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Background: The roll out of antiretroviral therapy in Botswana, as in many countries with near universal access to treatment, has transformed HIV into a complex yet manageable chronic condition and has led to the emergence of a population aging with HIV. Although there has been some realization of this development at international level, no clear defined intervention strategy has been established in many highly affected countries. Therefore we explored attitudes of policy-makers and service providers towards HIV among older adults (50 years or older) in Botswana. Methods: We conducted qualitative face-to-face interviews with 15 consenting personnel from the Ministry of Health, medical practitioners and non-governmental organizations involved in the administration of medical services, planning, strategies and policies that govern social, physical and medical intervention aimed at people living with HIV and health in general. The Shiffman and Smith Framework of how health issues become a priority was used as a guide for our analysis. Results: Amidst an HIV prevalence of 25% among those aged 50–64 years, the respondents passively recognized the predicament posed by a population aging with HIV but exhibited a lack of comprehension and acknowledgement of the extent of the issue. An underlying persistent ageist stigma regarding sexual behaviour existed among a number of interviewees. Respondents also noted the lack of defined geriatric care within the provision of the national health care system. There seemed, however, to be a debate among the policy strategists and care providers as to whether the appropriate response should be specifically towards older adults living with HIV or rather to improve health services for older adults more generally. Respondents acknowledged that health systems in Botswana are still configured for individual diseases rather than coexisting chronic diseases even though it has become increasingly common for patients, particularly the aged, to have two or more medical conditions at the same time. Conclusions: HIV among older adults remains a low priority among policy-makers in Botswana but is at least now on the agenda. Action will require more concerted efforts to recognize HIV as a lifelong infection and putting greater emphasis on targeted care for older adults, focussing on multimorbidity.
We conducted 15 one hour, face-to-face, semi-structured, in-depth interviews with consenting personnel from government and non-governmental organizations involved in the administration of medical services, care, strategies, planning and policies that govern social, physical and medical intervention aimed at PLWH and health in general in Botswana. The group consisted of six high-ranking civil servants directly involved with policy implementation from various departments within the government including the Ministry of Health and the National AIDS Coordinating Agency; four senior medical and nursing practitioners charged with HIV care at the HIV referral clinics in urban and rural areas; and four high ranking civil society representatives from three different non-governmental organizations directly involved with HIV care and management. Purposive sampling (Suen, Huang, & Lee, 2014) was employed to identify the individuals. Each individual was approached via email and the interview proceeded if the individual consented. All 15 people approached consented to be interviewed. The interviewee were asked closely related questions however taking into consideration their position and work mandate, The interviews were carried out at most convenient time for the interviewee to maximize their capacity for concentration and patience. Interviews were conducted until saturation was reached. A number of themes were raised during the interviews including: existing HIV services; existing aged care services; interviewee’s understanding of HIV among older adults; care for older PLWH in society; co-morbidities burden; and attitudes of care providers towards older PLWH. Twelve interviews were carried out in English and three were administered in Setswana. All interviews were recorded and then transcribed and translated into English where required. We used Shiffman and Smith’s framework (Shiffman & Smith, 2007) on determinants of political priority for global initiatives to guide our analysis. This framework has been used to examine why certain issues gain political prominence and others do not. The framework has been applied most prominently to maternal mortality and newborn survival (Shiffman, 2010, 2015). While the framework was designed for use on a global level, we adapted it for use at the national level. The four categories of analysis we used are: actor power; ideas; political and health system contexts; and issue characteristics. The coverage of these four categories was: (1) the strength and the extent which the national leaders were involved in the initiative: ‘actor power’; (2) the nature of political and health contexts that inhibit or enhance support of the issue: ‘political and health system context’; (3) the organizations and political systems in place to depict the problems posed by HIV and ageing: ‘Ideas’; and (4) the power of some characteristics of the complexities surrounding HIV and ageing, to inspire action: ‘issue characterization’. The Human Research Ethics Committee at the Ministry of Health in Botswana approved the project. Each interviewee consented to participate in the study. Confidentiality for interviewees was guaranteed to encourage more open discussion. Where direct quotes are provided, names are not attributed.
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