The main themes that were identified among healthcare providers participant interviews; (1) Health risks to the local population, (2) Ethical and public health implications, (3) Economic and emotional costs, (4) The need for regional health service integration. Additionally, the themes identified among migrants include 1)Barriers to Healthcare Access 2) Fear of Immigration and Police harassment 4) Challenges in accessing HIV and other essential treatments (5) Health Risks to the Local Population (6) Ethical and humanitarian concerns (7) Mother-to-Child Transmission (MTCT) of HIV.
Health risks to the local population
The exclusion of migrants from ART services increases the health risks not only for migrants but also for the local population. Untreated migrants with high viral loads are more likely to transmit HIV, particularly in cases of unprotected sexual relationships. Addressing these risks is crucial in Botswana’s broader HIV response. Participants highlighted the direct public health risk posed by untreated HIV-positive migrants. Without ART, viral loads remain high, increasing the likelihood of HIV transmission within both migrant and local populations. A participant suggests that inclusive treatment policies would be a more effective approach to epidemic control:
Those who are not on treatment are highly infectious, and you can imagine how risky it is. If migrants were given a chance to be treated, it would be better. The best way is to enrol everyone in the treatment and stop this.” (Nurse, 14)
Another participant reinforced the notion that excluding migrants from ART increases community-wide health risks. The participant acknowledges that HIV has no borders, and failure to treat migrants has spill-over effects on the general population.
Migrants should be provided with ARVs – HIV is an infectious disease, therefore they may interact with locals and put their lives in danger.” (Nurse, 1)
The risk extends to other infectious diseases such as tuberculosis and sexually transmitted infections (STIs), which can easily spread without adequate treatment. Addressing these health risks is crucial in controlling the overall HIV epidemic in Botswana.
Yes, there are health risks if migrants are denied services. For example, if a migrant has an STI or tuberculosis (TB) and we do not treat them, they will spread the infection to the rest of the population. They should be treated to protect the community. (Nurse, 3)
Ethical and public health implications
Participants question the ethical inconsistency in Botswana’s HIV response. Thus, testing individuals but denying them treatment contradicts public health ethics and the principle of equitable healthcare access. Denying ART to migrants raises serious ethical and humanitarian concerns, as healthcare should be a universal right, regardless of nationality or immigration status. A participant commented that:
Changes I would like to see in healthcare services for migrants include providing ARV treatment. If we test a foreigner and they are HIV positive but cannot access ARVs, what is the point of testing them? (Nurse, 5)
Participants emphasised that exclusion of migrants from ART jeopardises national HIV goals, particularly the UNAIDS 90-90-90 targets, particularly the goal of ensuring that 90% of diagnosed individuals receive ART. The ongoing transmission risk from untreated migrants makes epidemic control more challenging.
There is no way Botswana can achieve the 90-90-90 targets, especially the second 90, if all patients who test positive are not placed on ART. New infections will remain a challenge to control. (Nurse, 11)
In addition, even though the participants acknowledges financial constraints, they emphasised that migrants should not be denied ART based on nationality, aligning with ethical of universal healthcare rights.
Yes, migrants should have the same access to healthcare as those in Batswana. There are a lot of health risks when migrants are denied certain healthcare services. However, they should be accountable for their care—perhaps paying for services—but should never be denied access. (Nurse, 4)
Economic and emotional costs
Excluding migrants from ART services imposes significant economic and emotional burdens on healthcare providers and the system. Healthcare workers expressed frustration and moral distress over being unable to provide the necessary treatment, making their work emotionally exhausting. As a participant said that “It’s emotionally draining for us, assisting a person to die. I have cases of a person who tested negative and, in the long run, tested positive.” (PMTCT Coordinator, 2)
Additionally, untreated HIV among migrants increases long-term healthcare costs because the system must manage preventable HIV-related complications, new infections, and outbreaks. Participants highlighted the economic costs and treatment inefficiencies. Limited ART access leads to medication sharing, which can result in improper dosing, drug resistance, and higher healthcare costs eventually.
