|Migrants' Right to Health (UNAIDS, 2001, 60 p.)|
Promising approaches to HIV/AIDS/STD prevention and care for migrants cover a variety of interventions including assuring access to condoms, media campaigns to promote HIV/AIDS awareness and knowledge, theatre and small group education sessions, peer education, outreach and mobile health services, and specialized care and support programmes. The most effective are those that involve a number of different strategies.
Many countries have found that it is frequently both cost-effective and less threatening to integrate HIV/AIDS/STD into more general health services which address other health concerns of migrants. It should be noted that health services aimed at migrants need flexibility and commitment from staff, in conjunction with the involvement of target group representatives in the design and delivery of the services. Specialized training and continuous education are also often necessary for all staff and associated personnel.
One particular problem (not only in the migrants and HIV/AIDS/STD field) is the tendency for some successful programmes to be discontinued because of the belief that a target population has been well informed regarding prevention methods and access to care. It should be noted that successful programmes need to be continued (although perhaps modified), even in situations where saturation is estimated to have been reached. New recruits are constantly joining any target population (becoming sexually active, initiating drug use, entering sex work, etc.), while others need to have their knowledge and understanding increased or reinforced. Similarly, sometimes recommendations, guidelines and programmes are not necessarily fully implemented in the field,94 thus regular review and follow-up is required.
94 See, for example, an EC-funded Project Report from the Merchant Navy Welfare Board, UK: Seafarers: EC Co-ordination of Information on HIV and STDs. Final Report 1998
Outlined below are a number of projects: they are included as illustrative of some of the promising interventions underway in different parts of the world. It should be noted that successful interventions can rarely be transferred intact to another setting: these selected projects are mentioned both to show the scope of possible interventions and as a potential prompt for considering modifications of these projects for other settings. The one characteristic that all these projects have in common is that they all target policy-makers at one or multiple levels, in addition to any service delivery aspects of the project.
1. UNAIDS and UN system projects
i) West Africa
In Africa, projects aimed at reducing HIV vulnerability from mobility, migration and sex work (often accompanying migration) are being carried out by the West Africa Initiative, for which the UNAIDS Intercountry Team based in Abidjan serves as the secretariat.
Covering 17 countries and networks of NGOs and people living with HIV/AIDS, and funded (with contributions from the Canadian and German Governments) by the World Bank, the West Africa Initiative has produced a practical manual for organizations implementing HIV prevention projects with sex workers and their clients, and has created a strong network of technical experts to assist countries in project development and implementation.95
95 For full discussion, see UNAIDS Inter-country Team for West and Central Africa, Findings of the Research-Action 'Migration and AIDS' Project, available from UNAIDS, Geneva and Abidjan, and from the World Bank, Washington.
The action-research programme has involved seven countries: Burkina Faso, Cd'Ivoire, Ghana, Mali, Niger, Senegal and Togo. While some of the these projects are located in important market towns along international trade routes, others have been elaborated in frontier regions characterized by a high intensity of border crossings.
The success of these projects in West Africa has stimulated interest in Central African countries, which are now initiating similar programmes.
The West African Initiative, in collaboration with the United Nations Development Programme (UNDP), is also helping to strengthen associations of people living with HIV.
The Chad government has initiated a project in conjunction with the Swiss Institute of Tropical Medicine to develop a 'One Medicine' approach, grouping together attention to human and veterinary services for nomadic peoples in Chad. The project aims to ensure that access to services encompasses the particular needs of women and children, including nutritional attention, and will address both health care and health education (including STI) in active conjunction with the participating groups.
