HIV/AIDS in Mongolia: Crisis in the Making?

UNCLAS SECTION 01 OF 04 ULAANBAATAR 000670 SIPDIS SENSITIVE SIPDIS DEPT FOR S/GAC, EAP/CM, OES, AND DRL E.O. 12958: N/A TAGS: PHUM EAID SOCI PGOV PINR PREL MG KHIV SUBJECT: HIV/AIDS in Mongolia: Crisis in the Making? REF: 06 ULAANBAATAR 0392 ULAANBAATA 00000670 001.2 OF 004 SENSITIVE BUT UNCLASSIFIED - NOT FOR INTERNET DISTRIBUTION. ¶1. (SBU) SUMMARY: Mongolia retains its reputation as a country with a low rate of HIV infection, but testing among at-risk populations remains at a low level, and experts fear that official figures do not tell the whole story. To date 41 HIV/AIDS cases have been officially recorded (involving 35 Mongolian nationals and six foreigners). Of these 35, four have died and 25 are HIV-infected but have not yet converted to full-blown AIDS. Experts believe the real number of HIV/AIDs cases in Mongolia could be 10 to 15 times the official figure. Local analysts say the growing sex trade, high STD rates, low levels of condom use and increased mobility to neighboring countries with high HIV rates make Mongolia vulnerable to rapid growth in HIV/AIDS cases in the next few years. Citing low official figures, the Mongolian Government's response to the pandemic has been lackluster. With a few notable exceptions, the international community's response has also been underwhelming. Limited access to proper testing and strong social disincentives have kept many individuals from having themselves tested, thereby enabling further spread of the infection. To avert a catastrophe, the GOM will have to renew its political and financial commitment to fight the spread of HIV/AIDS. END SUMMARY. OFFICIAL INFECTION RATE LOW BUT MISLEADING -------------- ¶2. (U) Mongolia's first official case of HIV surfaced in August 1992 when a Mongolian MSM (men who have sex with men) became infected while living abroad. He died of pneumocystis pneumonia in 1999. Astonishingly, between 1992 and 1997, no new cases came to light despite extensive HIV testing among a large proportion of most at risk populations (MSM, mobile populations and female sex workers, or FSWs). The country's second case was not discovered until 1997, and involved a FSW who had had sexual contact with an HIV-positive Cameroon national. Out of the officially reported total of 35 HIV-positive cases to date, 26, or 74%, have emerged in the past two years. All cases are the result of sexual transmission, and 52% of all reported cases involve MSM. HEALTH GROUPS: TRUE INFECTION RATE MUCH HIGHER -------------- - ¶3. (U) Health organizations fear that Mongolia's infection rate is grossly underestimated, due to limited access to testing and disincentives for at-risk people to take the test. A recent labor fare in Ulaanbaatar for Mongolians aged 18 and 35 who wished to work in South Korea revealed that of the 10,000 who registered and underwent required medical testing, three were diagnosed as being HIV-positive. 18- to 35-year-olds make up approximately 33% of Mongolia's population, or 850,000 people. By extrapolating the ratio of three cases per 10,000 individuals to the larger population subset, experts believe that there could be 256 cases of HIV infection within this age group alone -- nearly eight times higher than the number of current registered cases. UN estimates go further, suggesting the total number of cases in the population is closer to 950 (or .03%). Whatever the figure, there is legitimate concern that there is a sufficient pool of potential unidentified cases for a near-term exponential increase in infection rates. SOCIAL DISINCENTIVES DETER TESTING -------------- ¶4. (U) Exacerbating the underreporting is that many Mongolians hesitate to take an HIV test, fearing a lack of confidentiality of test results and the social and legal consequences of being HIV-positive. The case of the African male and the Mongolian FSW raised concerns among international agencies regarding Mongolia's testing regimes. The FSW was identified as HIV-positive within a couple weeks after contact with the African male. However, international experts noted that current testing methods could not have detected HIV so soon in the FSW, suggesting transmission from another source. The GOM responded to this event by expelling the Cameroonian national and ordering HIV testing for all Africans resident in Mongolia, as well as for all women between 16 and 45. When it became clear that the capacity and justification for testing such numbers of women did not exist, the GOM dropped that ULAANBAATA 00000670 002.2 OF 004 requirement, but not before engendering a great deal of fear. (Note: Although the GOM now maintains that it works in accordance with the WHO's advisory against coercing any group to get tested, it has admitted to covert screening of hospital patients, prisoners, sex workers, traders and homeless people since 2002. End