VZCZCXRO0431
RR RUEHCN RUEHGH RUEHVC
DE RUEHUM #0670/01 3340905
ZNR UUUUU ZZH
R 300905Z NOV 07
FM AMEMBASSY ULAANBAATAR
TO RUEHC/SECSTATE WASHDC 1688
INFO RUEHOO/CHINA POSTS COLLECTIVE
RUEHBJ/AMEMBASSY BEIJING 5870
RUEHTA/AMEMBASSY ASTANA
RUEHVK/AMCONSUL VLADIVOSTOK 0183
RUEHYC/AMEMBASSY YAOUNDE 0006
RUEAUSA/DEPT OF HHS WASHDC
RUEHPH/CDC ATLANTA GA
RUEHC/DEPT OF LABOR WASHDC
RUCPDOC/DEPT OF COMMERCE WASHDC
RUEHRC/USDA FAS WASHDC
RUEKJCS/SECDEF WASHINGTON DC
RHHMUNA/CDR USPACOM HONOLULU HI
RUEHLMC/MILLENNIUM CHALLENGE CORP WASHINGTON DC

UNCLAS SECTION 01 OF 04 ULAANBAATAR 000670 
 
SIPDIS 
 
SENSITIVE 
SIPDIS 
 
DEPT FOR S/GAC, EAP/CM, OES, AND DRL 
 
E.O. 12958: N/A 
TAGS: PHUM EAID SOCI PGOV PINR PREL MG KHIV
SUBJECT:  HIV/AIDS in Mongolia: Crisis in the Making? 
 
REF: 06 ULAANBAATAR 0392 
 
ULAANBAATA 00000670  001.2 OF 004 
 
 
SENSITIVE BUT UNCLASSIFIED - NOT FOR INTERNET DISTRIBUTION. 
 
¶1. (SBU) SUMMARY: Mongolia retains its reputation as a country with 
a low rate of HIV infection, but testing among at-risk populations 
remains at a low level, and experts fear that official figures do 
not tell the whole story. To date 41 HIV/AIDS cases have been 
officially recorded (involving 35 Mongolian nationals and six 
foreigners).  Of these 35, four have died and 25 are HIV-infected 
but have not yet converted to full-blown AIDS.  Experts believe the 
real number of HIV/AIDs cases in Mongolia could be 10 to 15 times 
the official figure.  Local analysts say the growing sex trade, high 
STD rates, low levels of condom use and increased mobility to 
neighboring countries with high HIV rates make Mongolia vulnerable 
to rapid growth in HIV/AIDS cases in the next few years.  Citing low 
official figures, the Mongolian Government's response to the 
pandemic has been lackluster.  With a few notable exceptions, the 
international community's response has also been underwhelming. 
Limited access to proper testing and strong social disincentives 
have kept many individuals from having themselves tested, thereby 
enabling further spread of the infection.  To avert a catastrophe, 
the GOM will have to renew its political and financial commitment to 
fight the spread of HIV/AIDS.  END SUMMARY. 
 
OFFICIAL INFECTION RATE LOW BUT MISLEADING 
------------------------------------------ 
 
¶2. (U) Mongolia's first official case of HIV surfaced in August 1992 
when a Mongolian MSM (men who have sex with men) became infected 
while living abroad.  He died of pneumocystis pneumonia in 1999. 
Astonishingly, between 1992 and 1997, no new cases came to light 
despite extensive HIV testing among a large proportion of most at 
risk populations (MSM, mobile populations and female sex workers, or 
FSWs). The country's second case was not discovered until 1997, and 
involved a FSW who had had sexual contact with an HIV-positive 
Cameroon national. Out of the officially reported total of 35 
HIV-positive cases to date, 26, or 74%, have emerged in the past two 
years.  All cases are the result of sexual transmission, and 52% of 
all reported cases involve MSM. 
 
