UNDERSTANDING HIV AMONG NON-CITIZENS IN BOTSWANA

Patrick Mokgethi, SANTHE PhD Fellow at the Botswana Harvard Health Partnership (BHP), Gaborone, Botswana, is tackling a critical but often overlooked question: how does HIV affect non-citizens in Botswana, and what does this mean for treatment, prevention, and policy?

Botswana’s adoption of the Treat All policy – offering immediate antiretroviral therapy (ART) to all citizens living with HIV – was a milestone in public health. Since December 2019, this inclusive policy has extended treatment to non-citizens, a group previously excluded from the national programme. Mokgethi’s research aims to understand the virological landscape in this newly included population: which HIV-1 strains are present, how drug resistance manifests, and how these strains are connected to transmission networks among citizens. “Studying non-citizens now provides a critical baseline,” he explains. “It helps us optimise treatment, improve prevention, and ensure equitable healthcare.”

Mokgethi’s project combines laboratory work with population-level data analysis. He uses plasma and white blood cell samples to sequence HIV genes, identifying drug resistance mutations and mapping how viral strains are related. National surveillance data, covering 347,000 citizens and nearly 13,000 non-citizens from 2016 to 2023, adds a powerful epidemiological perspective. Early findings show that non-citizens’ HIV strains are not isolated. Instead, they are integrated into Botswana’s broader transmission networks, underscoring that HIV prevention and treatment efforts must include everyone – citizens and non-citizens alike. Encouragingly, newly diagnosed non-citizens show no resistance to dolutegravir, Botswana’s first-line treatment. However, archived resistance to older drugs was detected in about 40% of virally suppressed individuals, highlighting the need for vigilant monitoring.

Mokgethi’s research has already revealed tangible benefits of inclusive treatment. ART initiation among non-citizens increased from 47% to 76.8% post-policy, viral loads decreased, and immune health improved. These results provide strong evidence to sustain and strengthen inclusive policies in Botswana and the wider Southern African region. His phylogenetic analyses also reveal cross-border connections, showing that HIV does not respect national boundaries. “This makes a compelling case for harmonised HIV treatment guidelines, shared surveillance systems, and coordinated regional responses,” he notes.

Working with non-citizens brings unique challenges. Sample availability can be limited, participants are often mobile, and ethical considerations around confidentiality and stigma are paramount. Patrick and his team follow strict protocols to ensure that participants’ privacy and safety are protected.

Mokgethi emphasises that his work benefits from multidisciplinary collaboration – bringing together molecular biology, epidemiology, biostatistics, and public health policy. As a SANTHE Fellow, he receives training, mentorship, and network support that strengthens not only his research but African-led HIV science more broadly.

Early insights are promising: non-citizens are now integrated into treatment programmes, and molecular surveillance tools are being refined to monitor drug resistance even in virally suppressed individuals. Next steps include expanding phylogenetic analyses, finalising a proviral DNA genotyping assay, and integrating these tools into routine HIV monitoring. In the next five to 10 years, Mokgethi hopes his research will help create a Southern Africa where mobile and marginalised populations are fully included in national HIV programmes, contributing to epidemic control without leaving anyone behind.

“Seeing that inclusive policy saves lives, improves health outcomes, and shows that non-citizens matter motivates me every day,” he says. “This is not just science; it’s about people. And being part of SANTHE means I am contributing to a growing community of African scientists solving Africa’s health challenges from within the continent.”