Excerpts: UNAIDS Report on the HIV/AIDS Risk for Migrant Populations

12 March 2001

Excerpts: UNAIDS Report on the HIV/AIDS Risk for Migrant Populations

Migrants, refugees have greater risk than stable populations

Traveling workers, migrants and refugees face a greater risk from exposure to HIV/AIDS than stable populations, and a recent United Nations report urges greater attention to the needs of these vulnerable populations.

The report was prepared jointly by the United Nations' lead agency on HIV/AIDS, UNAIDS, and the International Organization for Migration. It attempts to dispel the suspicion dating from the early years of the disease's emergence that people traveling from one region or nation to another could be likely carriers of the disease. On the contrary, the report says, migrants and refugees can be more vulnerable to exposure because of the circumstances of their status, and because of the greater likelihood that they'll be exposed to poor living conditions and inadequate health care.

Issued in February 2001, "Population, Mobility and AIDS" suggests a variety of strategies for protecting these individuals and reducing their risks.

-- Include migrants and mobile people into national and local community AIDS plans;
-- Target education and counseling programs to these populations;
-- Target programs to particular areas attracting traveling populations where high risk behavior may occur, such as truck stops, train stations and markets;
-- Implement cross-border international programs; and
-- Improve legal status, working conditions and health care for migrants.

"Population, Mobility and AIDS" is available in full at http://www.unaids.org/whatsnew/newadds/index.html

Following are excerpts of the report:

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UNAIDS

Population, Mobility and AIDS

UNAIDS Technical Update

At a Glance

Migration, mobility, and HIV/AIDS are major global phenomena at the beginning of the new millennium. Since the start of the HIV/AIDS epidemic, a concern of governments has been that people moving between countries might be spreading HIV Today, however, there is increasing recognition that migrants and mobile people may be more vulnerable to HIV/AIDS than are populations that do not move. They may acquire HIV while on the move, and take the infection back with them when they return home, often without even knowing it. They also face greater obstacles in accessing care and support if living with HIV or AIDS.

Given the millions of migrants and mobile people in today's world, there is an urgent need for responses that address their particular vulnerabilities to HIV/AIDS. Such responses are critical to the effectiveness of national AIDS programs in the many countries that experience significant migration and population mobility. They are also critical to the effectiveness of regional and international efforts to combat HIV/AIDS.

Responses for migrants and mobile people must address HIV/AIDS prevention, care and support throughout their journey before they leave, as they travel, in communities and countries where they stay, and after they return home. These responses must be based on the social and contextual realities faced by migrants and mobile people and should be part of an empowerment that improves their legal, social, economic, and health status.

At a glance: suggested action for migrants and mobile people

-- Put migrants and mobile people into HIV/AIDS strategic planning, and into national and community AIDS plans.

-- Establish culturally and linguistically appropriate outreach in HIV/ AIDS programs targeted to migrants and mobile people. Establish peer counseling.

-- Support associations of migrants, and help them integrate HIV/ AIDS into their work.

-- Focus HIV/AIDS prevention efforts in zones where there is increased likelihood that risk behaviors will occur and HIV will be encountered, e.g. truck stops, bus and train stations, harbors, markets.

-- Implement programs that cross national borders.

-- Develop and implement pre-departure briefings, post-arrival and reintegration programs, and use the experience of those going back and forth across borders.

-- Improve the legal status of, and legal support for, migrants and mobile people and their families.

-- Work with those who employ migrants to improve their living and health conditions.

-- Make local health care facilities more accessible and 'user- friendly' to migrants and mobile people.

-- Conduct operational research on the links between migration, mobility and HIV/AIDS.

Who are migrants and mobile people?

