GOB STILL NOT READY TO TREAT HIV POSITIVE REFUGEES

UNCLAS SECTION 01 OF 03 GABORONE 001140 SENSITIVE SIPDIS STATE FOR AF/S, PRM, OGAC E.O. 12958: N/A TAGS: PREF PREL KHIV PHUM TBIO BC ZI SUBJECT: GOB STILL NOT READY TO TREAT HIV POSITIVE REFUGEES REF: A. STATE 102155 ¶B. GABORONE 723 ¶1. (SBU) SUMMARY: Botswana provides free antiretroviral therapy (ART) to over 90% of its citizens who need it, but the GOB does not include non-citizens resident in Botswana, including registered refugees, in its national ART program. Botswana's cabinet agreed to extend the ART program to registered refugees on condition that the USG will cover the associated costs. The USG has agreed to cover the cost of the ART for refugees under the Botswana PEPFAR program and the USG and GOB have exchanged a series of letters and diplomatic notes on this issue. Unfortunately, the Ministry of Health sent the Embassy a letter on November 26 indicating that the GOB is still not ready to proceed, because the government is "concerned about the sustainability of the program post-PEPFAR." Gaborone's UNHCR Representative met with Embassy officials December 4 to discuss a possible way forward on this issue. We agreed that Ambassador Nolan should raise the refugee/ART issue with President Khama to try to make him understand that though the USG will not be able to provide any additional written guarantees on this matter, our offer to fund the provision of ART to refugees is a sincere commitment. If a political approach to President Khama fails to break the impasse, the UNHCR has asked whether we would consider creating some type of "trust fund" through which this program could be funded in future. Post asks Washington (especially OGAC and PRM) for suggestions on possible funding mechanisms that would allow this program to move forward. We note that this discussion takes place in the climate of the global economic downturn, and Botswana, like the USG, is concerned about its ability to fund social programs (especially HIV/AIDS treatment) in the face of declining demand for its diamonds which is dampening government revenues. END SUMMARY. ¶2. (SBU) Although Botswana is widely and deservedly praised for providing antiretroviral therapy (ART) to over 90% of its citizens who require it, the government excludes non-citizens from its HIV/AIDS treatment program. The UNHCR approached post in 2007 seeking U.S. support for provision of HIV/AIDS treatment to registered refugees in Botswana, most of whom are resident at the Dukwe refugee camp north of Francistown. This prompted a months-long dialogue and negotiation among the U.S. Mission, GOB MOH, and UNHCR officials to find a workable solution to this issue, and one in which the GOB respects its treaty obligations under UN and international agreements vis-a-vis refugees. The USG agreed to cover the cost of treating infected refugees under the Botswana PEPFAR program, and in September 2008 the Embassy sent the Government of Botswana a carefully-worded and Department-cleared diplomatic note (reftels) explaining that though we anticipate PEPFAR funds will be available for the ARV program for the foreseeable future, all government programs are subject to Congressional appropriation. ¶3. (U) On November 26 the Embassy received a response from the Ministry of Health to our diplomatic note of September ¶26. Full text of the letter follows: Ministry of Health Private Bag 38 Gaborone Embassy of the United States of America PO Box 90 Gaborone 24 November 2008 REF:CMED:21/14/1 I 2008 Attention: Philip R Drouin RE: THE PROVISION OF FREE ANTIRETROVIRAL THERAPY TO REGISTERED REFUGEES RESIDING IN DESIGNATED REFUGEE CAMPS Your letter dated October 3rd concerning the above subject matter refers. As you are aware, Government of Botswana acceded to your request "on condition that the United States Government guarantees to meet all costs associated with the roll-out to registered refugees now and in the future." GABORONE 00001140 002 OF 003 I therefore write to seek clarity on the matter. As per your letter, PEPFAR funding will be available "for the foreseeable future" and that "ongoing support for this project is subject to the availability of appropriated funds." These qualifications fall short of our request. Could you please provide clarity on these, as our concern is sustainability of this project post PEPFAR. Thank You. Yours faithfully Dr. K.C.S. Malefho Acting Permanent Secretary cc: Coordinator of NACA Mr. Chris Molomo Ambassador Sasara George Ministry of Foreign Affairs and International Cooperation ¶4. (SBU) The UNHCR Representative in