Botswana: Following free ARV programme for non-citizens, adverse birth outcomes improve

Free antiretroviral therapy for non-citizens in Botswana: a further step towards the elimination of HIV

Following the expansion of antiretroviral therapy to migrants and non-citizens in Botswana, gaps have narrowed in the uptake of antenatal care and antiretroviral therapy during pregnancy between citizens and non-citizens living with HIV. Disparities in adverse birth outcomes were no longer observed after the change in policy, according to a report in the Journal of the International AIDS Society.

In Botswana, approximately 25% of female citizens aged 15 to 49 are living with HIV. Back in 2002, the government of Botswana launched a free universal antiretroviral therapy programme, which has proven to be very successful, including by improving birth outcomes of infants born to women with HIV. However, access to this programme was restricted to citizens of Botswana only, although non-Botswanan citizens represent as high as 7% of the country’s total population. Many are migrants from neighbouring countries with large HIV epidemics, such as Zimbabwe, Zambia and South Africa, with 13%, 11% and 19% HIV prevalence, respectively.

Only 29% of migrants in Botswana had personal health insurance or could afford to pay for HIV care, and research has shown that migrants had worse health outcomes than citizens of Botswana. Evidence has also shown that stigmatisation by healthcare and security staff in medical facilities were barriers to receiving care. Furthermore, pregnant non-citizens were less likely to receive antenatal care and more likely to receive care later in pregnancy, deliver at home and experience adverse birth outcomes than pregnant citizens of Botswana.

At the end of 2019, the government of Botswana drastically shifted its policy by authorising the free distribution of antiretroviral therapy to non-citizens living with HIV.

Dr Christina Fennel from Harvard University, with colleagues in Botswana and the US, evaluated the impact of this major policy change on antenatal care, antiretroviral therapy use and adverse birth outcomes among infants. For this, they compared outcomes in infants born to citizens and non-citizens living with HV, before (2014-2019) and after (2019-2021) the policy change. They used data from the Tsepamo Surveillance Study, a large birth outcomes surveillance programme that collects data from maternity sites in Botswana, including about 72% of all births in the country.

More specifically, the impact analysis was based on data from maternal records. Adverse birth outcomes analysed were preterm delivery, very preterm delivery, stillbirth, neonatal death, small for gestational age (babies smaller than usual for the number of weeks of pregnancy) and very small for gestational age. Because multiple births may be associated with adverse birth outcomes, only singleton births were included in the analyses of adverse birth outcomes.

Results

During the entire analysis period – 2014 to 2021 – there were 47,576 live deliveries and stillbirths among pregnant women with HIV recorded in the Tsepamo study, including 47,443 with known citizenship status – 45,917 (97%) Botswanan citizens and 1,516 (3%) non-citizens.

The proportion of non-citizens with unknown HIV status decreased significantly in the post-expansion period, from 6% to 1% (p < 0.001), whereas it remained the same (0.5% vs 0.4%; p = 0.02) for citizens.

The proportion of non-citizens with HIV attending antenatal care increased from 79% in the pre-expansion period to 87% following expansion, whereas attendance among citizens with HIV remained constant through both periods at approximately 96%. (Non-citizens can attend antenatal care by paying a modest fee, which did not change through the study period).

In the pre-expansion period, 65% of non-citizens received antiretroviral therapy, of whom only 7% had a dolutegravir-based regimen. After 2019, the proportion on antiretroviral therapy increased significantly to 90%, narrowing the gap with citizens (97%). Also, the proportion of non-citizens and citizens receiving dolutegravir almost equalised (42% vs 44%), showing a decrease in the use of old antiretrovirals such as nevirapine, which have a higher risk of adverse birth outcomes.

Regarding adverse birth outcomes, in the pre-expansion period infants born to non-citizens with HIV had significantly greater risks of preterm delivery (aRR = 1.28; 95% CI: 1.11, 1.46), very preterm delivery (aRR = 1.89; 95% CI: 1.43, 2.44) and neonatal death (aRR = 1.69; 95% CI: 1.03, 2.60) when compared with infants born to citizens with HIV. For reasons that are not clear, non-citizens had a reduced risk of having an infant who was small for gestational age (aRR = 0.75; 95% CI: 0.62, 0.89).

