Decades into the AIDS epidemic, how we understand the reality we face and who are most at risk are changing, and fast. We are used to cleaner, simpler strategies: some people at risk are ‘key populations’ and assumed to be at risk practically everywhere, e.g., gay men, sex workers, intravenous drug users. Others are simply ‘vulnerable populations’, and are not as fundamentally at risk.
In this latter group used to be groups like prisoners and mobile or migrant populations. More and more, however, as we wake up to the real-life situations of these vulnerable groups, it is not as easy to distinguish between key and vulnerable groups. And clearly, since who is a key population is ultimately a national decision based on national epidemiology, it can certainly be the case that prisoners or indeed migrants may already in fact be key populations at the national or sub-regional level. For example, a strong argument can be made that migrants from high HIV prevalence African countries are a key population for Europe. And key populations are prioritized for HIV services and have a first claim on limited human and financial HIV resources.
But migrants are not just a group at higher risk of HIV. Migrants are an essential component of development. Migrants send close to 600 million dollars back to their families each year. This is more than is contributed by foreign aid to developing countries. And whereas previously men were the most visible migrants leaving home to provide for their families in a foreign country or in some other rural or urban location, this is no longer the case. Whereas women used to migrate as the spouses or relatives of male migrants, now women clearly migrate in their own right, based on their own skills, in order to also better provide for their families. And just as there were HIV risks for men who often migrated alone, so now there are growing HIV risks for women who travel away from home to make a living, including labour and sexual exploitation and abuse.
Migration, however, is not a problem to be solved. It is an essential component of what it means to be human. Human evolution is itself a history of human mobility and migration, people on the move to find a better living. The challenge we face, therefore, is to urgently manage the significant risks associated with speeded up migration in our globalized world, included the risks specific to HIV.
“Migrant” is a loaded term. And there is no global agreement across countries about what we mean. So talking about or studying this topic can become a confusing case of comparing apples and oranges. Our data on migration is still too often weak and our conclusions can lack solidity.
Nevertheless, there are large numbers of people on the move around the world, not just refugees and asylum seekers or Roma or those from rural areas where local economies and traditional lifestyles are collapsing. Many are moving to urban centers for a better life or simply to have a more regular food supply. Cities are becoming the new ‘refugee centers’ with a lot of the same health challenges for displaced people, e.g., overcrowded living conditions, limited access to nutritional food for lack of financial resources, and separation from partners and families with associated psychosocial stressors. These challenges are fertile ground for contracting TB and HIV. And we know that TB is the number one killer for those infected with HIV who have not been able to get adequate HIV treatment; this is certainly the case right on our doorstep in Europe, right in Eastern Europe and Central Asia.
There are some things people are doing to respond more effectively to these situations. Key among these responses is the active engagement of civil society and non-governmental organizations who can bring health screening as well as HIV and TB testing into the heart of those places and communities where mobile and displaced people can be located, in neighborhoods, in community businesses, in religious gatherings. Such community-based delivery of testing and treatment options help to ensure early detection and entry into the healthcare system. They also minimize the likelihood of disease progression and greater burdens on local health systems. Going even further, some of these services include migrants in their delivery as peer supporters or educators or as cultural mediators. And some such services are also peer-led, where migrants have a say in how services are conceived, delivered and evaluated. All of this to help make sure everyone, including migrants, has access to the highest available standard of health.
About 1 in 7 people globally are migrants or people on the move. Sadly, at this very moment as we become more aware of the HIV and TB – not to mention Hepatitis – vulnerabilities of migrants and people on the move, as we become more convinced of the crucial role played by community-based healthcare outreach, we are also faced with uncertainties about whether we will have the human and financial resources to face these challenges. At the global level, governments have committed to ending HIV and TB as epidemics or public health threats by 2030, in 12 years from now. Will we be able to keep up the momentum in this fight? Will we be able to further replicate and expand on community based and other effective ways of addressing the HIV challenges faced by migrants and people on the move?
Migration can be beneficial or detrimental to people living with HIV (PLHIV) and other key populations. It can be beneficial if it enables some to move to a new country or a more urbanized location, for example, where there is less stigma or where their lives are not criminalized. It can mean access to a better level of healthcare and more skilled clinical providers. And in moments of crisis or when facing health challenges, it can mean returning home where one can receive care and support from one’s family and old friends.
Migration can also be detrimental. My previous blogs have referred to HIV and TB risks associated with migration. Migrants with little prior exposure to HIV may be particularly challenged by moving to a context where there is a generalized or a concentrated HIV epidemic. Migrants fleeing food insecurity may find certain kinds of urban living produce a whole new range of insecurities. Over-crowded living or working conditions may also leave one vulnerable to TB. And being on one’s own, away from families, can result in more risky forms of sexual behaviour that can put one at risk of contracting HIV.
And, yes, there are risks associated with travel: there can be traffic accidents along the way, there can be complications resulting from communicating across different languages and cultures. However, the most detrimental aspects of migration are usually associated with the man-made policies and laws that govern the migration process itself in various countries. These include policies and laws that deny access to healthcare for migrants or deny migrants’ right to health, that make it difficult to sustain a particular treatment regime from county to country, that stigmatize or even criminalize key populations, that threaten forced deportation as a radical final solution. Most of these policies and laws are based on outmoded views that see migration more as a cultural and health threat rather than as something that can benefit both sending and receiving countries and the migrant him/herself.
Sometime soon we will see a final or almost final draft of the Global Compact for safe, orderly and regular migration. It is expected that this Compact will be adopted by UN member states later this year. It aims to be a watershed approach to migration in aiming for improved safety in the process, which should include acknowledging the human and healthcare rights of migrants. It envisions a more orderly process, with less chaos and confusion as migrants have to cope with differing country-specific migration policies and laws. And it accepts that migration needs to be regularized, to be ‘mainstreamed’, to be integrated into our health and other social service planning and systems.
Amesterdam, July 2018