GFO Issue 464, Article Number: 2
ABSTRACT
This article reports that on 20 May 2025 Botswana became the first high HIV prevalence country to attain the World Health Organization’s gold tier for the elimination of mother-to-child transmission of HIV. It followed years of effective government action, HIV testing and treatment for pregnant women, and the help of communities and partners. And now that the rate of transmission is under 1 percent, Botswana has proven the end of this type of HIV transmission is within reach, even in a high-risk country.
On May 20, 2025, Botswana made history. The World Health Organization (WHO) announced that Botswana became the first high-HIV-burden country to achieve “gold tier” status in eliminating mother-to-child transmission (MTCT) of HIV. This means Botswana has met stringent global standards in stopping the spread of HIV from mothers to their babies during pregnancy, childbirth, or breastfeeding.
This announcement, made during the 78th World Health Assembly, celebrates more than two decades of concerted efforts by Botswana’s government, healthcare workers, communities, and international partners. In 2021, Botswana had already earned WHO’s “silver tier” by reducing the transmission rate to below 5%, treating over 90% of pregnant women with HIV, and limiting new HIV infections in newborns to fewer than 500 per 100,000 live births.
What the “Gold Tier” certification is all about
The gold tier is part of WHO’s Triple Elimination Initiative, which aims to end mother-to-child transmission of HIV, syphilis, and hepatitis B through integrated, people-centered health services. Launched in 2017, the initiative registers incremental country progress through bronze, silver, and gold levels. Achieving gold tier requires:
- At least 95% coverage with antenatal care, HIV testing, and antiretroviral therapy (ART)
- A vertical transmission rate under 5%
- Fewer than 250 new pediatric HIV infections per 100,000 live births
Botswana not only met but exceeded these benchmarks. By 2021, over 95% of pregnant women were receiving care and treatment, and MTCT rates had dropped below 2%.
The road to elimination: From crisis to global example
The journey to eliminating mother-to-child transmission of HIV in Botswana is a tale of courageous policy decisions driven by scientific breakthroughs, grassroots activism, and some of the boldest leadership on the continent of Africa.
In the late 1990s, Botswana had one of the most devastating HIV epidemics on the planet. By 1999 almost 30 per cent of adults were infected with HIV. Even more alarming was the fact that there was an estimated 40% transmission rate of HIV from mothers to newborns, leaving thousands of newborns at risk each year. Though such news was chilling, the government’s response was immediate and effective, with what would become one of Africa’s first and most ambitious national programs to prevent transmission of the virus from the mother to the child.
Scaling prevention: From pilot to policy
The first prevention of mother-to-child transmission program in Botswana was launched in 1999 in some selected pilot sites for HIV voluntary testing for pregnant women and ARV drug administration. The program became national by 2002. A game changer was the adoption of WHO’s Option B+ policy in 2013, which recommended that all pregnant and breastfeeding women living with HIV be provided with lifelong triple antiretroviral therapy, irrespective of their CD4 cell count.
Botswana is one of the first countries in Africa to implement this policy. The nation’s health system responded rapidly so that every pregnant woman would have access to HIV testing and treatment through routine antenatal care. Health care workers were trained throughout the country, supply chains were established to maintain drug availability, and clinics were prepared to offer maternal and child health services as an integral part of HIV care.
Strategic investments and technology
Botswana’s success has been the result of some smart investments in health infrastructure and data systems. The government created one of the region’s strongest laboratory networks for early infant diagnosis, enabling healthcare workers to identify HIV in newborns within weeks of birth, and start treatment right away if necessary. Innovations such as dried blood spot testing and digital health records made it possible to track outcomes and sustainability of follow-up care for both mothers and infants.
Collaborations with international partners like the United Nations Children's Fund and United States President's Emergency Plan for AIDS Relief as well as the Bill & Melinda Gates Foundation also contributed funds, technical know-how and new innovations to the work. Community health workers—mostly women from the communities they served—were the lifeblood of the program, building trust and ensuring people adhered to ART.
Cultural change and involving the community
Botswana also experienced a shift in public attitudes to HIV over the years. Extensive public education campaigns helped decrease stigma and prompted more women to get screened and treated while pregnant. Male participation in antenatal care increased as initiatives started involving fathers more explicitly.
In Serowe, a rural community, stories of mothers like Dora, who gave birth to a son who tested negative for HIV because she got treated, are more commonplace and uplifting. The number of new infections in children had plunged by 2021, with seven health districts seeing zero transmissions.
Results that speak volumes
Today, more than 95% of pregnant women in Botswana know their HIV status, and over 98% of those who are HIV-positive are on effective treatment. The result: mother-to-child transmission rates have fallen below 1%, far exceeding the silver-tier threshold of 5%. Botswana now meets the three critical criteria set by WHO for validation—a true testament to what is possible when evidence-based medicine meets political will and grassroots action.
Implications for other high burden countries
Botswana’s achievements in eliminating mother-to-child transmission of HIV demonstrate this is attainable even in high HIV burden contexts - not only in wealthy or low-prevalence countries. It shows that with political commitment, strategic investments and equitable health policies, any country can achieve major global health goals.
Other high-burden countries that would like to emulate Botswana can draw several important lessons. First, everyone must have access to HIV services, especially the people who are often excluded, including key populations. Without this, it is not possible to make progress. The second is the normalization of HIV testing and treatment at all levels of healthcare. This is to help expand access and to make sure people don’t miss out on services. Third, local data systems are a good investment. Good data helps to both improve services and ensure that health systems are held to account. Finally, countries require consistent political leadership. National governments need to take control of and fund their own programs instead of relying solely on donors. The Botswana story is a reminder that genuine change can happen - even in difficult circumstances - through the combination of focus, determination and action.
Sustainability and remaining challenges
Despite this milestone, long-term sustainability remains critical. Key priorities include:
- Reducing HIV acquisition risk among women of reproductive age
- Guaranteeing early diagnosis and treatment for infants
- Addressing the social and economic drivers of HIV risk and ART adherence
Additionally, to achieve full triple elimination certification, Botswana must continue progress on preventing transmission of syphilis and hepatitis B.
From certification to consolidation
Botswana’s gold tier status is a global call to action. It demonstrates that even in challenging environments, mother-to-child transmission of HIV can be virtually eliminated when political leadership, inclusive policies, and community-led action align.
As Botswana moves forward, the focus must shift from recognition to consolidation and sustainability - ensuring that the health systems and outcomes built over decades remain strong for future generations.
On May 20, 2025, Botswana made history. The World Health Organization (WHO) announced that Botswana became the first high-HIV-burden country to achieve “gold tier” status in eliminating mother-to-child transmission (MTCT) of HIV. This means Botswana has met stringent global standards in stopping the spread of HIV from mothers to their babies during pregnancy, childbirth, or breastfeeding.
This announcement, made during the 78th World Health Assembly, celebrates more than two decades of concerted efforts by Botswana’s government, healthcare workers, communities, and international partners. In 2021, Botswana had already earned WHO’s “silver tier” by reducing the transmission rate to below 5%, treating over 90% of pregnant women with HIV, and limiting new HIV infections in newborns to fewer than 500 per 100,000 live births.
What the “Gold Tier” certification is all about
The gold tier is part of WHO’s Triple Elimination Initiative, which aims to end mother-to-child transmission of HIV, syphilis, and hepatitis B through integrated, people-centered health services. Launched in 2017, the initiative registers incremental country progress through bronze, silver, and gold levels. Achieving gold tier requires:
- At least 95% coverage with antenatal care, HIV testing, and antiretroviral therapy (ART)
- A vertical transmission rate under 5%
- Fewer than 250 new pediatric HIV infections per 100,000 live births
Botswana not only met but exceeded these benchmarks. By 2021, over 95% of pregnant women were receiving care and treatment, and MTCT rates had dropped below 2%.
The road to elimination: From crisis to global example
The journey to eliminating mother-to-child transmission of HIV in Botswana is a tale of courageous policy decisions driven by scientific breakthroughs, grassroots activism, and some of the boldest leadership on the continent of Africa.
In the late 1990s, Botswana had one of the most devastating HIV epidemics on the planet. By 1999 almost 30 per cent of adults were infected with HIV. Even more alarming was the fact that there was an estimated 40% transmission rate of HIV from mothers to newborns, leaving thousands of newborns at risk each year. Though such news was chilling, the government’s response was immediate and effective, with what would become one of Africa’s first and most ambitious national programs to prevent transmission of the virus from the mother to the child.