After the expansion of antiretroviral therapy, none of the adverse birth outcomes were significantly higher among infants born to non-citizens with HIV than infants born to citizens with HIV. Also, there were declines in adverse birth outcomes among infants born to non-citizens, including preterm delivery (23% in 2014-2019 vs 14% in 2019-2021) and stillbirth (4% vs 3%). At the same time, no changes in birth outcomes for HIV-negative non-citizens were observed.

According to Fennel and colleagues, their findings suggest that greater access to antiretroviral therapy – including modern regimens – may have reduced adverse birth outcomes. They also underscore the substantial decrease of the proportion of pregnant non-citizens with unknown HIV status, as well as increased linkage to HIV therapy and antenatal care after the policy change.

In 2022, Botswana was praised for reaching, ahead of the 2025 target, the UNAIDS goals of 95% of all people living with HIV to be aware of their status, 95% of those aware of their status to receive sustained antiretroviral therapy, and 95% of people receiving this therapy to achieve viral load suppression. The results of this study further confirm that Botswana has become a model for other countries that may still hesitate to scale-up access to antiretroviral therapy and HIV care for all minorities, including migrants, not to mention those countries that might be tempted to introduce new restrictions.

References

Fennell C et al. The impact of free antiretroviral therapy for pregnant non-citizens and their infants in Botswana.Journal of the International AIDS Society 2023, 26:e26161 (open access).

https://doi.org/10.1002/jia2.26161

Cyprus: Decision to deport HIV positive student on the grounds of “carrying an infectious disease” is reversed

Deportation of HIV student halted after uproar

The civil registry and migration department on Saturday responded to being lambasted for ordering the deportation of a third-country student because he was HIV positive, saying they would be issuing him a residence permit under certain health conditions.

The Aids Solidarity Movement earlier in the day condemned the deportation order, labelling it an act of “severe discrimination” and calling for the reversal of the decision.

According to the statement, the student was informed by the civil registry and migration department on March 16 by letter that he would be deported on March 21 on the grounds of “carrying an infectious disease”.

The movement said that this decision completely ignored letters of support from both the Gregorios treatment centre and the Solidarity Movement itself, as well as the guidelines of the World Health Organisation, which state “that when a person living with HIV has an undetectable viral load, due to the effective medication they receive, they cannot transmit the virus, even through unprotected sex”.

“The student has access to medication from his country, does not burden the state in any way in relation to his antiretroviral treatment or medical supervision, and does not pose a risk to public health,” the statement added.

Moreover, with the student’s written consent, the movement sent his medical results, along with a note from Doctor Ioannis Demetriades, the head of the Gregorios Clinic and the head of the ministry of health’s HIV and Aids programme, to the migration department’s acting director, asking that the student be allowed to complete his studies.

“We denounce this serious discrimination based on the HIV status of an individual and demand the immediate change of the decision from all the competent bodies of the state that support human rights,” the statement concluded.

Later on Saturday a statement from the migration department said it would in the end be issuing the residence permit after receiving a confirmation from the competent medical services of the state that the student was not contagious.

The condition of the permit is that the student receive regular health checks at the Gregorios Clinic.

It added that it had only been following the law, which “prohibit entry into the country, or carry out deportations for those persons who are carriers or suffer from communicable or infectious diseases and which are a danger to public health”.

Cyprus: Migration Department cancels deportation of undetectable HIV-Positive student after backlash

Deportation of HIV student halted after uproar (Updated)

The Aids Solidarity Movement earlier in the day condemned the deportation order, labelling it an act of “severe discrimination” and calling for the reversal of the decision.

The condition of the permit is that the student receive regular health checks at the Gregorios Clinic.

New Zealand: HIV no longer blocks residency in New Zealand, but mandatory testing stays

Immigration removes HIV from list of high cost conditions

HIV is no longer considered a high cost condition following a policy review by the Immigration Minister. However, NZ is still among just 18 countries that will require migrants to get an HIV test for a visa or residence.

HIV infection has been removed from Immigration New Zealand’s list of medical conditions deemed likely to impose significant costs or demands on New Zealand’s health services after a review.

Immigration NZ has a list of more than 40 medical conditions, including HIV, deemed to impose “significant costs” on the public health system and/or education services.

Migrants seeking to apply for a work to residence visa have to complete a character test, which includes a police check, as well as a medical check known as the Acceptable Standard of Health (Ash) test.

