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