Some 150 million migrants currently live - and often work outside their country of citizenship, and between two and four million people migrate permanently each year. A small but significant percentage of people who move across borders have been forced to seek refuge outside their countries of origin: at the end of 1999 over fifteen million people were refugees and asylum-seekers. Hundreds of millions more people move within their countries each year. Of these, some 20 to 30 million have been displaced because of wars, ethnic tensions, and human rights abuse. Others move within countries in order to seek employment, to seek better living or working conditions, to seek markets or education, or to join family members. This document addresses the response to HIV/AIDS for migrant and mobile people. In doing so, it focuses on a wide range of situations. Mobile people can be described broadly as people who move from one place to another temporarily, seasonally or permanently for a host of voluntary and/or involuntary reasons. Key employment groups involving mobility include truckers, seafarers, transport workers, agricultural workers, itinerant traders, mobile employees of large industries (e.g. mining, oil companies), and sex workers.

Migrants are mobile people who take up residence or who remain for an extended stay in a foreign country. Women comprise some 47 per cent of migrants, and dominate migration in some regions. For example more than 60 per cent of migrants from Sri Lanka are now women, employed primarily in domestic service.

. . . .

Why migration, mobility and HIV/AIDS?

HIV/AIDS is also a well-established global phenomenon. More than 15 years after HIV was first identified, the virus is present in every region in the world. By the year 2000, it was estimated that almost 34 million people across the world were living with HIV. More than 95% of these infections have occurred in developing countries, where poverty, poor education and health systems, and limited resources for prevention and care fuel the spread of the epidemic, and where economic hardship and violence displace large numbers of people.

Studies on certain highly mobile groups (e.g. truck drivers, itinerant traders of both sexes, military seafarers) have identified travel or migration as a factor related to infection. In many countries, regions reporting higher seasonal and long-term mobility also have higher rates of HIV infection, and higher rates of infection can also be found along transport routes and in border regions. In addition, epidemiological studies focusing on more stationary migrant populations in several countries show that non-nationals are disproportionately affected by HIV and AIDS.

Such studies indicate that migration and mobility increase vulnerability to HIV/AIDS - both for those who are mobile and for their partners back home. Given the large numbers of migrants and mobile people, this vulnerability has far-reaching and tragic consequences. Yet governments have not yet done enough to address HIV/AIDS among those who are mobile.

A response early in the epidemic was to try to keep HIV-positive people out of a country by laws that restrict their entry or stay. Some 60 countries have such restrictions, most of which are applied to long-stay visitors, seasonal workers, migrant workers, and foreign students. However, according to the World Health Organization, UNAIDS and the Office of the High Commissioner for Human Rights, these restrictions have no public health justification. Such restrictions may in fact increase migrants' vulnerability to HIV/AIDS by driving them underground and discouraging them from coming forward for prevention information, testing, counseling and support - in both source and destination countries.

There is an urgent need to develop and implement more effective responses to HIV/AIDS for migrants and mobile populations. Such responses should empower migrants and mobile people to protect themselves against infection, reduce onward transmission of HIV, and provide care and support. This document briefly describes both the challenges involved and some possible effective responses.

Increased vulnerability

Migrants and mobile people may be highly marginalized while in transit, at destination, or on their return home. They may be subject to discrimination, xenophobia, exploitation and harassment, and have little or no legal or social protection in the host community. Such marginalisation increases vulnerability to HIV infection and also the difficulties of living with HIV/AIDS.

Migrants and mobile people may have little or no access to HIV information, health services, and means of AIDS prevention (condoms, treatment for sexually transmitted infections [STIs]). Cultural and linguistic barriers heighten their lack of access, as do unfamiliarity with the community, and the instability of mobility.

Migrants and mobile people may avoid attention from authorities, even if that attention is meant to provide health services, or to help improve their living conditions. They may also be uncomfortable and inexperienced in relating to the nongovernmental or community based organizations that might be there to help them.

Poverty and lack of resources may force those moving from one place to another to increase their risk of HIV by trading or selling unprotected sex for goods, services and cash in order to survive and/or continue their travel.