HEALTH GROUPS: TRUE INFECTION RATE MUCH HIGHER 
--------------------------------------------- - 
 
¶3. (U) Health organizations fear that Mongolia's infection rate is 
grossly underestimated, due to limited access to testing and 
disincentives for at-risk people to take the test.  A recent labor 
fare in Ulaanbaatar for Mongolians aged 18 and 35 who wished to work 
in South Korea revealed that of the 10,000 who registered and 
underwent required medical testing, three were diagnosed as being 
HIV-positive.  18- to 35-year-olds make up approximately 33% of 
Mongolia's population, or 850,000 people.  By extrapolating the 
ratio of three cases per 10,000 individuals to the larger population 
subset, experts believe that there could be 256 cases of HIV 
infection within this age group alone -- nearly eight times higher 
than the number of current registered cases.  UN estimates go 
further, suggesting the total number of cases in the population is 
closer to 950 (or .03%).  Whatever the figure, there is legitimate 
concern that there is a sufficient pool of potential unidentified 
cases for a near-term exponential increase in infection rates. 
 
SOCIAL DISINCENTIVES DETER TESTING 
---------------------------------- 
 
¶4. (U) Exacerbating the underreporting is that many Mongolians 
hesitate to take an HIV test, fearing a lack of confidentiality of 
test results and the social and legal consequences of being 
HIV-positive.  The case of the African male and the Mongolian FSW 
raised concerns among international agencies regarding Mongolia's 
testing regimes.  The FSW was identified as HIV-positive within a 
couple weeks after contact with the African male. However, 
international experts noted that current testing methods could not 
have detected HIV so soon in the FSW, suggesting transmission from 
another source.  The GOM responded to this event by expelling the 
Cameroonian national and ordering HIV testing for all Africans 
resident in Mongolia, as well as for all women between 16 and 45. 
When it became clear that the capacity and justification for testing 
such numbers of women did not exist, the GOM dropped that 
 
ULAANBAATA 00000670  002.2 OF 004 
 
 
requirement, but not before engendering a great deal of fear. (Note: 
Although the GOM now maintains that it works in accordance with the 
WHO's advisory against coercing any group to get tested, it has 
admitted to covert screening of hospital patients, prisoners, sex 
workers, traders and homeless people since 2002. End Note.) 
 
WIDESPREAD MISCONCEPTIONS 
------------------------- 
 
¶5. (U) Major misconceptions about HIV transmission persist, 
especially among those aged 14-24, and this has contributed to 
prejudice against those who are HIV-positive.  A recent WHO survey 
found that many young people believe that infection is possible 
through mosquitoes or other insects; sharing toothbrushes; using 
public toilets or public swimming pools; breathing air in close 
proximity to an HIV-positive person; sharing food preparation 
facilities; or  sharing a bed (a common and accepted practice in 
Mongolia). 
 
STRONG SUPPORT SEEN FOR FORCED HIV TESTING 
------------------------------------------ 
 
¶6. (U) Survey results have also raised a number of human 
rights-related questions.  Recent surveys found that 78 percent of 
respondents agreed that "the government should force those that are 
suspected of being HIV-positive to be tested," with nearly one third 
asserting that "the details of those that are HIV-positive should be 
published so that these people can be avoided."  Over half of the 
respondents agreed with the statement: "Those who are HIV-positive 
should not be allowed to have children," and that "If an 
HIV-positive woman becomes pregnant, she should be forced to have an 
abortion." 
 
GAY AND BISEXUAL MEN REPORT PRESSURE TO GET TESTED 
--------------------------------------------- ----- 
 
¶7. (U) Post has received reports from Mongolian MSM that they are 
often harassed by health officials to take HIV tests, with threats 
of public exposure or arrest by police.  However, many fear taking 
the test, as the results seem to become public knowledge quite 
readily.  A well-founded belief exists that health officials will 
sell test results to journalists for cash.  HIV cases, still 
relatively rare, remain an attention-grabber for the yellow and even 
mainstream press.  Persons so identified can be fired from their 
jobs and evicted from apartments without recourse, not to mention 
being ostracized by friends and family.  In one notorious case, a 
woman was identified in the press as being HIV-positive and was 
subsequently murdered by her husband for this reason.  It later 
turned out she was not HIV positive. 
 
