 0.56, 95% CI, 0.41-0.78, p < 0.01). In the adjusted model, loss was significantly associated with change of residence (OR = 2.72, 95% CI, 1.69-4.35, p < 0.01), having siblings (OR = 1.98, 95% CI, 1.30-3.01, p < 0.01) and being from urban areas (OR = 0.65, 95% CI, 0.46-0.93, p = 0.02). Age-specific interventions aimed at addressing the emotional, psychosocial and economic impacts of grief and loss are critical in preventing negative coping behaviors and improving the quality of life of orphans.

Evaluation of the effect of cellular SMS reminders on consistency of antiretroviral therapy pharmacy pickups in HIV-infected adults in Botswana: a randomized controlled trial.

OBJECTIVE: Several studies have demonstrated that cellular phone short message service (SMS) improve antiretroviral adherence for people living with HIV in Africa, although less data are available to support using SMS reminders to improve timeliness of antiretroviral therapy (ART) pharmacy pick up. This study tested the efficacy of SMS reminders on timeliness of ART pharmacy pickups at an urban clinic in Gaborone, Botswana. DESIGN: A randomized-controlled trial evaluating the effect of SMS reminders on ART collection for patients with HIV on treatment. METHODS: One hundred and eight treatment-experienced adult patients were enrolled and randomly assigned to a control group or an intervention group. Participants in the intervention group received SMS reminders that were sent in advance of monthly ART refills that needed to be collected. The primary outcome was 100% timeliness of pharmacy ART pickups. Secondary outcomes included frequency of physician visits, CD4 cell counts and viral loads. RESULTS: Baseline characteristics in the intervention (n = 54) and control arms (n = 54) were similar. After six months, 85% of those receiving SMS reminders were 100% on time picking up monthly ART refills compared to 70% in the control group (p = 0.064). In secondary analysis, there were no significant changes in the CD4 counts and viral loads over the course of the study. CONCLUSIONS: Timeliness of ART pickup was not significantly improved by SMS reminders. Additionally, the intervention had no impact on immunologic or virologic outcomes in treatment-experienced patients.

Health, schooling, needs, perspectives and aspirations of HIV infected and affected children in Botswana: a cross-sectional survey.

BACKGROUND: Antiretroviral treatment means many HIV infected children are surviving with a highly stigmatised condition. There is a paucity of data to inform policies for this growing cohort. Hence we carried out a study on the health, schooling, needs, aspirations, perspectives and knowledge of HIV infected and affected children in Botswana. METHODS: A cross-sectional survey using interviews and focus group discussions among HIV infected children aged 6-18 years versus HIV aged matched HIV uninfected counterparts living in the same households between August 2010 and March 2011. Supplemental clinical data was abstracted from medical records for HIV infected participants. RESULTS: Nine hundred eighty-four HIV infected and 258 affected children completed the survey. Females predominated in the affected group (63.6 % versus 50.3 %, P < 0.001). School attendance was high in both groups (98.9 % versus 97.3 %, P = 0.057). HIV infected children were mostly in primary school (grades 3-7) while affected children were mostly in upper primary or secondary grades. Sixty percent HIV infected children reported having missed school at least 1 day in the preceding month. Significantly more infected than affected children reported experiencing problems at school (78 % versus 62.3 %, P < 0.001). Twenty-two percent of 15-18 year old HIV infected children were in standard seven and below compared to only 8 % of HIV affected children (p = 0.335). School related problems included poor grades, poor health/school attendance, stigma and inadequate scholastic materials. The wish-list for improving the school environment was similar for both groups and included extra learning support; better meals; protection from bullying/teasing; more scholastic materials, extracurricular activities, love and care; structural improvements; improved teacher attendance and teaching approaches. Significantly more HIV infected children reported feeling hungry all the time (50.6 % versus 41 %, P = 0.007) and more trouble hearing (26.8 % versus 12.5 %, P = 0.028). The mean age for HIV disclosure 10 years was high. Sexual activity (9.2 % versus 3 %, P = 0.001) and emotions of anger (71 % versus 55.3 %, P < 0.001) were significantly higher among HIV affected children. Future perspectives were equally positive (93 % versus 96 %, P = 0.080), were predicated on children's school performance, self-belief/determination and/or ARVs and preference for medical or military careers was common. CONCLUSIONS: In Botswana almost all school-age HIV infected and affected children are attending school but many face daunting challenges that call for the creation of an empowering, empathetic, supportive, caring, and non-discriminating school environment.