Migrants in some countries face the possibility of involuntary testing for HIV, and deportation, if found to be positive 14. Their HIV status may be revealed to authorities in their destination or source countries, or to their communities and families. Such breaches of confidentiality give rise to stigma, discrimination and rejection. Deportation from a country in which advanced HIV care is available to one in which such care is not available may mean greater suffering and an earlier death.

The most vulnerable

The most vulnerable mobile people are refugees, those without legal status in the country in which they are living, and women.

Refugees and internally displaced people - People displaced by conflict and other emergencies live through chaotic conditions, during which HIV/AIDS is not likely to be seen as a priority. Yet HIV spreads fastest in conditions of poverty, powerlessness and social instability, the conditions that are at their extreme in complex emergencies. Physical, financial and social insecurity erode the caring and coping strategies of individuals and households. This often results in forced high-risk sexual behavior and sexual abuse. Women and girls find themselves coerced into sex to gain access to basic needs such as food, shelter, and security, and are also especially vulnerable to rape

Legal status - Whether a person is in a country legally or illegally has a powerful influence on his or her vulnerability to HIV/AIDS. Undocumented migrants live on the margin, trying to avoid contacts with authorities that may result in imprisonment and deportation. They have virtually no rights in the place where they live, including no legal access to social and health care services and to prevention and care for STIs and HIV/AIDS. They may be forced by their precarious circumstances into unsafe working conditions and accommodations, and be exploited for meager wages. Women and children may also be subject to sexual violence, thereby increasing their risk of HIV and other STIs.

Women and girls - Employment opportunities are usually more limited for women migrants, who may find themselves confined to a parallel economy, working under inferior conditions, subject to discrimination both as women and as migrants, and unable to claim the rights that are their due. They may have very little or no access to reproductive health services. They may also have little or no bargaining power to prevent unwanted and unsafe sex during travel and at a destination. Large numbers of women move to take up work as domestic employees. Often their rights are not respected, nor are they protected by local laws or customs. They may be sexually exploited by their employers. Some women migrate to take up occupations that involve increased risk of encountering HIV, such as sex work. Other women and girls (and boys as well) are deceived, coerced or trafficked into sex work. Still other women end up in precarious and vulnerable situations after they have entered countries clandestinely to join husbands or partners who had migrated. Finally, some women become vulnerable without ever having left their homes when their partner has gone abroad to work, and comes home with HIV.

Increased risk-taking

Migrants and mobile people are exposed to unique pressures, constraints, and living environments. Many are separated from their families and spouses or regular partners. They may feel anonymous. They may also feel freed from the social norms that guided their behavior in their family, community and culture. Lonely people away from home may be especially susceptible to peer pressure. These factors may provoke people to take risks and engage in behaviors they would not have engaged in at home.

In some settings, living and recreational environments for migrants and mobile workers are almost exclusively male. This leads to the development of commercial sex services and the pressure to use them. It may also lead to increased sex among men.

Lack of attention and resources

Financial, human and institutional resources in many countries are extremely limited for HIV/AIDS prevention and care programs. The resources that are available are most often targeted to local populations, with little or no resources going to the needs of migrants and people moving through the community.

The projects on HIV/AIDS and mobility established in some developing countries by international agencies and nongovernmental organizations (NGOs) have generally been limited in social and geographical coverage, and also in time.

Few national AIDS plans deal with population mobility in ways that take into account its importance to the epidemic. The challenge is thus for governments to acknowledge the need to address HIV/AIDS among migrants and mobile people. . . .

Migrant and mobile-friendly interventions

A basic rule is that interventions for HIV/AIDS prevention and care for migrants and mobile people must be offered in the appropriate language and tailored to the cultural context of the target group. It is often possible to share materials and messages between source and destination communities. Members of the migrant or mobile community should be involved to help design and implement the interventions Such community input will ensure that the interventions are relevant, and they will also help find ways to overcome barriers to HIV/AIDS prevention.