New Zealand’s publicly-funded health services are tax-funded and provide universal coverage for citizens, residents, and people on work visas staying for more than two years.

An Immigration NZ medical assessor determines whether the applicant is unlikely to impose significant costs on health services to pass the medical test. If applicants don’t meet the Ash requirements then they can seek a medical waiver.

For more than a decade, Immigration NZ has kept the threshold of “significant costs” at $41,000 per year within a period of five years from the date the assessment against health requirements is made or a lifetime if it is a chronic condition.

After years of advocacy, Immigration NZ has decided to remove HIV infection from the list.

However, New Zealand will continue to require HIV testing as a requirement for visa applicants intending to stay for more than 12 months, along with all other existing examination and test requirements.

INZ policy integration director Nick Aldous says the decision to remove HIV infection from Immigration NZ’s list of high-cost health conditions is because it is now considered to be a manageable chronic illness, and treatment costs are no longer considered significant.

However, Aldous says the continued testing requirement for visa applicants intending to stay in the country for more than a year is because HIV is still considered a serious chronic illness and can present a risk to public health given it’s easily spread through unprotected sexual contact and sharing contaminated needles.

The change came into effect on October 15.

According to the United Nations AIDS Still Not Welcome report published in 2019, 203 countries, territories and areas did not have any HIV-related restrictions on entry, stay and residence.

“We are so glad that the tireless mahi over many years has resulted in this step towards dismantling HIV stigma at an immigration level and has brought our country’s policies closer in line with the latest scientific and public health recommendations. It’s a proud moment.”
– Jason Myers, New Zealand AIDS Foundation

New Zealand is among 18 countries that still did, including Australia and Israel.

In a letter to the New Zealand AIDS Foundation, Immigration NZ chief medical officer Rob Kofoed said the removal of HIV infection from the list meant the individual health circumstances of each visa applicant with the condition could be assessed on a case by case basis.

INZ was previously obliged to determine that a resident visa applicant with HIV did not have an acceptable standard of health.

New Zealand AIDS Foundation chief executive Jason Myers said the decision came as a relief.

With appropriate treatment, he said, people living with HIV who maintained undetectable viral load do not transmit the virus through sexual contact, and treating HIV here no longer poses significant costs on the public health budget.

“We are so glad that the tireless mahi over many years has resulted in this step towards dismantling HIV stigma at an immigration level and has brought our country’s policies closer in line with the latest scientific and public health recommendations. It’s a proud moment.”

Myers did not comment on the requirement for testing still being part of the visa and residence process.

An Indian migrant, who did not want to be named, told Newsroom he is relieved by the news.

The man who was tested positive for HIV last year says INZ’s policy added to the anxiety and uncertainty he felt when he first learnt of his diagnosis.

“There is still a lot of stigma attached to it back home. I had many sleepless nights. I didn’t know how to tell my family back home, or work,” he says.

“I contacted lawyers last year who told me it is going to be really hard to apply for residency because it’s not up to acceptable health standards.”

But the man says removing the condition from the high cost list was “life changing” for him.

“I feel like the battle is finally over. No more having to convince immigration and the Ministry of Health. I think it’s a celebration for migrants.”

But he says INZ should do away with the ongoing requirement of testing for HIV, as it has removed it from the list of medical conditions.

“It’s irrelevant. If they’re removing it from the list, then why would you want to do the test? That’s not clear to me.”

Green Party MP Ricardo Menéndez March is seeking a full review of the “ableist” medical requirements from Immigration Minister Kris Faafoi.

Menéndez March said ideally the list should be removed from the health criteria qualifying residency, saying he was disappointed that migrants would still be required to undertake HIV tests for visas.

“For too long the Government has stigmatised migrants living with HIV and prevented them from being able to obtain visas on the basis of their diagnosis.

“Mandatory HIV testing for migrants only compounds to the existing stigma and the Ministry of Health released a report making it clear HIV testing should remain voluntary and only undertaken with the patient’s knowledge, consent and understanding that an HIV test is recommended.”

Disability advocates have also been calling on INZ to remove these medical requirements.

Faafoi told Newsroom last week he planned to review the Ash threshold.

“The details of the health requirements are still being worked through and will be made publicly available once immigration instructions have been signed.”