Botswana, Roy Hermann, met with DCM and Pol/Econoffs December 4 to discuss the ART impasse and brainstorm possible ways forward. Hermann noted that there are approximately 3000 registered refugees in Botswana, and the HIV prevalence rate amongst the community is not known, as they are reluctant to get tested since they are not guaranteed access to treatment. However, UNHCR estimates (based on prevalence rates from the countries of origin of the refugees) that there may be 350-400 HIV positive refugees in Botswana, of whom perhaps 150 would require antiretroviral treatment. He said that Botswana now has over 100,000 citizens on ART, so the financial impact of extending ART to registered refugees would be very small. Mr. Hermann reviewed the cooperation between UNHCR and the USG over the past few years to encourage Botswana to provide AIDS treatment to registered refugees. He explained that in 2008, Botswana's cabinet approved the inclusion of refugees in the national treatment program, so long as the USG would agree to cover the additional associated costs. Though the USG has agreed to fund this activity through the PEPFAR program and has communicated this commitment to the GOB (reftels),it is clear that the government is not confident that USG financial support will continue in the long term. ¶5. (SBU) As a way of easing this impasse, Mr. Hermann requested that Ambassador Nolan raise the issue of AIDS treatment for registered refugees with a senior Government of Botswana official, preferably President Khama, at the earliest possible opportunity in the new year, and Embassy officers concurred with this suggestion. Given our lengthy exchange of letters and diplomatic notes, we believe that there is no additional written guarantee that the USG could provide which will satisfy the GOB. The only hope to move forward is to convince President Khama that the USG is sincere in its commitment to fund ART for registered refugees. Furthermore, it is something that Botswana, as a sovereign state that has achieved middle-income status, needs to step up and do, irrespective of whether or not a donor like the USG funds it. If President Khama is unmoved, Mr. Hermann proposes that the USG instead provide funds to treat refugees outside of Botswana's National ART Programme. He suggests that the USG could establish some type of local trust fund that would allow the Office of the Catholic Bishop in Francistown to undertake this activity. (Note: the Francistown Catholic Bishop's office is already involved with some HIV care programs for a limited number of refugees at Dukwe camp. End note.) ¶6. (SBU) COMMENT: It is disappointing that after many months of effort, we have been unable to make any progress in convincing the Government of Botswana to allow legally registered refugees to receive antiretroviral therapy under its National ARV Programme. The Embassy and UNHCR previously agreed that we should push for inclusion of refugees in the government's own program, however, that strategy appears to have failed, given cautious GOB resistance. We agree with Mr. Hermann that one last diplomatic effort to convince President Khama to move forward with ARVs for refugees is worthwhile, but post is not yet convinced that Khama will respond favorably. During President Khama's speech on World AIDS Day December 1, he warned Botswana citizens that we must GABORONE 00001140 003 OF 003 all work harder to prevent new AIDS infections and he noted that the GOB has serious fears about its financial ability to continue to provide ARV treatment indefinitely to an ever-growing population in need of drugs. ¶7. (SBU) Post asks Washington (especially OGAC and PRM) for suggestions on possible mechanisms that would allow us to fund the provision of ARV treatment to registered refugees resident in Botswana, most likely through the PEPFAR program. We note that this discussion takes place in the climate of the global economic downturn, and Botswana, like the USG, is concerned about its ability to fund social programs (especially HIV/AIDS treatment) in the face of declining government revenues. However, there is little motivation for refugees to know their HIV status and behave responsibly when treatment is not available to them, and we fear that ignoring this vulnerable population will only encourage the spread of HIV not only amongst refugees but also to their Batswana friends and neighbors. Providing ART to refugees is not only humane, but prudent public health policy, so it is in our interest, and ultimately Botswana's, to find a way to break this impasse soon. END COMMENT. NOLAN