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Cablegate: Gob Still Not Ready to Treat Hiv Positive Refugees

VZCZCXRO6570
PP RUEHBZ RUEHDU RUEHJO RUEHMR RUEHRN
DE RUEHOR #1140/01 3650702
ZNR UUUUU ZZH
P 300702Z DEC 08
FM AMEMBASSY GABORONE
TO RUEHC/SECSTATE WASHDC PRIORITY 5465
INFO RUCNSAD/SOUTHERN AF DEVELOPMENT COMMUNITY COLLECTIVE
RUEAUSA/DEPT OF HHS WASHINGTON DC
RUEAIIA/CIA WASHDC
RUCNDT/USMISSION USUN NEW YORK 0392
RHEFDIA/DIA WASHDC
RUEHGV/USMISSION GENEVA 0332
RHMFISS/HQ USAFRICOM STUTTGART GE

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

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