TREATMENT OPTIONS LACKING 
------------------------- 
 
¶8. (U) Nor does the treatment of HIV positive and AIDS sufferers 
inspire much confidence.  There are currently four people known to 
be living with AIDS in Mongolia.  According to the current head of 
Positive Life, a local NGO that works with the HIV-positive and 
their families, two of the four currently take anti-retroviral 
medication (ARVs).  Indications are there will be four by the end of 
the year, and 10 by 2008.  ARVs are only available through the 
National Center for Communicable Diseases (NCCD), funded by the UN 
Global Fund.  Those taking the ARVs report that their treatment is 
often interrupted for months at a time with no explanation, risking 
ARV-resistance, and that they do not receive adequate information 
regarding the medications and their side effects. Patients also say 
that doctors are unaware of how to manage dosages and changes in ARV 
treatment; that they are not given any choice in their treatment 
options; and that doctors often treat them with contempt.  Rural 
HIV-positive residents who attempt to obtain treatment at 
Ulaanbaatar's National Center for Communicable Diseases report that 
the doctors sometimes refuse to see them altogether, or shunt them 
from doctor to doctor, a process that often results in the worn-down 
patient returning to the countryside without having been seen or 
treated. 
 
POSSIBLE RAPID EXPANSION OF HIV/AIDS 
 
ULAANBAATA 00000670  003.2 OF 004 
 
 
-------------------------------------- 
 
¶9. (U) Despite the low prevalence of reported HIV/AIDS cases to 
date, Mongolia is considered highly vulnerable to the spread of HIV 
infection.  Fifty percent of the population is under 25; there is a 
high prevalence of STDs among in both the general population and 
among high-risk groups; sexual activity among those 19 to 24 is high 
(close to 50% have had sex or are sexually active) and the 
consistent use of condoms during sex outside monogamous 
relationships is low (20%, according to some surveys); contributing 
factors such as alcoholism, unemployment and poverty are widespread; 
access to proper testing facilities is limited, especially in the 
countryside; Mongolians are among the highest per capita users of 
injection needles (albeit for vitamins and other medicinal purposes 
rather than narcotics) and the country's neighbors include China, 
Russia and Kazakhstan, which register high growth rates for 
HIV/AIDS.  As infrastructure improves and mobility between the three 
countries increases, the likelihood of the HIV/AIDS pandemic 
sweeping through Mongolia rises dramatically. 
 
FALSE SENSE OF SECURITY 
------------------------ 
 
¶10. (U) Mongolia's deceptively low prevalence rates have led GOM 
health officials to place a lower priority for programs that would 
support greater awareness and precautionary behavior.  Limited 
external funding, coupled with the GOM's insufficient budget 
allocation, makes it unlikely that Mongolia will maintain its low 
prevalence status.  Compounding this is wishful thinking by 
Mongolian officials, some of whom have privately told Post that it 
is only the dregs of society, meaning MSM, FSW, and drug users, who 
are at risk, leaving most "good" Mongolians safe and sound.  Nor do 
officials know what an HIV or AIDS patient will cost Mongolia if the 
problem gets out of control.  Consequently, the total government 
budget allocation for HIV/AIDS for FY2007 was US$10,000. 
 
¶11. (U) Mongolia is not recognized by multilateral and bilateral 
funding agencies as a priority country because of its currently low 
HIV/AIDS rates, thus the country receives limited external funding 
and technical support. USAID has a pilot project implemented by PACT 
to increase public awareness about and help prevent the spread of 
HIV/AIDS.  The project created an innovative 26-part television 
series which aimed to educate the public and the most at risk 
populations about HIV/AIDS transmission and prevention. See reftel. 
 
