WHAT PRACTICES AND FACTORS LED TO BOTSWANA’S 90-90-90 ACHIEVEMENT AND HOW CAN LESSONS LEARNED BE ADAPTED AND IMPLEMENTED IN OTHER SUB-SARAHAN AFRICAN COUNTRIES?

Botswana’s achievement of the UNAIDS 90-90-90 targets demonstrates that HIV epidemic control is possible in resource constrained countries. Resource deployment, attention to key populations, and the country setting (defined in this context as the political will, cultures and norms, laws, policies, actions, behaviors and health mechanisms), are factors that define the 90-90-90 achievement, and ultimately HIV epidemic control, ecosystem. Classified as an upper middle income (UMIC) country with stable social, government, and health care systems, the cultural backdrop in Botswana is different from many other sub-Saharan African (SSA) countries. These differences must be considered and accounted for when assessing the reproducibility of learnings from the Botswana HIV experience in other SSA countries. It is not practical, feasible, nor desirable for countries in SSA to reproduce exactly the specific practices and factors that led to Botswana’s 90-90-90 target achievement. To do so would require untangling country-level cultural DNA and reconstructing their communities, government, and “way of life” in the image and likeness of Botswana. Instead, SSA countries should learn from the Botswana HIV experience; aim to localize, adapt, and acculturate interventions based on the factors that cut across and influence the entire 90-90-90 continuum (resources, setting description, and key populations), and; enable sustainable and effective practices to combat and control their HIV epidemic. Based on insights and lessons learned from the literature review, quantitative analysis of UNAIDS data, and key informant interviews with experts in Botswana’s HIV response, 90-90-90, and/or a combination of the two, this study presents an original framework and approach, named the HIV Epidemic Control Readiness Framework (HECRF). The HECRF is based on 13 third party, publicly available metrics, and designed as a tool to inform the sustainability and effectiveness of the HIV response in 46 SSA countries and signal: 1) how their HIV prevalence compares to other SSA countries, 2) where they score relative to other SSA countries in their progress towards 90-90-90, 3) where they score relative to other SSA countries in the sustainability and effectiveness of their HIV programs, 4) where they score relative to other SSA countries in their HIV epidemic control readiness and, 5) where increased focus and/or change agency - in areas related to HIV program sustainability or effectiveness - is best placed.Doctor of Public Healt