Note.) WIDESPREAD MISCONCEPTIONS -------------- ¶5. (U) Major misconceptions about HIV transmission persist, especially among those aged 14-24, and this has contributed to prejudice against those who are HIV-positive. A recent WHO survey found that many young people believe that infection is possible through mosquitoes or other insects; sharing toothbrushes; using public toilets or public swimming pools; breathing air in close proximity to an HIV-positive person; sharing food preparation facilities; or sharing a bed (a common and accepted practice in Mongolia). STRONG SUPPORT SEEN FOR FORCED HIV TESTING -------------- ¶6. (U) Survey results have also raised a number of human rights-related questions. Recent surveys found that 78 percent of respondents agreed that "the government should force those that are suspected of being HIV-positive to be tested," with nearly one third asserting that "the details of those that are HIV-positive should be published so that these people can be avoided." Over half of the respondents agreed with the statement: "Those who are HIV-positive should not be allowed to have children," and that "If an HIV-positive woman becomes pregnant, she should be forced to have an abortion." GAY AND BISEXUAL MEN REPORT PRESSURE TO GET TESTED -------------- -------------- ¶7. (U) Post has received reports from Mongolian MSM that they are often harassed by health officials to take HIV tests, with threats of public exposure or arrest by police. However, many fear taking the test, as the results seem to become public knowledge quite readily. A well-founded belief exists that health officials will sell test results to journalists for cash. HIV cases, still relatively rare, remain an attention-grabber for the yellow and even mainstream press. Persons so identified can be fired from their jobs and evicted from apartments without recourse, not to mention being ostracized by friends and family. In one notorious case, a woman was identified in the press as being HIV-positive and was subsequently murdered by her husband for this reason. It later turned out she was not HIV positive. TREATMENT OPTIONS LACKING -------------- ¶8. (U) Nor does the treatment of HIV positive and AIDS sufferers inspire much confidence. There are currently four people known to be living with AIDS in Mongolia. According to the current head of Positive Life, a local NGO that works with the HIV-positive and their families, two of the four currently take anti-retroviral medication (ARVs). Indications are there will be four by the end of the year, and 10 by 2008. ARVs are only available through the National Center for Communicable Diseases (NCCD),funded by the UN Global Fund. Those taking the ARVs report that their treatment is often interrupted for months at a time with no explanation, risking ARV-resistance, and that they do not receive adequate information regarding the medications and their side effects. Patients also say that doctors are unaware of how to manage dosages and changes in ARV treatment; that they are not given any choice in their treatment options; and that doctors often treat them with contempt. Rural HIV-positive residents who attempt to obtain treatment at Ulaanbaatar's National Center for Communicable Diseases report that the doctors sometimes refuse to see them altogether, or shunt them from doctor to doctor, a process that often results in the worn-down patient returning to the countryside without having been seen or treated. POSSIBLE RAPID EXPANSION OF HIV/AIDS ULAANBAATA 00000670 003.2 OF 004 -------------- ¶9. (U) Despite the low prevalence of reported HIV/AIDS cases to date, Mongolia is considered highly vulnerable to the spread of HIV infection. Fifty percent of the population is under 25; there is a high prevalence of STDs among in both the general population and among high-risk groups; sexual activity among those 19 to 24 is high (close to 50% have had sex or are sexually active) and the consistent use of condoms during sex outside monogamous relationships is low (20%, according to some surveys); contributing factors such as alcoholism, unemployment and poverty are widespread; access to proper testing facilities is limited, especially in the countryside; Mongolians are among the highest per capita users of injection needles (albeit for vitamins and other medicinal purposes rather than narcotics) and the country's neighbors include China, Russia and Kazakhstan, which register high growth rates for HIV/AIDS. As infrastructure improves and mobility between the three countries increases, the likelihood of the HIV/AIDS pandemic sweeping through Mongolia rises dramatically. FALSE SENSE OF SECURITY -------------- ¶10. (U) Mongolia's deceptively low prevalence rates have led GOM health officials to place a lower priority for programs that would support greater awareness and precautionary behavior. Limited external