Botswana should consider expansion of free antiretroviral therapy to immigrants

Botswana has among the highest level of HIV viral suppression globally, yet HIV incidence remains > 1% per year in adults aged 15 to 49 [1,2]. Although causes of this continued elevated incidence have been postulated, a firm understanding remains elusive, especially in the presence of a highly successful HIV treatment programme in Botswana [1]. Although Botswana provides free antiretroviral therapy (ART) for all citizens living with HIV through its national HIV programme, the first free national ART programme in sub-Saharan Africa, non-citizen immigrants (documented/undocumented) are currently ineligible for treatment within the national programme. Documented refugees living with HIV in camps do have free access to ART as long as they remain within the confines of the camp. Private HIV treatment is available, but remains prohibitively expensive for many non-citizens. In addition to gaps in treatment coverage among men and young people [3], the lack of free treatment for non-citizens may contribute to elevated HIV incidence in Botswana, as suggested by research in other settings [4]. There is precedent for providing government-sponsored HIV treatment to non-citizens in Botswana. In 2014, a court ruling found that denying non-citizens in prison access to ART violated their right to receive basic health services, as guaranteed by the Botswana Constitution [5]. This ruling, however, has not affected the eligibility of non-citizens outside of prison. Despite generally accepted international obligations under human rights law to provide access to ART to non-citizens as a means to ensure health services without discrimination [6], Botswana has yet to expand eligibility for those who lack citizenship. Becoming a Botswana citizen is not easy for immigrants, it takes a waiting period of up to 10 years to naturalize, a process which has no guarantees. Only citizens are accounted for in national estimates of people living with HIV, HIV incidence and treatment outcomes, leaving the impact of the HIV epidemic among immigrants largely hidden. Understanding the HIV epidemic in the immigrant population may inform considerations in expanding treatment coverage, and may ultimately help Botswana achieve greater viral suppression, and reduce HIV incidence throughout the population. As Botswana considers joining regional neighbours such as South Africa and Lesotho in developing national HIV treatment policies that include non-citizens [7], it should consider the available empirical data regarding HIV care among noncitizens, and identify critical gaps in knowledge. Along with learning from recent policies in countries supporting HIV care to Venezuelan migrants (Brazil, Colombia) [8], we believe there are four essential questions that must be addressed to understand the impact an ART coverage expansion may have on a nation-wide scale: