Botswana is among the highest HIV/AIDS epidemic burden bearing countries in the world. While treatment for HIV was introduced in Botswana in 2002, the uptake and adherence of the antiretroviral (ART) and Prevention of Mother-to-Child Transmission (PMTCT) therapies are still relatively low. The goal of this research is to provide recommendations on how to improve adherence to ART and PMTCT treatment regimens for adult men and women, and pregnant women and new mothers living with HIV in Botswana. With improved ART adherence, there is high potential for a reduction in new HIV infections as a result of suppressed viral load. This reduction will contribute to the global goal of the UNAIDS (United Nations AIDS) "Treat All Program" to eliminate new HIV infections by 2030. ART adherence is measured in two ways (a) biological (serum CD4 count and viral load) and (b) using a composite score of biological and behavior, including reporting missed dosages. With this in mind, this study will examine three dimensions of ART non-adherence in a sampled population of HIV infected adult men (n = 239) and women (n = 419), including pregnant women or new mothers (n = 67) attending 21 ART clinics in Greater Gaborone. First, ART adherence was investigated at the individual-level to assess and evaluate differences by gender, age and geography. Second, PMTCT was investigated at the individual-level to identify challenges to adherence during pregnancy and early motherhood. Third, the climate of Botswana is hot, arid and dry and this study therefore, investigate the impacts of weather extremes on adherence behavior. The findings from this study show that men have lower adherence to ART than women; and men 30+ years are at the highest risk of transmitting HIV infection. Lower adherence in men 30-40 years may in part, be explained by taking other drugs for co-conditions in addition to ARVs. With increasing age, lower adherence among men 50+ years is largely explained by single marital status and the need to seek other companions for support later in life. Second, among pregnant women and mothers, a majority cohabit with HIV infected men (n = 45) and many (n = 22) do not know their partner's HIV status. Post-partum, many women do not disclose their own HIV status until later in their infant's first year of life, in part because mother's are processing their own HIV status as trust is evolving in the relationship. Not knowing a partner's HIV status and/or not disclosing one's own HIV status, do not significantly lead to poor adherence and increased the risk of HIV transmission, however, declining trends in CD4 counts are observed, suggestive that there are difficulties adhering to ART for both partner and mother post-partum. Third, high ambient temperature is an important barrier to monthly clinic visits for both men and women living in urban, peri-urban and rural areas; and water rationing is a significant risk factor for non-adherence in rural areas. Being turned away by the clinic because of no water availability, is another important barrier for women including, pregnant and post-partum mothers and men living with HIV in Greater Gaborone. The findings from these three studies recommend (a) targeting men 30+ years living with HIV for medical and social support to ensure high ART adherence, to reduce HIV transmission; (b) provide additional social services for women and their partners, during pregnancy and post-partum to enhance trust associated with HIV disclosure, to ensure high ART adherence; and (c) increase public health messaging about how to overcome environmental barriers to ART adherence, especially on extremely hot days and days of water rationing, while also ensuring water availability in all ART clinics. These recommendations may be extended beyond Botswana, to other sub-Saharan African countries to optimize ART treatment success and the elimination of HIV transmission over the next decade.
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