Publications by Year: 2026

The World Health Organization (WHO) estimated 660,000 new cervical cancer cases and 350,000 deaths globally in 2022, with over 90% occurring in low- and middle-income countries (LMICs). Global elimination targets call for vaccination of >90% of girls against human papillomavirus (HPV) by age 15 by 2030. While Botswana's national policy aligns with these targets, progress monitoring is constrained by fragmented, predominantly paper-based health information systems. We describe our experience verifying individual-level HPV vaccination status among adolescent girls and young women living with HIV (AGYWLWH) in Botswana. This activity was conducted to determine eligibility for the HOPE II trial, a randomized controlled study evaluating the efficacy of a single-dose nonavalent HPV vaccine. Verification followed the national rollout of school-based HPV vaccination in 2015, targeting girls aged 9-13 years. Participants provided pre-screening consent for review of vaccination records held in school health systems, Ministry of Health (MoH) registers, and participant-held vaccination cards where available. We sought HPV vaccination records for 80 potential participants across 80 schools and 68 clinics. Only 15 participants (18.8%) had verifiable records: 2 (2.5%) retained vaccination cards, 4 (5.0%) had documentation in school records, and 9 (11.3%) had entries in MoH registers. Most school records were incomplete or missing, and several sites reported loss or disposal of records due to relocation, fire damage, or storage constraints. These findings highlight critical gaps in HPV vaccination documentation. Strengthening electronic immunization registries, standardizing record transfer, and improving data integration could enhance monitoring and support equitable progress toward cervical cancer elimination.

BACKGROUND: In the era of widespread antiretroviral therapy (ART), the relationship between HIV and hypertensive disorders of pregnancy remains unclear. This study compares the prevalence, severity, and neonatal outcomes of pre-eclampsia in women living with HIV (WLWH) and women without HIV in Botswana, a country with high ART coverage.

SETTING: The study was conducted at Princess Marina Hospital, Botswana's largest public tertiary referral center, where national ART guidelines support universal treatment and high rates of viral suppression among pregnant WLWH.

METHODS: We analyzed data from 11,754 women delivering at Princess Marina Hospital (November 2021-December 2023), combining 2 prospective surveillance cohorts. Pre-eclampsia was defined using American College of Obstetrics (ACOG) criteria. ART use, CD4 counts, and viral load data were collected. Primary outcome was pre-eclampsia prevalence; secondary outcomes included disease severity and adverse neonatal outcomes.

RESULTS: Pre-eclampsia prevalence was similar among WLWH and women without HIV (8.4% vs. 8.6%). However, after adjusting for age, parity, and hypertension history, WLWH had a lower risk (adjuste risk ratio 0.84, 95% CI: 0.71 to 0.98). Neonatal outcomes among those with pre-eclampsia did not differ significantly by HIV status. Among WLWH, initiating ART preconception and achieving undetectable viral loads were associated with reduced pre-eclampsia risk.

CONCLUSIONS: In settings with high ART coverage, WLWH may have a lower risk of pre-eclampsia than HIV-negative peers. HIV status does not seem to affect neonatal outcomes when ART is effective. These findings support early ART initiation and sustained viral suppression to optimize maternal health.

BACKGROUND: Depression significantly impacts cancer patients globally, complicating treatment outcomes by negatively affecting quality-of-life (QOL), self-care and treatment adherence. However, little is known about the prevalence of depression and its effects on QOL among cancer patients in Botswana.

AIM: This study aimed to assess the prevalence of depression and its relationship with QOL among cancer patients at Princess Marina Hospital's oncology unit.

SETTING: Patients seen at the oncology unit of Princess Marina Hospital, Botswana's largest tertiary referral hospital.

METHODS: A cross-sectional study was conducted from February 2023 to August 2024. The sample size was 302. Socio-demographic data were collected using a researcher-designed questionnaire. Depression was assessed using the PHQ-9, with a score of 9 or higher indicating depression, and QOL was measured using the WHOQOL-BREF.

