Saving Lives, Transforming the Economy: Making “Treat All” Real and Saving 23,000 More Batswana from HIV by 2030

Author(s): MEASURE Evaluation

Year: 2018

Abstract:

Botswana has a considerable burden of HIV, with the third highest HIV prevalence globally. However, through bold leadership, the country is a global trailblazer in responding to the AIDS epidemic, and is on the cusp of realizing an AIDS-free generation.

In June 2016, informed by a rigorous investment analysis, a “Treat All” policy was launched to provide all people living with HIV (PLHIV) in Botswana–regardless of disease state—with free, publicly-financed lifesaving treatment. By “leaving no one behind”—a key principle of Botswana’s National Development Plan 2017–2023 (NDP 11)—this policy shift seeks to optimize investments in the national AIDS response and accelerate progress towards epidemic control, with a view to end AIDS as a public health threat by 2030.

To date, the implementation of the “Treat All” policy has focused on providing this free, publicly financed antiretroviral therapy (ART) only to citizens, leaving noncitizens behind. Botswana’s 170,000 noncitizens in residence constitute 7 percent of the country’s total population; of these, an estimated 30,000 are living with HIV. Most noncitizens originate from India, South Africa, Zambia, Zimbabwe, and the United Kingdom, and 80 percent of them are between the ages of 15 and 49: the age group that is most sexually active and economically productive. Only 29 percent of all noncitizens living with HIV are accessing HIV treatment.

Recognizing that multiple concurrent partnerships increase the spread of HIV through sexual networks, the government acknowledges that without fully implementing the Treat All strategy, by covering treatment both of citizens and noncitizens, there will be no epidemic control. Rather, the government would face more new HIV infections and a growing HIV expenditure.

To address the HIV treatment of noncitizens in Botswana, the government would need an additional total investment of US$18 million for the period 2018 through 2030—an average of US$1.4 million per year. This translates into an additional 1.2 percent of spending on the current ART program (estimated at US$103 million per year) and would help achieve 90-90-90 and 95-95-95 treatment targets by 2020 and 2030, respectively, among the noncitizen population.

Treating noncitizens is another way of protecting the citizen population. By treating noncitizens, Botswana can save 22,745 citizens from HIV infection and 1,373 citizens from tuberculosis (TB) infection. The country would also avert 6,741 deaths from AIDS. Compared with treating citizens only, this strategic investment yields 64 percent more new HIV infections averted, at a cost of only 1.2 percent more. Other benefits of enacting a policy change to provide access to HIV treatment for noncitizens are US$112 million in savings on HIV treatment (which the government would incur to treat citizens if infections are not averted) and US$4 million in savings on TB treatment (which would occur among noncitizens living with HIV who are not on treatment). Additionally, US$30 million in productivity gains would accrue to the economy owing to increased productivity yielded by treatment and avoided infections among previously untreated noncitizens living with HIV.

Overall, for every U.S. dollar invested in treating noncitizens, the country gets US$8 in return.

By not acting now, the government increases the risk of not meeting the Treat All goals for epidemic control. Moreover, the government will incur an additional US$116 million expenditure to treat HIV and TB infections. The country will be exposed to an additional 23,000 new HIV infections among citizens, as well as an economic loss of US$30 million in worker productivity owing to untreated HIV.

As a way forward, we recommend investment in treating both citizens and noncitizens through the Treat All program. This will accelerate epidemic control, improve financial sustainability of the Treat All program, and produce long-term healthcare savings. To implement this policy recommendation sustainably, potential pathways are to work with development partners to fund the initial phase of the program, followed by transition to full financing by the Government of Botswana as cost savings are realized.