Credit: Siphiwe Sibeko/Reuters
In 2016, Botswana adopted a “treat all” strategy to provide anti-retroviral treatment (ART) to all HIV-positive citizens of the country. But not every resident of Botswana is a citizen, and the strategy left an estimated 23,000 HIV-positive residents without access to treatment – residents with just as much potential impact on the spread of new infections as their citizen counterparts.
A cost-benefit analysis was conducted by MEASURE Evaluation and an interagency team, which concluded that for every dollar invested in treatment for non-citizens, six dollars in savings would be achieved by 2030. What’s more, according to the analysis, providing ART to non-citizens could prevent more than 22,000 new infections and over 6,500 AIDS-related deaths, while helping Botswana achieve its goal of ending the epidemic.
The interagency team presented the analysis to the government of Botswana in early 2019, and effective 1st December 2019, Botswana now provides ART to non-citizens – making it the final country in the region to do so.
Research shows that 80% of non-citizens in Botswana are between 15 and 49 years of age and are less likely than citizens to know their HIV status. This makes treatment crucial for epidemic control. Left untreated, these individuals are more likely to pass the infection to others – citizens and non-citizens alike.
“Foreigners, non-citizens are sleeping with our daughters, our children,” says Manyana Village Chief Kgosi Kebinatshwene Mosiele. “We have daughters with foreigner boyfriends. As such we must treat foreigners for HIV---otherwise, we will move around in circles.“
While wealthier non-citizens may access private healthcare providers, many are low-wage workers who lack the means to travel frequently or pay out of pocket for treatment. In addition, unmarried sexual partners of citizens were not eligible for treatment to prevent transmission of HIV to their children.
While its treatment guidelines are aligned with other southern African countries, Botswana was the only country in the region that did not provide free ART to non-citizens. The analysis showed that excluding non-citizens would increase the risk of Botswana failing to reach its commitment to achieving 95% ART coverage for people living with HIV by 2030.
The analysis projects that in addition to the economic benefits of a healthier workforce, this change will save Botswana USD 112 million in HIV treatment costs, and another USD 4 million in tuberculosis treatment costs by 2030. To assist Botswana in realizing these benefits, PEPFAR has committed funding to assist with the first three years of implementation.
As a member of the MEASURE Evaluation team, Palladium conducted the cost-benefit analysis of providing ART to all HIV-positive residents of Botswana, working with the National AIDS Coordinating Agency, Ministry of Health and Wellness of Botswana, PEPFAR, UNAIDS, and others.