ii) East Africa
The "Great Lakes Initiative on HIV/AIDS" focuses on mobile populations and HIV/AIDS, and includes Burundi, Democratic Republic of Congo, Kenya, Rwanda, Uganda and United Republic of Tanzania. Activities include information exchange, care support, integration of the response to HIV/AIDS into socioeconomic and development agendas, promotion of operational research, development of mechanisms of coordination and collaboration between countries, and resource mobilization.96
96 Meeting of national programme managers of GLIA countries, Kampala, Uganda, March 1998.
iii) Central America and Mexico
Mobility and sex work are the focus of a sub-regional initiative in Central America and Mexico involving governments, bilateral agencies, NGOs and the UN system. The initiative, launched in 1999, will prioritize the prevention of HIV and sexually transmitted diseases among mobile populations, including sex workers and their clients living in border and port communities.97
97 Bronfman M. Diagnostic, Intervention and Evaluation of AIDS and Migration in Central America and Mexico, project proposal, 1999.
iv) South and South-East Asia
In South and South-East Asia, a similar initiative is under way for truck drivers, whose lengthy absences from home increase their risk of acquiring and transmitting HIV in both casual partners and spouses. The initiative is intended to increase HIV awareness and condom use among drivers. UNAIDS provided some seed funding; as at mid-1999, the Asian Development Bank and the German technical aid agency, GTZ, had pledged substantial funding.98
98 see http://www.hivundp.apdip.net
v) UNAIDS Intercountry Teams
The UNAIDS Intercountry Teams (ICTs) have, for the last few years, concentrated their efforts on facilitating and strengthening collaboration between intercountry and regional bodies on cross-border issues, migration and mobility. For example, the Asia-Pacific Intercountry Team in Bangkok is facilitating intercountry collaboration and regional dialogue on migration and drug use, two issues with particular relevance for the region. The Asia-Pacific ICT is also supporting rapid applied research on HIV vulnerability and migrant labour in the region.
The Cluster Team for the Caribbean intends to address the issue of mobility in the Caribbean - this programme will include research on immigrants, sex work and tourism.
Working with Seafarers in the Pacific
A significant proportion of the populations of most Pacific Island countries are seafarers (or wives of seafarers). The Secretariat of the South Pacific (SPC) is working through the regional maritime training schools and colleges to ensure they provide quality HIV/AIDS and STD training. Some of the main activities include:
Curriculum development - in consultation with the Regional Maritime Training Programme a module has been developed and included in the regional maritime training curriculum to be implemented by 14 colleges in 12 Pacific Island countries.
Train the trainer workshops - for maritime, health department and NGO trainers who are responsible for implementing the module, or who have an on-going role in providing information and/or support to students and seafarers.
Resource support - through in-country assistance by a member of the SPC team in partnership with college trainers. Provision of a training guide, videos, and other training and information materials for students and trainers.
Peer education training - offered through sub regional workshops for young seafarers who are prepared to assume a role as a peer educator.
Small grants - for each participating country to develop their own materials or to translate other materials into local languages.
Condom supply - in consultation with the college principals, condoms will be supplied to colleges during 1999 and 2000.
The project is being implemented in Vanuatu, Fiji, Tuvalu, Solomon Islands, Tonga, Kiribati, Samoa, Federated States of Micronesia, Marshall Islands, and to a lesser extent, in Papua New Guinea.99
99 Armstrong W. Pacific Islands HIV/AIDS and STD project final report, 1998.
2. European projects
i) European AIDS & Mobility Project
The European Project AIDS & Mobility was initiated at the request of the (then) Global Programme on AIDS of the World Health Organization. Established in 1991, it has predominantly focused on HIV/AIDS prevention, targeting travellers and migrants in Europe. In recent years, it has increased its attention to care and support issues.100, 101
100 AIDS and Mobility Project. AIDS & STDs and Migrants, Ethnic Minorities and other Mobile Groups; the State of Affairs in Europe, de Putter J (ed.). June 1998
101 European Project AIDS & Mobility: Access to New Treatments for Migrants Living with HIV and AIDS - conclusions and recommendations. August 1999; European Project AIDS & Mobility: Access to New Treatments for Migrants Living with HIV and AIDS - Second Annual Seminar, National Focal Points, European Project AIDS & Mobility. Clarke K and Brg G (eds) October 1999; Athens Declaration, November 1999
The Project brings together National Focal Points representing 14 European Union Member States, and operates by stimulating collaboration and exchange of information on AIDS activities aimed at ethnic minority and migrant communities. The EU Member States represented include Austria, Belgium, Denmark, Finland, France, Germany, Greece, Italy, Ireland, The Netherlands, Portugal, Spain, Sweden, and the United Kingdom.
