Background: To achieve the UNAIDS 90-90-90 targets, Botswana adopted “Treat All” in 2016, encouraging ARV initiation for all HIV-positive clients regardless of CD4 count. The Botswana HIV Testing Services (HTS) guidelines were revised to update HTS for implementing Treat All, address gaps in the existing guidelines, ensure alignment with the 2015 WHO Consolidated Guidelines on HTS and guide program managers and service providers in planning and implementing HTS in the Treat All era.
Description: Revision of the Botswana HTS Guidelines was led by the Ministry of Health and Wellness, which fostered a strong collaborative partnership including donors, implementing partners, NGOs and CSOs. In the guidelines, quality standards were improved. Ethical guidance was aligned with WHO''s “5 C''s”. Innovative HTS approaches, such as ''self-testing and partner notification were adopted to promote services for under-served populations in facility and community based settings. Serial-testing algorithm was adopted for cost-effectiveness as well as retesting of HIV positive clients prior ART initiation. Additionally, program monitoring and evaluation was strengthened by updating and standardizing recording and reporting tools. Standardized refresher trainings were implemented to execute the revisions.
Lessons learned: Active participation of a wide group of stakeholders leveraged expertise to ensure development of comprehensive guidelines that met international standards while tailored to the local context. Strengthening quality guidance decreased discordant results to 0.3%. As the revised guidelines were implemented, strategies to provide services for hard-to-reach populations were identified. For example, the provision of facility-based extended-hours testing increased HIV case identification among men. Transitioning from parallel to serial algorithm required intensive coordination by training and supply chain management teams. Implementation of these policy changes standardized service delivery at facility and community testing sites, integrated HTS across primary care, led to the development of Linkage to Care and Partner Notification policies and ultimately reduced HTS burden at health facilities.
Conclusions/Next steps: Botswana''s experience of adapting the WHO HTS Guidelines is a significant step in reaching epidemic control of HIV, demonstrating the nation''s commitment to rigorous strategies that ensure all Batswana know their status and have timely access to prevention and treatment services. Lessons learned from this process will benefit other countries implementing Treat All.

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