Scaling prevention: From pilot to policy
The first prevention of mother-to-child transmission program in Botswana was launched in 1999 in some selected pilot sites for HIV voluntary testing for pregnant women and ARV drug administration. The program became national by 2002. A game changer was the adoption of WHO’s Option B+ policy in 2013, which recommended that all pregnant and breastfeeding women living with HIV be provided with lifelong triple antiretroviral therapy, irrespective of their CD4 cell count.
Botswana is one of the first countries in Africa to implement this policy. The nation’s health system responded rapidly so that every pregnant woman would have access to HIV testing and treatment through routine antenatal care. Health care workers were trained throughout the country, supply chains were established to maintain drug availability, and clinics were prepared to offer maternal and child health services as an integral part of HIV care.
Strategic investments and technology
Botswana’s success has been the result of some smart investments in health infrastructure and data systems. The government created one of the region’s strongest laboratory networks for early infant diagnosis, enabling healthcare workers to identify HIV in newborns within weeks of birth, and start treatment right away if necessary. Innovations such as dried blood spot testing and digital health records made it possible to track outcomes and sustainability of follow-up care for both mothers and infants.
Collaborations with international partners like the United Nations Children's Fund and United States President's Emergency Plan for AIDS Relief as well as the Bill & Melinda Gates Foundation also contributed funds, technical know-how and new innovations to the work. Community health workers—mostly women from the communities they served—were the lifeblood of the program, building trust and ensuring people adhered to ART.
Cultural change and involving the community
Botswana also experienced a shift in public attitudes to HIV over the years. Extensive public education campaigns helped decrease stigma and prompted more women to get screened and treated while pregnant. Male participation in antenatal care increased as initiatives started involving fathers more explicitly.
In Serowe, a rural community, stories of mothers like Dora, who gave birth to a son who tested negative for HIV because she got treated, are more commonplace and uplifting. The number of new infections in children had plunged by 2021, with seven health districts seeing zero transmissions.
Results that speak volumes
Today, more than 95% of pregnant women in Botswana know their HIV status, and over 98% of those who are HIV-positive are on effective treatment. The result: mother-to-child transmission rates have fallen below 1%, far exceeding the silver-tier threshold of 5%. Botswana now meets the three critical criteria set by WHO for validation—a true testament to what is possible when evidence-based medicine meets political will and grassroots action.
Implications for other high burden countries
Botswana’s achievements in eliminating mother-to-child transmission of HIV demonstrate this is attainable even in high HIV burden contexts - not only in wealthy or low-prevalence countries. It shows that with political commitment, strategic investments and equitable health policies, any country can achieve major global health goals.
Other high-burden countries that would like to emulate Botswana can draw several important lessons. First, everyone must have access to HIV services, especially the people who are often excluded, including key populations. Without this, it is not possible to make progress. The second is the normalization of HIV testing and treatment at all levels of healthcare. This is to help expand access and to make sure people don’t miss out on services. Third, local data systems are a good investment. Good data helps to both improve services and ensure that health systems are held to account. Finally, countries require consistent political leadership. National governments need to take control of and fund their own programs instead of relying solely on donors. The Botswana story is a reminder that genuine change can happen - even in difficult circumstances - through the combination of focus, determination and action.
Sustainability and remaining challenges
Despite this milestone, long-term sustainability remains critical. Key priorities include:
- Reducing HIV acquisition risk among women of reproductive age
- Guaranteeing early diagnosis and treatment for infants
- Addressing the social and economic drivers of HIV risk and ART adherence
Additionally, to achieve full triple elimination certification, Botswana must continue progress on preventing transmission of syphilis and hepatitis B.
From certification to consolidation
Botswana’s gold tier status is a global call to action. It demonstrates that even in challenging environments, mother-to-child transmission of HIV can be virtually eliminated when political leadership, inclusive policies, and community-led action align.
As Botswana moves forward, the focus must shift from recognition to consolidation and sustainability - ensuring that the health systems and outcomes built over decades remain strong for future generations.
