HIV testing remains the most important step in HIV prevention and care. HIV diagnostic approaches in the two countries differ. Botswana utilizes point‐of‐care HIV testing (POCT) with two rapid HIV tests at clinics, hospitals, community‐based organizations, testing centres and mobile testing campaigns. In Australia, POCT with rapid tests is used for screening; laboratory‐based diagnostic testing is required. HIV testing in Australia occurs through public sexual health and general practitioners’ clinics and hospitals.

Rapid testing uptake in Australia has been modest, with lack of medical insurance reimbursements for tests deterring use of POCT. Strategies to enhance the reach and frequency of HIV testing must recognize local needs, with consideration of HIV distribution by risk populations, geography and system capacity. Australia's concentrated epidemic, high coverage of primary care services in urban areas and public subsidy of testing has meant 90% of PLHIV know their status 8. In Botswana, POCT delivered across clinical, programme and community settings suits a more generalized and geographically dispersed epidemic.

Botswana and Australia have demonstrated that POCT needs to be accessible and targeted at key and vulnerable populations to identify new HIV infections. In Australia, MSM, people who inject drugs (PWID) and sex workers are key populations, while indigenous populations are considered vulnerable 8. In Botswana, female sex workers (FSWs), MSM and non–citizens (illegal immigrants) are key populations, while adolescents/young people are considered vulnerable and the testing rate is low in men 16, 18. Botswana has expanded HIV testing beyond facility‐based testing to involve communities using community‐based HIV testing campaigns.

To progress, within countries, systems need to respond to changes in epidemiology and political and structural environments. Identification of key and vulnerable populations and then enhancing systems that increase HIV testing, linkage to care and treatment in these groups is key. In Australia, recent outbreaks of HIV among indigenous people and PWID 8 suggest that new strategies are needed to reach these groups. Similarly, in Botswana the ongoing targeting of FSWs and increasing recognition of MSM as a key population may require adapted models of testing to maintain and increase diagnosis among PLHIV, such as the integration of HIV self‐testing into existing programmes.

Botswana adopted the World Health Organization's (WHO) “treatment for all” strategy (universal ART) 22 in mid‐2016 23, whereas Australia formally implemented universal ART policy in 2014 24. Interestingly, Botswana had a similarly high estimated ART coverage (87%, vs. 84% in Australia) among persons with diagnosed HIV infection even before offering universal ART 7, 8.

Botswana offers free ART to citizens through all levels of its decentralized healthcare system and excludes immigrants. In Australia, ART is provided through GPs’ clinics, sexual health clinics, and hospitals for citizens and permanent residents, publicly funded through Australia's universal healthcare system with low direct costs for patients. Immigrants living with HIV holding short‐term visas are not covered, but generally access ART through compassionate programmes.

Universal ART access in Botswana and Australia – combined with initiation of treatment in community settings – promotes rapid ART initiation and reduced periods of infectivity. Both healthcare systems must prepare for challenges associated with universal ART, including drug resistance, adherence and retention, particularly in marginalized subgroups such as immigrants, refugees and PWID. In Botswana, a decentralized non‐siloed healthcare system improves ART coverage; integration of ART into maternal, newborn and child health services, and tuberculosis treatment to reduce multiple visits to services, could further enhance effectiveness 25.

Viral suppression rates for people on ART (defined as <400 HIV RNA copies/ml in Botswana 23 and <200 HIV RNA copies/ml in Australia 24) are very high and above 90% in both countries (Table 2). Six‐monthly viral load monitoring is recommended and available for stable patients on treatment in both countries 23, 24. As WHO guidelines specify, Australia and Botswana have routine access to viral load monitoring in their public health system, unlike many resource‐limited settings 26.

Sustained viral suppression is driven by adherence to ART and absence of drug resistance. Enablers and disablers of adherence should be identified and addressed. In Australia, social/economic/cultural/patient engagement factors are associated with suboptimal adherence while ART regimen/clinical factors are not 27. Community‐based programmes that enhance the continuum of care could also benefit adherence and sustained viral suppression 28, assisting both countries in achieving the 2030 targets.

Governments and/or donors must provide sustainable HIV response financing. Scaled HIV testing, linkage to care, universal ART, monitoring patients on treatment, stronger condom programming and biomedical prevention tools (e.g. VMMC, PrEP) all require funding with strong human resources and supply chain management.

Australia has a GDP of $1.3 trillion, while Botswana's is $14.3 billion (Table 2). This difference in GDP impacts on the funding pathways for the HIV response: in Australia, the HIV response is predominantly funded by government 24; in Botswana, the government funds at least 60% of its HIV response budget, with the balance from international and private funding 19. A decline in international funding for Botswana, because of its new upper middle‐income status 29 and an overall adverse global economic environment for aid, highlights the vulnerability of its HIV response 19. Cost‐benefit assessments may identify optimal approaches to the HIV response, but the cost relative to a country's budget is often critical. Innovative funding strategies, combined with improved efficiency, will be required to ensure Botswana and similar countries can sustain high‐level HIV responses 30.

Reliable data sources and standardized methodologies and definitions are required to accurately report progress towards the 90‐90‐90 targets 31, however, considerable disparities in reporting methods exist. Use of complete population‐based datasets from clinical elements of a centralized healthcare system to report the HIV testing and treatment cascade has been proposed 32.

Botswana's reported progress towards targets is based on an ongoing population survey of adult members of 20% of households in 30 rural and peri‐urban communities (nested within a clinical trial of interventions targeted at enhancing HIV testing, linkage and treatment), with sensitivity analyses including standardization to age/sex distribution from census and HIV surveillance data 7. Despite intensive efforts to achieve high survey participation, these data may not be representative of the entire population, and non‐participants may differ from survey participants in key ways. In Australia, state‐based and centralized national programmes monitor and report HIV data 8. Population‐level data from surveillance embedded within inter‐linked rather than stand‐alone health services would be ideal, but such approaches are costly and sometimes impractical.