During 1999, each of the National Focal Points organized a national seminar with themes based on priorities set at country level with respect to HIV/AIDS and STD prevention and migrant and ethnic minority communities and other mobile groups. Network activities have included regional training programmes, aimed at NGOs and CBOs, and addressing peer education among migrant populations, migrants living with HIV/AIDS, and culturally and linguistically appropriate services.
In addition, the Project provides an information and documentation centre, with material and literature databases connected to the internet.102 The project regularly publishes an updated bibliography of relevant books, articles and reports, as well as providing a reference service to other organizations in Europe that are active in the field of migration and health.
In their Athens Declaration of November 1999, the Project noted that access of migrants living with HIV/AIDS in Europe to health care, and specifically to HIV treatment, was frequently very restricted. They noted that this was due to such factors as legal and administrative obstacles, socioeconomic problems, lack of culturally and linguistically appropriate information and services, and stigmatization.
The Project has acknowledged the general need to make health services more accessible for migrants. The collaborating parties have noted that they need to work for strengthening of the services that already work with migrants, improved collaboration between the different services, increased involvement by migrant workers, and sensitization of health/social professionals to cultural and linguistic issues and needs of migrants.
The AIDS & Mobility Project noted that although EU Member States in theory are not allowed to expel migrants with serious health problems to countries where their health needs cannot be met, there are many examples of such people being deported. The Project has called for access to new treatments to be guaranteed for all people with HIV infection and AIDS, living in the member states of the European Union, whatever their residency status. A recent Project report makes reference to each National Focal Point having drawn up a plan of action to provide a basis for future activities in their country to specifically improve migrants' access to treatments for HIV infection and AIDS.103
103 European Project AIDS & Mobility: Access to New Treatments for Migrants Living with HIV and AIDS - Second Annual Seminar, op. cit. p5
ii) Transnational AIDS/STD Prevention among migrant prostitutes in Europe Project (TAMPEP)
TAMPEP104 commenced in 1993, with the aim of developing models of health promotion for women and transvestites/transsexuals (men to women) from Eastern Europe, Latin America, Africa and South-east Asia who were working in the prostitution industries of Western, Northern and Southern Europe. The main concern of the project is HIV/STD prevention, but the project notes that, in order to support safe behaviour they have needed to address health in general for the target populations, as well as the overall social position and the working conditions of the migrant sex workers.
104 Transnational AIDS/STD Prevention among migrant prostitutes in Europe Project (TAMPEP) October 96/September 97 Final Report, 1997
In general, migrant sex workers in Europe have extremely limited access to health care services.105 The specialized TAMPEP project had been effective in reaching migrant sex workers: from 1995 to 1997, the TAMPEP national teams had contacted more than 30,000 migrant sex workers in Italy, Austria, Germany and the Netherlands.106
105 EUROPAP/TAMPEP: 1996 - 1997 Final Report, October 1997
106 TAMPEP Final Report, op. cit., p1
About 30,000 persons work in prostitution in the Netherlands. Official authorities estimate that 50-60% of all sex workers originate from non-EU countries and are residing illegally in the Netherlands. TAMPEP notes that its outreach activities find that 80-90% of sex workers in the windows are migrants.
In 1997, there were between 200,000 and 400,000 women working in Germany in the sex industry: the percentage of migrant sex workers varied between 60 and 70 per cent in towns and border areas.
From 1994 to 1997, TAMPEP had noted an increase in both the numbers of female/transsexual sex workers and in their originating countries: in 1997, 25 nationalities were recorded in the four participating countries. The sociocultural characteristics of the workers had also been broadening. In addition, by 1997, TAMPEP was noting an increased mobility within and between countries by migrant sex workers in Europe. The majority of women contacted by TAMPEP teams worked in at least two different European countries in any given year, with many working in three or more countries.107
107 ibid, p3
TAMPEP has increasingly linked its own prevention work with an international network of service providers and basic projects in the countries of origin, transition and final destination, linking, for example, with EUROPAP, a project which targets all sex workers in Europe. They have been developing as a centre of expertise for training, consultation and advice on migrant sex work for service providers and policy-makers (government and non-government) in all EU member countries, and to some extent more broadly.
