Botswana was one of the countries hit hardest by HIV. In 2001 alone, an estimated 320,000 people in Botswana were living with HIV—slightly more than one in four. Girls and young women bore disproportionate risk. By 2004, they were three times as likely to test HIV positive as their male counterparts.^source Beyond the human toll, HIV also threatened to unravel the country’s decades of economic and social progress.

In 2001, with the toll of HIV/AIDS rising, Botswana President Festus Mogae pledged to make HIV a national priority. He warned, “Botswana is threatened with extinction”.^source This was a bold statement at the time, when many leaders around the world—most conspicuously in South Africa, the powerhouse next door—remained in a state of denial about HIV. The following two decades saw growing global activism. Thanks to the Accelerating Access Initiative and other changes in the landscape, access to antiretroviral therapy (ART) more and more success HIV treatment programs had started in low- and middle-income countries.

The government's firm commitment to addressing the urgent situation inspired help from philanthropists and businesses. As life-saving drugs rose up the agenda, government officials embarked on a collaboration with Merck, the Merck Foundation, and the Bill & Melinda Gates Foundation and formed the African Comprehensive HIV/AIDS Partnership (ACHAP). The foundations wanted to test the notion that a comprehensive approach, including attention to prevention, diagnosis, treatment, and care, supplemented by behavior change and infrastructure development, could be an effective national response to the HIV/AIDS crisis and save lives in a relatively poor setting.^source Botswana, with its high prevalence of HIV, committed leader, and stable democratic regime, represented a perfect candidate. 

In 2002, the Botswana government's National AIDS Coordinating Agency (NACA) worked on a comprehensive strategy for HIV/AIDS treatment rollout. When the government decided to make ART widely available as a central component of the strategy, Merck agreed to donate the drugs free of charge. And in 2002, Botswana was ready to take on its ambitious program. The government christened its new HIV program Masa, meaning "New Dawn" in Setswana, in four urban centers around the country: Gaborone, Francistown, Maun, and Serowe.

Despite disappointing initial coverage—by the end of 2002, only 3,500 people were enrolled in the program, far below the goal of 19,000—ART coverage grew swiftly with national rollout just two years later. By mid-2005, over half of the eligible population, 43,000 people, benefited from Masa.^source

The massive increased uptake of ART was thanks, in large part, to increased testing and the decentralization of the program to satellite districts around the country. Other contributing factors included Masa’s collaboration with and outsourcing of HIV testing and ART provision to Botswana’s private sector, and the program’s expansion of eligibility criteria. By the end of 2013, the national ART program covered nearly 224,000 people, or about 87 percent of all eligible people.^source

The program also included health system strengthening efforts that narrowed in on infrastructure development and health worker training. Investments went to strengthening and creating new treatment and resource centers, laboratories, and dispensing clinics. Critical to effective patient monitoring, treatment centers and dispensing clinics procured and distributed CD4 count and viral load machines. A computerized patient management system was used in ART distribution facilities to track patient adherence and adverse reactions.

Botswana has seen a dramatic drop in AIDS deaths, from a high of 21,000 in 2002 to 5,800 in 2013.^source Several studies have tracked the contribution of the national ART program to mortality reduction and other health gains; all of them have identified a link between ART rollout and the drop in AIDS-related deaths. However, these are the results of studies that were observational rather than experimental, which limits their ability to confirm causality.^source

Early concerns that people in low- and middle-income countries would not adhere to ART treatment regiments did not hold in Botswana. In fact, adherence rates in Botswana (85-90 percent) have risen higher than those observed in the United States (70 percent),^source and the rate in Botswana has remained high.^source As a result, most people enrolled in the program stayed alive and healthy. 

In addition to the drop in deaths, other signs pointed to a positive impact from Botswana’s national ART program. For example, only a few wealthy Batswana could afford ART prior to the public program. Nationwide scale-up meant all eligible residents had the right to free lifelong treatment. The expansion of eligibility criteria over time has allowed many more people living with HIV to access the benefits of ART.