funding, coupled with the GOM's insufficient budget allocation, makes it unlikely that Mongolia will maintain its low prevalence status. Compounding this is wishful thinking by Mongolian officials, some of whom have privately told Post that it is only the dregs of society, meaning MSM, FSW, and drug users, who are at risk, leaving most "good" Mongolians safe and sound. Nor do officials know what an HIV or AIDS patient will cost Mongolia if the problem gets out of control. Consequently, the total government budget allocation for HIV/AIDS for FY2007 was US$10,000. ¶11. (U) Mongolia is not recognized by multilateral and bilateral funding agencies as a priority country because of its currently low HIV/AIDS rates, thus the country receives limited external funding and technical support. USAID has a pilot project implemented by PACT to increase public awareness about and help prevent the spread of HIV/AIDS. The project created an innovative 26-part television series which aimed to educate the public and the most at risk populations about HIV/AIDS transmission and prevention. See reftel. HEALTH SYSTEM ILL-EQUIPPED -------------- ¶12. (U) Without increased financial resources, Mongolia's health system will remain ill equipped to deal with the growing crisis. Health care professionals are undereducated on how to deal with HIV/AIDS (testing, counseling, etc.),underpaid and generally overburdened. Turnover is high, especially at provincial hospitals. STD drugs, condoms and test kits are frequently out of stock or expired. Delayed supply and delivery to provinces and sub-provinces, exacerbates the problem. Urban and provincial hospitals and laboratories suffer from limited funding, limited facilities, outdated equipment and lack of test kits. ECONOMIC TOLL -------------- ¶13. (U) The annual direct health expenditure for a Mongolian with AIDS is between two and six times higher than the annual income of an average Mongolian family, or US$5,000 to US$30,000. It is estimated that between 2004 and 2014, the direct expenses resulting from the spread of HIV/AIDS will reach between 1.3 - 3.6 billion MNT, with the direct expenses from AIDS mortality reaching between 11.9-15.4 billion MNT. ¶14. (U) Concerned Ministry of Health officials have acknowledged that failure to implement effective prevention measures may yield as many as 2,500 AIDS deaths by 2014. Domestic and foreign health professionals worry about the ability of the Ministry of Health to ULAANBAATA 00000670 004 OF 004 adequately manage either the current or an escalated infection rate. The scenario outlined here suggests a potential convergence of factors that can only result in a significant increase in infection rates and economic burdens. GDP COULD BE NEGATIVELY IMPACTED -------------- ¶15. (U) Around 59% of Mongolia's citizens are aged between 15 and ¶60. A decreased number of working-age people impact any country's economy at the macro level, decreasing economic capacity, productivity and gross domestic product (GDP). A decrease in Mongolia's already small population of 2.8 million people would be widely felt. It is estimated that within 10 years HIV/AIDS cause at least a 2% drop in Mongolia's GDP or approximately US$60 million using 2006 GDP figures. Mongolian Civil Society organizations have calculated that indirect costs related to the loss of labor productivity caused by AIDS illness or on care of AIDS-affected persons, including child care expenses for children whose parents die of HIV/AIDS, is expected to reach US$25,000 to US$28,000. COMMENT -------------- ¶16. (SBU) COMMENT: To avert the catastrophe of an HIV/AIDS epidemic sweeping through Mongolia in the coming years, the GOM will need to renew its political and financial commitment to fight the spread of HIV/AIDS, increase awareness programs, strengthen human resource capacities in the health sector, and develop closer ties with NGOs. A recent study by the NGO Pact Mongolia indicated that knowledge of HIV is relatively high across the Mongolian population. However, there has been limited awareness raising activities reaching a mass audience, including direct action messaging, and without further reinforcement it is unlikely that this knowledge will lead to changes in attitudes and behavior. More commitment will also be required from the international community on the prevention of HIV/AIDS in low-prevalence countries, such as Mongolia. ¶17. (SBU) In Mongolia's case, effective and well-funded prevention efforts now would yield continued low prevalence and save funds that would otherwise be spent on treatment, care, support and mitigation of other destructive effects of the rapidly approaching full scale epidemics of HIV/AIDS. If the current situation continues on its current trajectory, Mongolia is very likely to repeat the mistakes of countries that have widespread HIV/AIDS epidemics. END COMMENT. Minton