TAMPEP has mediated some increased access to health and social services for migrant sex workers in the original four participating countries. However, the majority of migrant sex workers even in these countries have very little access to health and social services.108 It should be noted that most EU countries provide HIV and STD testing (and some treatments) usually free of charge, and in many cases anonymously. Unfortunately, many migrant sex workers are unaware of this, or distrust government services.
108 Access to specialized health care for (illegal) migrant sex workers is reasonably easy and inexpensive or free in most areas of The Netherlands. Germany allows non-insured people to have anonymous and free HIV tests, but they cannot obtain any kind of treatment or have preventive therapy. Official institutions (apparently also German sex worker groups) tend to be unwilling to adapt services to better meet the needs of migrants, and very few migrant sex workers use any health care service. For Austria, where free medical check-ups are only available for legal residents, a network providing inexpensive or free medical care for migrant sex workers has been started in Vienna and Linz. In Italy, officially, free-of-charge emergency outpatient treatment is available to anyone, including temporarily-resident foreigners - however, TAMPEP notes that in practice many regions do not provide these services (regions cite budget constraints), and migrant sex workers rarely use any health care service.
3. North America
i) Whitman Walker Clinic, Washington, DC, USA
The Whitman Walker Clinic (WWC) in Washington, DC, is one of the largest AIDS service organizations in the United States: it provides services for people living with HIV and AIDS109 in the United States irrespective of their immigration status.110 Consequently, they provide care and support to possibly more undocumented than legally documented migrants. The clinic has a wide range of services available to persons living with HIV, ranging from anonymous testing and counselling to medical and dental care, legal services, case management services, mental health and addiction treatment services, and day treatment services. In addition, they have a food bank and housing services for clients who have been diagnosed with AIDS. All of the Clinic's services are available regardless of a client's income, insurance status or 'documented' status.111
109 Persons living with HIV/AIDS
110 Personal communication, Glenn Clark, Director, Fleming-Morgan Access Center, Whitman-Walker Clinic, 17 September 1999
111 At the point of intake, Clinic personnel assess a client's situation and need for services, including their eligibility for public benefits. Legal services, available in-house, can assist a client in applying for public benefits. Although undocumented immigrants are ineligible for many public benefits programmes in the United States, they are eligible for the AIDS Drug Assistance Program, which provides free HIV medications to low-income clients. All information gathered about a client is kept confidential. Language barriers are addressed by providing access to staff who speak the language, if available, or by providing an interpreter to ensure the client is actively involved in their service provision. For Latino/Latina clients, the Clinic has developed a Latino Services department. The Access Center, specifically, is funded by a private donor, which thus allows WWC leeway in how intake services are provided. The funding sources for other HIV services (which include federal, local and private funding) also allow the Clinic to provide services to clients regardless of their migrant status.
i) CARAM (Coordination of Action Research on AIDS and Migration)
CARAM, established in March 1997, is a regional network of NGOs from South and South-east Asia engaged in a major action research programme on Mobility and HIV/AIDS.112 The organizations involved in CARAM as of mid 1999 included Tenaganita (Malaysia), CCDB (Bangladesh), Kalayaan (Philippines), CARE Thailand, CARE Vietnam, CARE Cambodia and UCM (Indonesia). It is likely that the network will soon expand to more countries of the region. The network is technically supported by the staff of Health Care and Culture of the Vrije Universiteit, the Netherlands.