As one of the participants commented that:
Lack of ARVs for migrants is risky because they have relationships with the local population, leading to HIV transmission. If a Motswana is HIV positive, they may share medication with their migrant partner due to lack of access. (Nurse, 7)
Furthermore, participants also pointed out that the economic burden of delayed treatment will cost the government in the future. Preventive ART is more cost-effective than managing advanced HIV complications, which strain Botswana’s healthcare resources.
Denying ART to migrants will only cost the healthcare system more in the future. Treating someone temporarily and not ensuring continuity is not economical for the country. (Nurse, 10)
The need for regional health service integration
Participants strongly emphasized the urgency of integrating health services across borders to address the fragmented care experienced by migrants, particularly those living with HIV. The lack of regional coordination disrupts treatment continuity for mobile populations, undermining adherence to antiretroviral therapy (ART) and increasing the risk of reinfection and further transmission within and across borders.
Healthcare workers described how migrants frequently travel between neighbouring countries such as Zimbabwe and South Africa, yet the absence of shared health information systems and cross-border protocols often results in treatment defaulting. This undermines both national HIV control efforts and regional public health objectives. The need for regional cooperation was framed not only as a health systems concern but also as a moral and ethical obligation to protect vulnerable populations and the broader community.
One nurse explained the consequences of failing to coordinate care across countries:
Migrants engage in relationships with locals, leading to reinfection. We need healthcare integration across countries. (Nurse, 6)
Another participant raised concerns around gaps in maternal care and the exclusion of migrant mothers from prevention of mother-to-child transmission (PMTCT) services due to inability to pay:
If a migrant mother gives birth here, we don’t test the baby at six weeks unless they pay first. I have seen cases where a baby was later diagnosed HIV-positive. (Nurse, 12)
The absence of regionally harmonized HIV services was also seen as a barrier to achieving epidemic control:
If we don’t integrate healthcare services across borders, migrants will continue defaulting, and we will never control the spread of HIV. (Nurse, 15)
These accounts highlight the need for stronger regional health governance structures that enable ART continuity, data sharing, and inclusion of migrants, particularly pregnant women within national HIV programs. Participants called for more migrant-sensitive health policies that go beyond national borders and recognize the interconnectedness of health outcomes in southern Africa.
Themes for migrantsBarriers to access to healthcare
The findings from migrant participants show that they experience multiple barriers to healthcare access, including financial constraints, documentation requirements, and discriminatory policies when accessing healthcare in public health facilities. High healthcare costs for non-citizens create inequities in service accessibility, forcing many migrants to delay seeking treatment or forego healthcare entirely. The requirement to provide official documents further limits access, particularly for undocumented migrants, increasing their vulnerability to preventable illnesses. These challenges create a healthcare environment in which migrants are unable to access timely care, often delaying or entirely avoiding treatment. As one participant noted:
I don’t feel equal to Batswana nationals because I pay more money at hospitals than in Zimbabwe where we are given services for free. (Migrant 1)
The requirement to present official identification was repeatedly mentioned as a restriction that excludes undocumented individuals from care:
At the clinic, they require me to present papers, or they don’t give me treatment. (Migrant 3)
Even when I am very sick, they turn me away. How do they expect me to survive? (Migrant 2)
Such experiences highlight systemic exclusion that pushes migrants further to the margins of the healthcare system, increasing their risk of preventable illness and health deterioration.
Fear of immigration and Police harassment
Another key theme of this study is that fear of arrest, detention, and deportation discourages migrants from seeking healthcare services, even when they are in critical need. Migrants reported avoiding clinics and hospitals due to the risk of being reported to immigration authorities, resulting in delayed or missed treatments. This fear-driven behaviour leads to worsened health outcomes, higher mortality rates, and increased transmission risks for communicable diseases such as HIV.
I don’t go to the clinic because I don’t have papers, and I am afraid of being detained. (Migrant 4)
In some instances, participants recounted being denied emergency care due to their migrant status:
The police once beat me, and I was very injured, but when I was taken to the hospital, they didn’t help me. (Migrant 5)
This environment of fear not only contributes to worsened health outcomes but also undermines trust in the healthcare system, deterring migrants from seeking help in critical moments.