 
 
HEALTH SYSTEM ILL-EQUIPPED 
-------------------------- 
 
¶12. (U) Without increased financial resources, Mongolia's health 
system will remain ill equipped to deal with the growing crisis. 
Health care professionals are undereducated on how to deal with 
HIV/AIDS (testing, counseling, etc.), underpaid and generally 
overburdened.  Turnover is high, especially at provincial hospitals. 
 STD drugs, condoms and test kits are frequently out of stock or 
expired.  Delayed supply and delivery to provinces and 
sub-provinces, exacerbates the problem.  Urban and provincial 
hospitals and laboratories suffer from limited funding, limited 
facilities, outdated equipment and lack of test kits. 
 
ECONOMIC TOLL 
------------- 
 
¶13. (U) The annual direct health expenditure for a Mongolian with 
AIDS is between two and six times higher than the annual income of 
an average Mongolian family, or US$5,000 to US$30,000. It is 
estimated that between 2004 and 2014, the direct expenses resulting 
from the spread of HIV/AIDS will reach between 1.3 - 3.6 billion 
MNT, with the direct expenses from AIDS mortality reaching between 
11.9-15.4 billion MNT. 
 
¶14. (U) Concerned Ministry of Health officials have acknowledged 
that failure to implement effective prevention measures may yield as 
many as 2,500 AIDS deaths by 2014.  Domestic and foreign health 
professionals worry about the ability of the Ministry of Health to 
 
ULAANBAATA 00000670  004 OF 004 
 
 
adequately manage either the current or an escalated infection rate. 
 The scenario outlined here suggests a potential convergence of 
factors that can only result in a significant increase in infection 
rates and economic burdens. 
 
GDP COULD BE NEGATIVELY IMPACTED 
-------------------------------- 
 
¶15. (U) Around 59% of Mongolia's citizens are aged between 15 and 
¶60. A decreased number of working-age people impact any country's 
economy at the macro level, decreasing economic capacity, 
productivity and gross domestic product (GDP). A decrease in 
Mongolia's already small population of 2.8 million people would be 
widely felt.  It is estimated that within 10 years HIV/AIDS cause at 
least a 2% drop in Mongolia's GDP or approximately US$60 million 
using 2006 GDP figures.  Mongolian Civil Society organizations have 
calculated that indirect costs related to the loss of labor 
productivity caused by AIDS illness or on care of AIDS-affected 
persons, including child care expenses for children whose parents 
die of HIV/AIDS, is expected to reach US$25,000 to US$28,000. 
 
COMMENT 
------- 
 
 
¶16. (SBU) COMMENT: To avert the catastrophe of an HIV/AIDS epidemic 
sweeping through Mongolia in the coming years, the GOM will need to 
renew its political and financial commitment to fight the spread of 
HIV/AIDS, increase awareness programs, strengthen human resource 
capacities in the health sector, and develop closer ties with NGOs. 
A recent study by the NGO Pact Mongolia indicated that knowledge of 
HIV is relatively high across the Mongolian population. However, 
there has been limited awareness raising activities reaching a mass 
audience, including direct action messaging, and without further 
reinforcement it is unlikely that this knowledge will lead to 
changes in attitudes and behavior.  More commitment will also be 
required from the international community on the prevention of 
HIV/AIDS in low-prevalence countries, such as Mongolia. 
 
¶17. (SBU) In Mongolia's case, effective and well-funded prevention 
efforts now would yield continued low prevalence and save funds that 
would otherwise be spent on treatment, care, support and mitigation 
of other destructive effects of the rapidly approaching full scale 
epidemics of HIV/AIDS.  If the current situation continues on its 
current trajectory, Mongolia is very likely to repeat the mistakes 
of countries that have widespread HIV/AIDS epidemics. END COMMENT. 
 
Minton