Sharing the Formula: Lessons from Botswana’s Maternal HIV Prevention for South Africa

Background

Human immunodeficiency virus (HIV) is a virus that attacks and weakens the body's immune system by targeting CD4+ white blood cells, increasing vulnerability to opportunistic infections, such as tuberculosis (TB) and HIV-associated malignancies, such as Kaposi sarcoma [1]. According to the World Health Organization (WHO), HIV has claimed approximately 44.2 million lives worldwide to date [1]. By the end of 2025, it is estimated that 41.0 million people will be living with HIV, with 64% of them residing in the WHO African Region, notably in the Eastern and Southern regions with an estimated 20.8 million individuals affected [2]. African women of reproductive age and children bear a disproportionate burden of the epidemic [3], yet as this post aims to highlight, mothers can be grassroot leaders of change.

HIV is transmitted via body fluids, including blood, breast milk, and semen and can be passed from mother to infant, known as Mother-To-Child Transmission (MTCT). MTCT can occur during pregnancy, labor, delivery, or breastfeeding [1][4]. Without intervention, the rates of MTCT globally range from 15% to 45% [4]. According to a 2018 report from the WHO, 13.2 million children between the ages of 0 and 14 who were living in sub-Saharan Africa were exposed to HIV [4]. There is currently no cure for HIV, but it can be effectively prevented and treated with antiretroviral therapy (ART) which helps strengthen a person’s immune system, reduces the amount of the virus in their body, alleviates symptoms, and prevents transmission of HIV to the fetus [4].

WHO’s Path to Elimination of Vertical Transmission (MTCT)

In 2017, the WHO established a tiered Path to Elimination (PTE) for countries with a high prevalence of HIV and syphilis, among pregnant women, with hepatitis B virus (HBV) being added in 2021[5]. These tiers, “bronze, silver, and gold” were developed to recognise high burden countries for their efforts as they move towards elimination (i.e reducing MTCT to a level where it is no longer a public health issue) [5,6]. High burden countries can apply for recognition of their steps on the PTE [5].

The Front Runner - Botswana

In 2021, Botswana became the first nation to apply successfully for silver-tier status on the WHO’s PTE [5]. This was a significant milestone as Botswana was the first high-burden HIV country to be certified for this achievement, moving closer to eliminating MTCT of HIV [7]. The country earned this recognition by meeting the WHO's requirements, which included reducing the HIV MTCT rate to under 5%, providing antenatal care and antiretroviral treatment to more than 90% of pregnant women, and achieving an HIV case rate of fewer than 500 per 100,000 live births [7] . This accomplishment was particularly notable for a country that previously faced one of the most severe HIV epidemics in the world [7].

In 2025, Botswana also became the first country to achieve "gold tier status" on the WHO’s PTE [6]. The country successfully reduced the annual case rate of new HIV pediatric infections from fewer than 500 per 100,000 live births to under 250 per 100,000 live births. Additionally, it increased service coverage for antenatal care attendance, HIV testing, and treatment for pregnant women living with HIV from 90% to 95% [6]. According to the 2024 UNAIDS Spectrum estimates, the country’s MTCT rate dropped to just 1.2%, well below the 5% benchmark, and fewer than 100 infants were born with HIV in 2023 [7]

Botswana’s success strategy

In the early 2000s, Botswana had a HIV prevalence rate of 28.2% among the country's general population, one of the highest globally [8]. According to UNAIDS, estimated rates of MTCT varied from 20 to 40%, and one in eight infants were reported to be infected at birth [9]. HIV-related mortality among children under five nearly quadrupled between 1990 and 2000 [9].

So how did Botswana achieve its remarkable success? At the heart of the country’s achievement was its comprehensive and robust Prevention of Mother-To-Child Transmission (PMTCT) program which decreased vertical transmission rates from 4.9% in 2015 to less than 1.2% in 2023, resulting in fewer than 100 babies being born with HIV in 2023 [7]. The program incorporated routine HIV testing during prenatal care, prompt initiation of ART for expectant mothers, and ongoing support throughout the nursing period [8]. These were government initiatives carried out over two decades. For example, in 2002 the Masa ART Program provided free ART to all individuals diagnosed with HIV (one of the first of its kind in Africa), enabling high ART coverage nationwide [8]. Another significant program was the 2013 adoption of the Option B+, which ensures lifelong treatment for all pregnant and breastfeeding women living with HIV [7][8]. It also provided HIV-positive pregnant women with immediate access to lifelong treatment [10]. For over 20 years, the government of Botswana has been supported by the U.S. Center for Disease Control and Prevention through the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), in creating its HIV programs. According to UNAIDS, the Government of Botswana funded “two thirds” of its HIV response (about US$90–95 million) before the United States stopped providing foreign aid. So while some community level HIV care services have been disrupted, Botswana’s government health facilities continue to operate and ARTs are still widely available.

What about South Africa ?

ARTs are still widely available ARTs are still widely available The MTCT rate in South Africa has decreased from over 30% in 2000 to approximately 2.7% today [11]. However, the absolute number of vertical transmissions remains high (around 7,000 newborns per year), despite the lower MTCT rates [11], which is attributed to the high prevalence of maternal HIV in the country.

