CROI 2017: With free treatment for citizens, but not for immigrants, Botswana sees progress, and evidence of why that progress has stalled

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Science Speaks is covering the 2017 Conference on Retroviruses and Opportunistic Infections in Seattle Washington live this week, from February 13-16, with breaking news on HIV research findings and implications.

SEATTLE – On one hand, Botswana stands before the world, and certainly before its nearest neighbors as a model of determined and successful policies that confront one of the largest HIV burdens in the world. With possibly 22 percent of people there living with the virus, the country still is considered close to achieving the UNAIDS 90-90-90 goals for diagnosis, treatment, and successful HIV viral suppression, that if reached by 2020 could lead to lasting control of the epidemic. On the other hand, the country exemplifies a frustrating plateau — with more than 1 percent of people there acquiring the virus yearly.

A gap in the Botswana’s AIDS policy gives one clue to what might be stalling advances against the epidemic there. While offering free antiretroviral treatment to all of its citizens who live with the virus — preventing transmission as well as illness  — that policy doesn’t extend to non-citizens, or as they are also called, immigrants. Seeking to assess the impact of that policy, researchers led by Tafireyi Marukutira, working with the U.S. Centers for Disease Control and Prevention looked at results of an HIV testing campaign and assessments in communities participating in the the Botswana Combination Prevention Project. Of 36,608 people either tested, or with documentation of test results, three percent were non-citizens. Of them 18 percent were living with HIV. And in contrast to citizens, the vast majority of non-citizens did not know their HIV status, or were newly diagnosed, and were not receiving treatment, Marukutira said. For example, while 71 percent of citizens in the study with HIV were accessing antiretroviral treatment, only 29 percent of the non citizens — or just 61 out of 222 of the immigrants living with HIV — were on treatment. The obstacles to treatment that they face are significant, according to Marukutira, and include the cost and inconveniences of seeking the medicine, through private practitioners, and by traveling to neighboring Zimbabwe.

Given the progess that Botswana has made, the lack of free antiretroviral treatment for migrants “might be” hindering progress, Marukutira said. His presentation came during a session documenting the multiple risks of HIV infection, illness, and transmission facing immigrants, including exposures in their countries of origin, challenges in transit that can lead to transactional sex, unprotected sex, and sexual violence, and problems in destination countries that can include isolation, exploitation, lack of resources, language barriers and fears of deportation or arrest. To address the needs those conditions raise, Marukutira said, “All Southern African countries need to have a plan,”

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