RESULTS: The prevalence of depression was 35.8% (95% confidence interval [CI]: 30.3%, 41.5%). Patients with depression had a higher mean pain score (6 vs. 4, p < 0.001) and poorer QOL across all domains: physical health (40.9 vs. 59.7, p < 0.001), psychological health (52.3 vs. 69.3, p < 0.001), social relationships (49.0 vs. 68.3, p < 0.001) and environmental health (48.1 vs. 58.8, p < 0.001). A new diagnosis of cancer was associated with an increased risk of depression (p = 0.03).

CONCLUSION: The prevalence of depression among cancer patients is high in Botswana, and it is associated with poorer QOL, highlighting a significant public health concern.

CONTRIBUTION: Treatment of depression in this group of patients, along with pain management, may be crucial in improving their QOL.

OBJECTIVE: To determine histopathologic outcomes one year after LEEP for CIN2/CIN3 in women living with HIV on ART in Botswana and assess whether a 12-month follow-up interval is appropriate.

METHODS: This was a prospective cohort study of women living with HIV who previously underwent LEEP for confirmed CIN2/CIN3. Participants underwent follow-up approximately 12 months later, either through Ministry of Health or a standardized sub-study protocol, with colposcopy or VIA and tissue sampling performed per clinical algorithm. The primary outcome was histopathologically confirmed CIN2+ at follow-up. Associations between clinical factors, demographics, and CIN2+ were evaluated; chi-square and two-sample T-test were used to compare data and risk ratios (RR) were calculated.

RESULTS: Of 127 eligible participants, 90 attended follow-up at a median of 16 months (IQR 13 - 20). Almost all were on ART with a mean CD4 count of 728 (SD ± 310) cells/mm3. Of 66 participants with histopathology results, 29% had CIN2+ and one participant had invasive cancer. Positive endocervical margins at baseline were associated with increased risk of CIN2+, while age, time on ART, and CD4 count were not. Follow-up interval of ≥24 months was associated with more than double the risk of CIN2+ at follow-up (crude RR 2.3, 95% CI 1.1-4.7).

CONCLUSION: In a cohort of women living with HIV on ART, 29% had persistent/recurrent CIN2+ at follow-up. Follow-up interval and endocervical margin status were the strongest predictors. These data support the WHO recommendation for a 12-month follow-up interval in women living with HIV who are well-controlled on ART.

OBJECTIVE: Cervical cancer is the leading cause of cancer deaths among women in Botswana, yet uptake of cervical screening remains suboptimal. Understanding knowledge and barriers to screening is essential to inform strategies to achieve cervical cancer elimination.

METHODS: We conducted high-risk human papillomavirus (hrHPV) testing and an accompanying cross-sectional survey at health clinics and in the community in South East District, Botswana (February 2022-July 2023). Eligible participants were women aged ≥25 years with an intact cervix and no prior diagnosis of cervical cancer. Interviewer-administered structured questionnaires assessed demographics, prior screening attendance, knowledge of cervical cancer, and perceived barriers to screening. Open-ended responses were thematically categorized. Logistic regression was used to examine factors associated with knowledge and screening barriers.

RESULTS: Of 3000 women screened, 2994 (99.8%) had known HIV status and were included. Median age was 43 years (interquartile range [IQR] 36-51), and 1500 (50.1%) were women with HIV (WWH). Overall, 67.2% (2005/2994) reported prior cervical cancer screening, with substantially higher uptake among WWH than women without HIV (80.0% vs 54.5%, P < 0.001). Knowledge of cervical cancer etiology was limited, with only 27.1% (788/2905) correctly identifying hrHPV as the cause. Younger age, HIV-positive status, higher education, formal employment, and prior screening attendance were independently associated with better knowledge. Among women who had never been screened, the most commonly reported barriers were lack of prioritization (38.3%; 376/981), fear (17.0%; 167/981), lack of awareness (17.0%; 167/981) and service provision issues (12.0%).

CONCLUSION: Despite relatively high screening uptake, important gaps in knowledge and persistent individual- and system-level barriers remain. Strengthening cervical screening delivery through HPV self-collection alongside targeted education, would address current barriers to cervical screening in Botswana.