Impact of Community-Based Clinical Breast Examinations in Botswana.

PURPOSE: We evaluated a clinical breast examination (CBE) screening program to determine the prevalence of breast abnormalities, number examined per cancer diagnosis, and clinical resources required for these diagnoses in a middle-income African setting. METHODS: We performed a retrospective review of a CBE screening program (2015-2018) by Journey of Hope Botswana, a Botswana-based nongovernmental organization (NGO). Symptomatic and asymptomatic women were invited to attend. Screening events were held in communities throughout rural and periurban Botswana, with CBEs performed by volunteer nurses. Individuals who screened positive were referred to a private tertiary facility and were followed by the NGO. Data were obtained from NGO records. RESULTS: Of 6,120 screened women (50 men excluded), 452 (7.4%) presented with a symptom and 357 (5.83%) were referred for further evaluation; 257 ultrasounds, 100 fine-needle aspirations (FNAs), 58 mammograms, and 31 biopsies were performed. In total, 6,031 were exonerated from cancer, 78 were lost to follow-up (67 for ≤ 50 years and 11 for > 50 years), and 11 were diagnosed with cancer (five for 41-50 years and six for > 50 years, 10 presented with symptoms). Overall breast cancer prevalence was calculated to be 18/10,000 (95% CI, 8 to 29/10,000). The number of women examined per breast cancer diagnosis was 237 (95% CI, 126 to 1910) for women of age 41-50 years and 196 (95% CI, 109 to 977) for women of age > 50 years. Median time to diagnosis for all women was 17.5 [1 to 32.5] days. CBE-detected tumors were not different than tumors presenting through standard care. CONCLUSION: In a previously unscreened population, yield from community-based CBE screening was high, particularly among symptomatic women, and required modest diagnostic resources. This strategy has potential to reduce breast cancer mortality.

Antimicrobial utilization research and activities in Botswana, the past, present and the future.

A number of activities are ongoing to reduce AMR in Botswana by improving antimicrobial utilization across all sectors. However, there is a need to share experiences. With the objective of sharing these, the second one day symposium was held in the University of Botswana in October 2018 involving both private and public hospitals. In Lenmed Bokamoso hospital, ESKAPE organisms were associated with 50-90% of clinical infections; however, there was no correlation between healthcare associated infections (HAIs) and admission swab positivity with ESKAPE or ESBL isolates. Hang times, the time between a prescription and IV administration, were also discussed. At Nyangabwe Hospital, the prevalence of HAIs was 13.54%, 48.9% were laboratory confirmed of which 8.5% were blood stream infections (BSIs). The prevalence of different bacteria causing neonatal BSIs was also investigated. At Princess Marina Hospital, positive cultures were seen in 22.4% of blood cultures with contaminants comprising the majority. Several activities are ongoing in Botswana across sectors as a result of the findings and will be periodically reported to further improve antibiotic utilization.

Point prevalence study of antimicrobial use among hospitals across Botswana; findings and implications.

Objective: There is an urgent need to undertake Point Prevalence Surveys (PPS) across Africa to document antimicrobial utilisation rates given high rates of infectious diseases and growing resistance rates. This is the case in Botswana along with high empiric use and extended prophylaxis to prevent surgical site infections (SSIs) Method: PPS was conducted among all hospital sectors in Botswana using forms based on Global and European PPS studies adapted for Botswana, including rates of HIV, TB, malaria, and malnutrition. Quantitative study to assess the capacity to promote appropriate antibiotic prescribing. Results: 711 patients were enrolled with high antimicrobial use (70.6%) reflecting an appreciable number transferred from other hospitals (42.9%), high HIV rates (40.04% among those with known HIV) and TB (25.4%), and high use of catheters. Most infections were community acquired (61.7%). Cefotaxime and metronidazole were the most prescribed in public hospitals with ceftriaxone the most prescribed antimicrobial in private hospitals. Concerns with missed antibiotic doses (1.96 per patient), high empiric use, extended use to prevent SSIs, high use of IV antibiotics, and variable infrastructures in hospitals to improve future antibiotic use. Conclusion: High antibiotic use reflects high rates of infectious diseases observed in Botswana. A number of concerns have been identified, which are being addressed.

Clinical outcomes of a cohort of migrants and citizens living with human immunodeficiency virus in Botswana: implications for Joint United Nation Program on HIV and AIDS 90-90-90 targets.