The Ash requirements for the newly announced one-off 2021 Resident Visa would not be reviewed, he said.

“The health requirements will be limited and will only screen for the most serious health conditions.”

Nepal: How critical HIV medicine reached a traveler stranded in Nepal during the pandemic

Stranded in Nepal without HIV medicine

Wang Tang (not his real name) had never been to Nepal before, but at the end of March 2020 it was one of the few countries that had not closed its borders with China. Since he was desperate to get away from Beijing after having had to stay at home for months after the coronavirus outbreak spread throughout China, he bought a ticket.

But days after he arrived, while he was staying in Pokhara, the fourth stop on his trip, the local government announced that the city would be shut down. He heard that the lockdown would not last longer than a month.

As someone who is living with HIV, he had brought along enough HIV treatment to last for a month. However, he soon learned that the re-opening of the city was to be postponed, which meant that he was at risk of running out of the medicine he needed to take regularly in order to suppress his HIV viral load and stay healthy.

Mr Wang swallowed hard while counting the remaining tablets. He had no idea how to get more.

As the lockdown dragged on, it seemed that no end was in sight. Mr Wang started to take his medicine every other day so that his supply would last a little bit longer.

He contacted his friends back at home, hoping that they could send medicine to Nepal, but they couldn’t. The country was under lockdown—nothing could be imported.

Then, Mr Wang contacted his friend Mu-Mu, the head of Beijing Red Pomegranate, a nongovernmental organization providing volunteer services for people living with HIV. It was with Mu-Mu’s help that Mr Wang learned how to obtain HIV treatment after he was diagnosed as living with HIV. Having known each other for many years, Mu-Mu had the trust of his friend. Mu-Mu contacted the UNAIDS Country Office for China to see if it was possible to deliver medicines to Mr Wang. A UNAIDS staff member quickly got in touch with the UNAIDS Country Office for Nepal.

Everything happened so quickly that Mr Wang was shocked when he received a message from Priti Acharya, who works for AHF Nepal and had been contacted by the UNAIDS Nepal office, saying that she would bring the medicine to him.

The next day, Ms Acharya rode her motorbike for 15 km on a dusty road before reaching the place where she would meet Mr Wang. When he came down from the mountains to meet her, Ms Acharya, drenched in sweat, was waiting under the midday sun.

“I was so happy and thankful for her hard work. She gave me a sunny Nepalese smile in return, as well as detailed instructions on the medicine’s dosage,” said Mr Wang.

They took a photograph together, then Mr Wang watched Ms Acharya as she left on her motorbike. Her image, disappearing in the distance, is carved into his memory. To attend the five-minute meeting, Ms Acharya had to ride a round trip of more than 30 km.

“For half a month or so, I had been suffering from pain and anxiety almost every day due to the lack of medication and the loneliness of being in a foreign country on my own. I could not believe that I got the HIV medicine in such a short time,” said Mr Wang. After the trip, he wrote to thank Ms Acharya, explaining how important the medicine he now had in his hand was: “it’s life-saving.”

At the end of his stay in Nepal, Mr Wang wanted to do something for UNAIDS. As he is an experienced photographer, he volunteered to carry out a photo shoot for UNAIDS’ Nepal office.

The subject he chose was former soccer player Gopal Shrestha, the face of an HIV charity in Nepal and the first person living with HIV to reach the summit of Mount Everest. After his HIV diagnosis in 1994, Mr Shrestha launched the Step-Up Campaign and spent many years climbing mountains worldwide, hoping to give strength and hope to people living with HIV.

In 2019, Mr Shrestha reached the peak of the world’s highest mountain, Mount Everest, recording a historic breakthrough for people living with HIV. “If 28 000 people have already climbed Mount Everest, why can’t I?” he said. “By climbing the highest mountain in the world, I want to prove that we are no different from anyone else and that we can all make a difference.”

“The moment I saw him, I could tell he was a sophisticated man,” said Mr Wang. Without instructions, Mr Shrestha posed naturally in front of the camera. He displayed confidence and charm. His eyes, content and clear, reflected nature’s beauty. “The eyes surely are the window to the soul,” Mr Wang said.

Mr Wang is looking forward to his next trip to Nepal. After the pandemic, Pokhara’s lakeside will be flooded with tourists, and he looks forward to seeing the mountain town bustling with people like it used to.