112 CARAM-Asia: Coordination of Action Research on AIDS and Migration. The vulnerability of migrants to HIV/AIDS. June 1998
The objectives of CARAM are:
· production of information on vulnerability and health status of migrant workers in general and HIV/AIDS especially
· advocacy work to improve the living conditions of migrants and to demonstrate how migration contributes to increased vulnerability to HIV infection
· development of grass-roots interventions in the field of health, especially STD/HIV/AIDS education for migrants and the improvement of access to facilities
· development of action research models to do the above and to collect the data that are needed for CARAM's advocacy work
· protection of the human rights of migrants.
The partner organizations of CARAM are primarily responsible for the production of information and the development and stimulation of local/national interventions (ranging from provision of health services at the grassroots level to advocacy at local and national levels). CARAM-Asia leads in regional advocacy and international coordination and information exchange.
CARAM-Asia and its partner organizations try to ensure that migrants within the region are accessed at both point of origin and destination. For example, if the Ministry of Labour in Cambodia announced that a significant number of women will be going as housemaids to Malaysia, then CARAM-Cambodia would start developing pre-departure programmes, CARAM-Malaysia would develop interventions for Cambodian women on arrival, and CARAM-Asia would react at policy level concerning issues such as HIV testing for these women.113
113 ibid, p28
Members of CARAM-Asia have noted that multiple-country and multiple-level mobility interventions and studies are rare. They advise, however, that "experience with participatory action research from the CARAM programme has shown that involvement of the people themselves in learning what the problems are, the collection of information that is needed, and the analysis, contributes greatly to the feasibility of interventions that result from the research. The nature of the research in the field of HIV/AIDS (sexual behaviour, hidden prejudices against foreigners, people with other sexual preferences, etc.) makes the cooperation of those involved very important. People that are stigmatized and fear discrimination (if not worse) are in no way likely to be willing to share information with people from outside".114
114 Wolffers I, Fernandez I, Verghis S and Painter T. A Model for Evaluating HIV/AIDS Interventions For Mobile Populations, Paper presented at the Fifth International Congress on AIDS in Asia and the Pacific, Kuala Lumpur, 23-27 October 1999
CARAM-Asia has now developed a matrix framework for intervention involving the concepts of "vulnerability (leading to community interventions and empowerment), risk (related to a more personalised intervention and making individual choices) and human rights (related to advocacy work)" and "opportunities in time, place and conditions for implementation of interventions." The intervention framework also encompasses explicit attention to gender issues. The dimensions of time and place that are important include the pre-departure process, the migration itself, the initial period of adaptation, successful adaptation, return migration, and re-integration into the original community.115
115 ibid, p8
ii) Australian multicultural AIDS projects
Within a context of considerable government/NGO attention to ethnic communities, particularly new arrivals, both national and state governments in Australia have funded a range of HIV/AIDS education projects targeting ethnic communities, especially those with large populations of people who speak English poorly or not at all.
A video (in 6 language versions plus English) on HIV/AIDS-related issues, produced for new arrivals by the New South Wales Multicultural AIDS Project, won the 1999 Australian Multicultural Marketing Award.
All national and state HIV/AIDS media campaigns have at least one component in multiple languages, and in most cases printed information is translated into more than 16 languages. In addition, there are specialized HIV and ethnic group health care workers in most parts of Australia, including specialized targeted sex worker and IDU projects.
Siren's Story is a booklet in Tagalog for Filipina sex workers in Australia. It contains information about how to work and manage money as well as health information and tips for negotiating safe sex. There are different versions of the booklet for sex workers from different countries.
While government-funded health care is officially only available to legal residents, sometimes unofficial arrangements are possible. Undocumented migrants with HIV/AIDS in Australia have been treated through the Sexual Health Centre network. Sexual Health Centres run confidential services and do not ask for identification, whereas most other health services have to ask for the national health insurance card which is only available to legal residents. This means that people with HIV/AIDS without legal residence in Australia can obtain outpatient care and treatment at relatively little or no personal cost, including antiretrovirals, other relevant drugs and health monitoring. The situation becomes more complicated if patients have to be admitted to hospital since they need to show a health insurance card, have private health insurance or pay for the care themselves.
Australia provides a (free access) national translating and interpretation service, 24 hours a day, seven days a week in over 100 languages.