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

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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
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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
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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
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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

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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
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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
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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
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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
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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

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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
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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

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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
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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
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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