Challenges in accessing HIV and other essential treatments
Migrants living with HIV face substantial difficulties in accessing ART, family planning services, and other essential treatments due to restrictive healthcare policies. ART interruptions increase the likelihood of HIV progression, contribute to higher viral loads, and elevate the risk of transmission. The exclusion of migrants from ART programs directly contradicts Botswana’s commitment to achieving the UNAIDS 95-95-95 targets, which require ensuring that 95% of people living with HIV know their status, 95% of diagnosed individuals receive ART, and 95% of those on ART achieve viral suppression. These barriers are driven by restrictive policies that exclude non-citizens from national programs:
My fellow Zimbabweans end up dying because of being denied medication. (Migrant 6)
One of the participants reported being refused access to reproductive health services:
They refused to give me family planning pills. Migrants should have access to condoms, PrEP, and family planning like Batswana. (Migrant 8)
Interrupted ART access often resulted in poor adherence and risk of treatment failure:
I have missed doses many times because sometimes I cannot afford to travel to the clinic, and other times they tell me only citizens can get medication. (Migrant 7)
These findings point to urgent gaps in HIV care, undermining both individual health and Botswana’s efforts to meet the UNAIDS 95-95-95 targets.
Health risks to the local population
The lack of ART access for migrants not only endangers their health but also poses public health risks to the local population. Without treatment, HIV-positive migrants are more likely to have high viral loads, increasing the likelihood of transmission to their sexual partners and communities. Some migrants reported sharing ART medication due to lack of access, a practice that contributes to poor adherence, treatment failure, and the emergence of HIV drug resistance (HIVDR). The spread of drug-resistant HIV strains presents a significant challenge for Botswana’s HIV response and underscores the need for inclusive treatment policies that prioritise public health. Participants recognized that untreated HIV among migrants increases the risk of transmission within communities:
If migrants are not treated, they will pass HIV to other people in the community. (Migrant 9)
The practice of sharing medication, driven by desperation and inaccessibility, poses further health risks:
Some people who don’t get treatment share pills, and that is not safe. (Migrant 10)
These accounts raise concerns about the emergence of drug-resistant HIV strains and the consequences for Botswana’s HIV response efforts.
Ethical and humanitarian concerns
Denying migrant access to ART and other essential healthcare services raises profound ethical and humanitarian concerns. Migrants expressed frustration at being treated as outsiders in healthcare settings despite their urgent medical needs. The exclusion of migrants from lifesaving treatments violates fundamental human rights and contradicts the principles of medical ethics, including the duty to provide care without discrimination. Migrants shared strong feelings of being treated unfairly and inhumanely within the healthcare system, particularly when denied essential care:
We are all human beings, but they don’t treat us the same way when we are sick. (Migrant 11)
Denying people treatment just because they are not from Botswana is not fair. (Migrant 12)
Such statements reflect not only a sense of exclusion but also a deeper humanitarian crisis that challenges the ethical foundations of medical practice and the right to health for all.
Mother-to-Child transmission (MTCT) of HIV
The findings indicate that pregnant migrant women struggle to access prenatal care and PMTCT (Prevention of Mother-to-Child Transmission) services, increasing the risk of HIV transmission to new-borns. Limited access to ART during pregnancy results in higher rates of vertical HIV transmission, negatively impacting maternal and infant health outcomes. The exclusion of pregnant migrants from PMTCT programs contradicts global commitments to eliminating mother-to-child transmission and highlights the need for more inclusive maternal healthcare policies. Ensuring that all pregnant women, regardless of their migration status, receive comprehensive maternal and neonatal care is crucial for improving health outcomes for both mothers and children. Participants described cases where women were unable to access ART during pregnancy, resulting in infants being born HIV-positive:
I know a woman who was pregnant and couldn’t get ART, and her baby was born with HIV. (Migrant 13)
In addition to lack of care, some migrants reported experiencing disrespect and surveillance during labour:
One day, my wife was in labor, and they told the security guard to watch us because we might run away. (Migrant 14)
The exclusion of pregnant migrants from essential maternal health services not only undermines international commitments to eliminate mother-to-child transmission but also perpetuates structural discrimination against migrant women:
A nurse told my friend that migrants should not have babies if they cannot afford care, but what choice do we have? (Migrant 16)
These narratives highlight the need for more inclusive maternal health policies that ensure equitable care for all pregnant women, regardless of migration status.