Representative images of pathology in patients with skin of color are lacking in most medical education resources. This particularly affects training in dermatology, which relies heavily on the use of images to teach pattern recognition. The presentation of skin pathology can vary greatly among different skin tones, and this lack of representation of dark skin phototypes challenges providers’ abilities to provide quality care to patients of color. In Botswana and other countries in sub-Saharan Africa, this challenge is further compounded by limited resources and access to dermatologists. There is a need for improved and accessible educational resources to train medical students and local medical providers in basic skin lesion description and diagnosis. We examined whether online Perceptual and Adaptive Learning Modules (PALMs) composed of representative dark skin images could efficiently train University of Botswana medical students to more accurately describe and diagnose common skin conditions in their community. Year 4 and 5 medical students voluntarily completed PALMs that teach skin morphology, configuration, and distribution terminology and diagnosis of the most common dermatologic conditions in their community. Pre-tests, post-tests and delayed-tests assessed knowledge acquisition and retention. PALMs training produced statistically significant (P < .0001) improvements in accuracy and fluency with large effect sizes (1.5, 3.7) and good retention after a 12.5-21-week median delay. Limitations were a self-selected group of students, a single institution, slow internet connections, and high drop-out rates. Overall, population-specific PALMs are a useful tool for efficient development of pattern recognition in skin disease description and diagnosis.

Objectives: This study aimed to investigate the psychological impact of the COVID-19 outbreak on healthcare workers across multiple hospitals in different districts in Botswana. Methods: We conducted a cross-sectional study in five public-funded hospitals from three districts in Botswana from 1 June 2020 to 30 October 2020. We used the neuroticism subscale of the 44-item Big Five Inventory, Patient Health Questionnaire, the Oslo 3-item Social Support Scale, the Anxiety Rating Scale, and the 14-item Resilience Scale to obtain data from 355 healthcare workers. Results: The participants’ mean age (standard deviation) was 33.77 (6.84) years. More females (207, 59%) responded than males (144, 41%). Anxiety and depression were experienced by 14% and 23% of the participants, respectively. After multiple regression analyses, neuroticism predicted depression ( B = 0.22; p < 0.01) and anxiety disorder ( B = 0.31; p < 0.01). Lower educational status ( B = −0.13; p = 0.007) predicted anxiety and younger age ( B = −0.10; p = 0.038) predicted depression, while resilience negatively correlated with both disorders. Conclusion: There is a need to develop and implement interventions targeted at these identified risk and protective factors that can be easily delivered to healthcare workers during this pandemic.

Background: Morbidity and mortality due to cardiovascular diseases (CVDs) are high and increasing in low- and middle-income countries. People living with HIV (PLWH) are more likely to experience CVD than members of the general population. Therefore, we aimed to assess whether PLWH were more likely to have previously been screened for cardiovascular disease risk factors (CVDRFs) than people without HIV. Methods: A population-based, cross-sectional study was conducted among individuals aged 16 to 68 years across 22 communities in Botswana from February to August 2017 as part of a larger community-based cluster randomized HIV treatment-as-prevention trial. Participants were asked if they had been screened for and counselled on cardiovascular disease risk factors (history of hypertension or blood pressure check, blood glucose and cholesterol measurements, weight check and weight control, tobacco smoking and cessation, alcohol use and physical activity) in the preceding 3 years. HIV testing was offered to those with an unknown HIV status. Multiple logistic regression analysis controlling for age and sex was used to assess the relationship between CVDRF screening and HIV status. Results: Of the 3981 participants enrolled, 2547 (64%) were female, and 1196 (30%) were PLWH (93% already on antiretroviral therapy [ART]). PLWH were more likely to report previous screening for diabetes (25% vs. 19%, p < 0.001), elevated cholesterol (17% vs. 12%, p < 0.001) and to have had their weight checked (76% vs. 55%, p < 0.001) than HIV-uninfected participants. PLWH were also more likely to have received counselling on salt intake (42% vs. 33%, p < 0.001), smoking cessation (66% vs. 46%, p < 0.001), weight control (38% vs. 29%, p < 0.001), physical activity (46% vs. 34%, p < 0.001) and alcohol consumption (35% vs. 23%, p < 0.001) than their HIV-uninfected counterparts. Overall, PLWH were more likely to have received screening for and/or counselling on CVDRFs (adjusted odds ratio 1.84, 95% CI: 1.46–2.32, p < 0.001). Conclusion: PLWH were almost two times more likely to have been previously screened for CVDRFs than those without HIV, indicating a need for universal scale-up of integrated management and prevention of CVDs in the HIV-uninfected population.