The aim of the study was to evaluate the human immunodeficiency virus (HIV) treatment cascade and mortality in migrants and citizens living with HIV in Botswana.Retrospective 2002 to 2016 cohort study using electronic medical records from a single center managing a high migrant case load.Records for 768 migrants and 3274 citizens living with HIV were included. Maipelo Trust, a nongovernmental organization, funded care for most migrants (70%); most citizens (85%) had personal health insurance. Seventy percent of migrants and 93% of citizens had received antiretroviral therapy (ART). At study end, 44% and 27% of migrants and citizens, respectively were retained in care at the clinic (P < .001). Among the 35% and 60% of migrants and citizens on ART respectively with viral load (VL) results in 2016, viral suppression was lower among migrants (82%) than citizens (95%) (P < .001). Citizens on ART had a median 157-unit [95% confidence interval (CI) 122-192] greater increase in CD4+ T-cell count (last minus first recorded count) than migrants after adjusting for baseline count (P < .001). Five-year survival was 92% (95% CI = 87.6-94.8) for migrants and 96% (95% CI = 95.4-97.2) for citizens. Migrants had higher mortality than citizens after entry into care (hazard ratio = 2.3, 95% CI = 1.34-3.89, P = .002) and ART initiation (hazard ratio = 2.2, 95% CI = 1.24-3.78, P = .01).Fewer migrants than citizens living with HIV in Botswana were on ART, accessed VL monitoring, achieved viral suppression, and survived. The HIV treatment cascade appears suboptimal for migrants, undermining local 90-90-90 targets. These results highlight the need to include migrants in mainstream-funded HIV treatment programs, as microepidemics can slow HIV epidemic control.

Ongoing initiatives to improve the use of antibiotics in Botswana: University of Botswana symposium meeting report.

BACKGROUND AND OBJECTIVE: There are ongoing initiatives in Botswana to enhance appropriate antibiotic use. The objective of this meeting was to discuss ongoing initiatives in Botswana since February 2016 to improve antibiotic use. Subsequently, use the findings to refine national and local action plans. METHOD: Presentation and review of ongoing initiatives. RESULTS: There was a high rate of antibiotic prescribing among ambulatory care patients in the public sector (42.7%) as well as for patients with upper respiratory tract infections in the private sector (72.9%). Prophylactic antibiotics were given to 73.3% of surgical patients to reduce surgical site infections (SSIs) in a leading tertiary hospital in Botswana; however, SSIs at 9% of patients can be reduced further with better timing of antibiotic prophylaxis. To date, 711 patients have been enrolled into the national point prevalence study. Highlighted concerns included limited ordering and use of sensitivity tests despite functional laboratories, as well as concerns with missed doses of antibiotics across most hospitals. CONCLUSION: A number of issues and concerns regarding antibiotic use were highlighted. Activities are ongoing across sectors to address identified concerns.

Research activities to improve the utilization of antibiotics in Africa.

There is a need to improve the rational use of antibiotics across continents including Africa. This has resulted in initiatives in Botswana including treatment guidelines and the instigation of Antibiotic Stewardship Programs (ASPs). The next steps involve a greater understanding of current antibiotic utilization and resistance patterns (AMR). This resulted in a 2-day meeting involving key stakeholders principally from Botswana to discuss key issues including AMR rates as well as ASPs in both the public and private sectors. Following this, the findings will be used to plan future studies across Africa including point prevalence studies. The findings will be presented in July 2016 at the next Medicines Utilization Research in Africa meeting will ideally serve as a basis for planning future pertinent interventional studies to enhance the rational use of antibiotics in Botswana and wider.

Outcome of the second Medicines Utilisation Research in Africa Group meeting to promote sustainable and appropriate medicine use in Africa.

The second Medicines Utilization Research in Africa (MURIA) group workshop and symposium again brought researchers together from across Africa to improve their knowledge of drug utilization (DU) methodologies and exchange ideas to further progress DU research in Africa. This built on extensive activities from the first conference including workshops and multiple publications. Anti-infectives were again the principal theme for the 2016 symposium following the workshops. This included presentations regarding strategies to improve antibiotic utilization among African countries, such as point-prevalence studies, as well as potential ways to reduce self-purchasing of antibiotics. There were also presentations on antiretrovirals including renal function and the impact of policy changes. Concerns with adherence in chronic treatments as well as drug-drug interactions and their implications were also discussed. The deliberations resulted in a number of agreed activities including joint publications before the next MURIA conference in Namibia in 2017.