In South Africa's public healthcare system, pregnant women are routinely tested for HIV. If they test positive, they are offered ART [11]. However, problems arise when a woman contracts HIV late in her pregnancy or shortly after giving birth, which can lead to transmission of the virus to her infant through breastfeeding before she receives a diagnosis and begins treatment to suppress the virus [11]. Studies show that HIV acquisition is most likely during the second and third trimesters of pregnancy, as well as the first six months after giving birth. According to the most recent estimates from Thembisa, a mathematical model of the HIV epidemic in South Africa, most newborn HIV transmissions now occur during the postnatal breastfeeding phase rather than at birth [11]. Data from the model indicates that only 2,500 of the approximately 7,200 infants in South Africa who were infected with HIV between mid-2023 and mid-2024 tested positive at or before delivery [11]. The remaining transmissions occurred during breastfeeding in the months following delivery, and while some mothers were receiving ART, many had not yet been diagnosed with HIV [11]. Maternal HIV seroconversion is a major factor, as the proportion of MTCT attributable to this phenomenon during late pregnancy or postpartum in South Africa, is estimated to be 34%. So while ART can help manage the burden of HIV, additional measures such as monoclonal antibodies or an HIV vaccine are necessary to eliminate transmission through breast milk or prevent MTCT in the country [11].

What strategies could help strengthen South Africa’s HIV programs, and how can women drive this progress?

South Africa can learn from Botswana's implementation of government-supported flexible baby feeding options and provision of lifelong ART for mothers [12], a model whose success has also depended on women's own engagement with care.

Botswana has also established national guidelines that support exclusive breastfeeding for the first six months for mothers with a reduced viral load, in addition to being on ART [12]. Additionally, the government offers free infant formula for up to one year, allowing women to select the feeding method that best suits their circumstances [12]. During their initial prenatal care appointments, pregnant women in Botswana are also provided with routine HIV testing and counseling [12], and it is their willingness to seek out and return for this care that has made early detection possible at such a scale. These practices can be implemented in South Africa’s PMTCT programs to decrease HIV transmission through breast milk.

Lastly, increased focus on patient awareness and education is crucial. More investment, visibility, and community support are needed in PMTCT programs. Education about the higher risks associated with pregnancy and breastfeeding should be stressed, especially among women who test HIV-negative during their prenatal visits [11]. Botswana has continuously championed HIV awareness and encouraged more people to seek treatment, which has aided in destigmatizing HIV testing [8], a shift also driven by mothers coming forward as advocates and role models within their communities, including promoting regular testing to enable early detection [11].

References

1. World Health Organization. HIV and AIDS [Internet]. World Health Organisation. 2025 [cited 2026 Aug 28]. Available from: https://www.who.int/news-room/fact-sheets/detail/hiv-aids
2. World Health Organization. HIV/AIDS [Internet]. WHO | Regional Office for Africa. 2022 [cited 2026 Aug 28]. Available from: https://www.afro.who.int/health-topics/hivaids
3. Oso TA, Okesanya OJ, Adebayo UO, Ayelaagbe OB, Obadeyi KB, Chukwu CN, et al. Elimination of mother to child transmission of HIV in Africa using health system lessons from brazil. Discover Public Health. 2026 June 16;23(1).
4. WHO. Mother-to-child transmission of HIV [Internet]. www.who.int. 2023 [cited 2026 Aug 28]. Available from: https://www.who.int/teams/global-hiv-hepatitis-and-stis-programmes/hiv/prevention/mother-to-child-transmission-of-hiv
5. World Health Organization. Path to elimination [Internet]. www.who.int. [cited 2026 Aug 28]. Available from: https://www.who.int/initiatives/triple-elimination-initiative-of-mother-to-child-transmission-of-hiv-syphilis-and-hepatitis-b/validation/path
6. World. Botswana advances to gold tier on the path to elimination of mother-to-child transmission of HIV [Internet]. Who.int. World Health Organization: WHO; 2025 [cited 2026 Aug 28]. Available from: https://www.who.int/news/item/20-05-2025-botswana-advances-to-gold-tier-on-the-path-to-elimination-of-mother-to-child-transmission-of-hiv
7. UNICEF. Botswana leads the way in eliminating mother-to-child transmission of HIV [Internet]. Unicef.org. 2025 [cited 2026 Aug 28]. Available from: https://www.unicef.org/esa/press-releases/botswana-leads-way-eliminating-mother-child-transmission-hiv
8. Kesaobaka Batisani, Simusokwe R, Hezron Lumemba, Chimanga B, Panji Kwanga, Kamilo Mununga. Botswana’s 95–95–95 achievement: Pathways to HIV epidemic control. Health Science Reports [Internet]. 2026 Feb 23 [cited 2026 Aug 28];9(2):e71904. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC12929189/
9. Cox D. Botswana was once ‘at risk of extinction’ from HIV. now it is a world leader in eliminating the virus in children [Internet]. the Guardian. The Guardian; 2025 [cited 2026 Aug 28]. Available from: https://www.theguardian.com/global-development/2025/aug/22/botswana-health-hiv-aids-disease-africa-mothers-babies-extinction-cure
10. 1Jones SH, Darby A. World health organization guidelines (option a, b, and b+) for antiretroviral drugs to treat pregnant women and prevent HIV infection in infants | the embryo project encyclopedia [Internet]. embryo.asu.edu. 2021 [cited 2026 Aug 28]. Available from: https://embryo.asu.edu/pages/world-health-organization-guidelines-option-b-and-b-antiretroviral-drugs-treat-pregnant-women
11. Schütz E. Why some babies in south africa are still getting HIV [Internet]. Spotlight. 2025 [cited 2026 Aug 28]. Available from: https://www.spotlightnsp.co.za/2025/05/14/why-some-babies-in-south-africa-are-still-getting-hiv/
12. Volpe LJ, Powis KM, Legbedze J, Sun S, Abrams EJ, Mmasa NK, et al. A counseling and monitoring approach for supporting breastfeeding women living with HIV in botswana. J Acquir Immune Defic Syndr [Internet]. 2022 Feb 1 [cited 2026 Aug 28];89(2):e16. Available from: https://pubmed.ncbi.nlm.nih.gov/34723927/