Objectives The aim was to establish the community prevalence of central obesity in Botswana and assess its association with HIV status. Design We performed a one-time central obesity assessment nested within a community-based cluster-randomised controlled HIV treatment and prevention trial (Botswana Combination Prevention Project (BCPP)) conducted in Botswana. Setting The BCPP enrolled consenting adults from a random sample of 20% of households in 30 rural/peri-urban communities. Participants A subset of participants from 22 communities was selected for a nested central obesity study. Primary and secondary outcome measures Central obesity was defined as a waist-to-hip ratio (WHR)>0.90 for males and >0.85 for females or as a waist circumference (WC) ≥94 cm for males and ≥80 cm for females. A modified Poisson regression model was used to ascertain the association between central obesity and HIV status. Additionally, the same model was used to estimate the adjusted prevalence ratio (aPR) for central obesity among participants with missing waist and hip measurements by applying inverse probability weighting, and then adjusting for sex and age in the final multivariate models. Results Of the 3981 adults, 2039 (51%) completed central obesity assessment (67% female, 29% people living with HIV and median age 35.4 years (IQR 26.4–48.3 years). Central obesity prevalence was 43.5% (95% CI 41.4% to 45.7%) and 50.8% (95% CI 48.6% to 52.9%) as defined by WHR and WC, respectively, and was higher among females than males by WHR (46.9% (95% CI 44.2% to 49.5%) vs 36.7% (95% CI 33.1% to 40.4%)) and WC 68.5% ((95% CI 65.9% to 70.9%) vs 15.1% (95% CI 12.4% to 17.8%)) and increased with age. In fully adjusted models, there was no difference in central obesity by HIV status for both WHR and WC, aPR 0.99 (95% CI 0.90 to 1.09), p value 0.88, and 0.93 (95% CI 0.85 to 1.01), p value 0.06, respectively. Conclusion Over two-thirds of adult females in Botswana had central obesity; however, living with HIV was not consistently associated with central obesity. Trial registeration number NCT01965470.

Cytomegalovirus (CMV) has been linked with increased cardiovascular risk and monocyte activation in people living with HIV (PLWH). This cross-sectional study aimed to compare CMV immunoglobulin G (IgG) levels between combined antiretroviral therapy (cART)-treated PLWH versus ART-naïve PLWH and those without HIV, and to investigate their associations with biomarkers of endothelial injury and carotid atherosclerosis, in Gaborone, Botswana. All participants were between 30 and 50 years old. Carotid intimal media thickness (cIMT) and biomarkers of endothelial injury and monocyte activation were also assessed. The association between quantitative CMV IgG and cardiovascular disease risk was assessed in multivariate logistic regression analysis. The results showed that the mean CMV IgG level among ART-naïve participants was significantly higher than both the cART group and controls. However, CMV IgG levels did not differ significantly between the controls and cART groups. Among PLWH, CMV IgG levels were associated with ICAM-1 levels and cIMT. Increases in CMV IgG among ART-naïve participants were significantly associated with increases in log VCAM-1. In conclusion, CMV IgG levels are elevated among PLWH in sub-Saharan Africa, and higher levels are associated with biomarkers of endothelial injury and cIMT. Future research should investigate the long-term impact of elevated CMV IgG among PLWH.

Due to the success of HIV treatment, people living with HIV (PWH) have aged to develop chronic conditions. InterCARE is evaluating the integration of hypertension treatment into HIV care in Botswana. This involves adapting the Electronic Health Records [EHR], health care workers training, and the use of treatment partners. A pilot hybrid type 2 effectiveness implementation trial in two public HIV clinics found high effectiveness, adoption, and fidelity overall but low adoption of EHR. This mixed-methods research aimed to explain mean variation in these outcomes to inform future scale-up. Guided by the Consolidated Framework for Implementation Research, we recruited community members, healthcare workers, patients, and treatment partners to complete surveys ( n = 100), and semi-structured interviews in-person ( n = 10), 12 months after InterCARE implementation. Descriptive statistics and Fischer’s exact tests were calculated for surveys, and a deductive analysis was completed for interviews (Cohen’s Kappa = 0.86). Qualitative analysis found high acceptability of InterCARE compared to standard of care for HIV and hypertension. Integration improved patient experiences by increasing efficiency of care (e.g., reduced visit frequency, less time spent accessing care, reduced out-of-pocket costs). Integration of care and use of treatment partners increased medication adherence. Barriers included insufficient resources, HIV-related stigma (both internalized and perceived), high healthcare workers workload, and need for HIV providers’ training in hypertension. To improve implementation, suggestions included increasing client awareness and understanding of services through education, using various dissemination strategies (e.g., social media, community meetings, handouts), and enhancing provider buy-in. Overall, results showed positive perceptions of the strategies and overall integration. This research provides valuable insight into factors that affect outcomes from bundled implementation strategies supporting integration among chronic diseases and HIV in resource-limited settings.