Yet coverage is not yet universal. After a steady rise, the proportion of eligible people receiving ART dropped and prevention efforts have lagged. Tragically, many Batswana facing the highest risk of infection—female sex workers and men who have sex with men—are not reached with prevention programs.^source Laws that prohibit same-sex relationships and stigma about sexual orientation in Botswana have made it particularly difficult to reach this group.^source

By 2012, total annual spending on HIV/AIDS had reached US$347 million in Botswana, of which 68 percent was covered by the government—a remarkable sum for a sub-Saharan country, but a challenge for the government to sustain.^source The Bill & Melinda Gates Foundation contributed US$50 million and the Merck Foundation US$56.6 million to get Masa up and running; each contributed another US$30 million in 2010. The remainder came from international sources, including the President's Emergency Plan for AIDS Relief (PEPFAR) and The Global Fund to Fight AIDS, Tuberculosis and Malaria.

In 2014, treatment costs for the national ART program were estimated at US$480 per person.^source This cost is expected to rise to US$600 per person by 2030, primarily due to the growing need for second- and third-line ART as the virus becomes more resistant to the first-line option. 

Researchers for Millions Saved estimate that the reported mortality decline led to nearly 114,000 averted deaths, which translated to over 8 million DALYs averted. Pairing that with government estimates of cost per patient-year, they calculated a cost-effectiveness ratio of US$475  per DALY averted between 2002 and 2010. This falls well below the World Health Organization's threshold of the country's GDP per capita, which for Botswana was US$7,734 in 2011.^source

President Mogae's no-nonsense leadership steered Botswana to a long-term investment in the national ART program, while the economy enabled Botswana to make good on that pledge. 

The ART program benefited from Botswana’s robust network of public clinic and hospitals within a functional public health system.^source Nevertheless, the government wrestled with inadequate human and physical resources to effectively facilitate massive ART rollout. A combination of new infrastructure, laboratory decentralization, task shifting, and intensified training helped filled the gap.^source These efforts enabled regular viral load monitoring from program inception—unique among African programs at the time and a crux of the program’s success.

High levels of adherence to ART underpinned the major health gains among Batswana. Adherence was monitored using computers and was facilitated by adherence counselors, who encouraged people on ART to have a treatment buddy or partner.^source In addition, patients received ART on a monthly basis, allowing regular interaction with health workers who reinforced adherence messages.^source

Botswana, given its relative wealth and stability, differs in important ways from most of its neighbors. Still there are many aspects of Masa that are applicable elsewhere, starting with the need for sustained political and financial commitment. Botswana's ongoing financial commitment to ART is particularly crucial given the drop in its donor funding following its graduation to upper-middle-income country status.^source In 2014, in the wake of declining resources, a technical working group was convened to develop an investment case to strengthen Botswana’s national HIV response. If the group’s recommendations are taken forward, more than 76,000 HIV infections and over 43,000 HIV-related deaths could be prevented by 2030. The price tag to make this happen: additional funding of US$50-100 million per year through to 2030.^source

Another important challenge to the sustainability of any treatment program is the burden that caring for so many people on ART puts on health systems. In Botswana, the downsizing of governmental health staff since 2010 has hindered the national HIV response. This is indicated in failure rates—indicators of ART’s declining ability to repress HIV—that have jumped from less than 6 percent among adults in 2012 to 10 percent in 2013.^source 

To stop new infections, it is of paramount importance that governments prioritize prevention alongside sustained treatment efforts. HIV prevalence in Botswana, 18.5 percent, remains among the highest in the region.^source Incidence has also held steady, dropping only slightly from 1.45 percent in 2008 to 1.35 percent in 2013. Specific groups remain particularly vulnerable, especially female sex workers. Nearly two-thirds of them are HIV positive. HIV testing rates have stagnated and less than half of young people can accurately describe how to prevent HIV infection.^source 

Moving forward, the government is prioritizing the integration of HIV treatment, care and support into routine healthcare delivery.^source Leadership and innovation are essential to guide future program evolution and ensure that early gains are not lost. Worldwide, nearly 13 million people were on lifesaving HIV treatment by the end of 2013. For the other 63 percent of people living with HIV who are not on treatment, ART may seem like a distant fantasy.^source But as Botswana's experience shows, government commitment and international coordination can help turn that dream into a reality.