Effective approaches include making sure that condoms are available. Reproductive health services, including treatment for STIs, should also be made available. Culturally and linguistically appropriate HIV/AIDS information may be provided through media campaigns, street theatre, small group education sessions, and peer education. To ensure sustainability, intervention strategies should be linked to migrant associations, to local authorities, and to local NGOs. Links between sending and receiving communities should also be made.

Interventions should also address factors that may marginalize the migrant and mobile person. These would include poverty, discrimination, segregation and lack of legal status. They would also include mobility itself: special interventions must be designed for people who are more or less always 'on the move', such as itinerant traders, truckers, seafarers, or transport workers. Interventions for highly mobile populations involve outreach to individuals and groups, working with specially trained and highly flexible staff, use of mobile facilities, and working with local police and community authorities to increase access.

Focusing on risk zones

A promising approach is one that focuses not on groups or individuals, but on the sites or areas where risks may occur. This 'risk zone' approach targets interventions in places through which a large number of mobile people pass. Examples might be truck stops, autogares, train and bus stations, marketplaces, harbors, and customs zones. The advantage of the approach is to focus on more than one or two specific groups (such as truck drivers and sex workers), to cover everyone potentially at risk in the area (such as bar and hostel workers, traders, or simply local young people coming to where the excitement is).

Focusing on destination communities

Some industries depend on workers who will migrate to a specific place for a term or season. Examples are agriculture, logging, mines and construction sites. The conditions in these destinations, and how these conditions may contribute to HIV/STI vulnerability, should be assessed and improved with the participation of private and public sectors, including relevant local NGOs and trade unions. Responses should take into account the needs of the local population, as well as the impact of in-migration on that population. In the best of cases interventions should benefit both migrant and local populations.

Another level of intervention is to work on policies that affect such migrant workers, such as that of single sex labor migration. Allowing migrant workers to live with their families if they so wished would reduce the HIV risks that occur when large numbers of lonely people live in single sex barracks. Living, working and health conditions can often be significantly influenced by the employer. For example, employers can ensure that decent housing is available, and that there is access to basic health care services, including HIV prevention and care services and condoms.

Focusing on cross-border and regional responses

Migration - movement across borders - can involve even greater challenges with regard to HIV/AIDS interventions than does internal mobility. In the destination country such migration usually involves increased linguistic, cultural, and legal barriers. Migrant communities are usually segregated and marginalized.

Reintegration back to home countries may also be difficult, when migrants return to families and communities that have changed during their absence.

Creative cross-border approaches are ones that link opportunities in source and destination countries. They provide information on HIV prevention and care services to people moving between these countries. Such approaches may involve efforts between respective governments to establish and harmonize contacts, policies and programs for migrant groups. They may also involve international and regional NGOs forming alliances across borders for certain groups, and/or the establishment of self-help and support associations efforts by migrant communities themselves on both sides of the border.

Mobilizing communities of migrants and mobile people

HIV/AIDS prevention and care activities are most effective when undertaken by those for whom they are intended. It is members of the target community who will best be able to assess their own particular vulnerabilities, and propose effective solutions. Experience shows that migrant communities, like any other communities, will contain individuals and associations willing to make significant contributions to prevent HIV/ AIDS and to assure access to care among their own. Given the necessary tools and resources, community members can provide peer education - and support for behavior change and health needs - that will be more effective than that coming from 'outsiders.' In collaboration with partners from host countries migrant communities can also mobilize to influence the policies that affect them.

Increasing care and support

Much remains to be done to improve the situation of migrants and mobile people living with HIV and AIDS. In destination communities, efforts should be made to increase legal and actual access to local HIV/AIDS health and support services. This may involve developing and implementing specialized health services for migrants and mobile people, or it may involve adapting existing health services. In either case services for people living with HIV/AIDS should address cultural and linguistic barriers, as well as barriers caused by mobility and lack of legal status.

Migrants and mobile people living with HIV who return home often do not know they are infected. People who are aware of their HIV status are in a better position to seek support and care, and also to further protect themselves and their partners. In reintegration and receiving programs, returning migrants should thus be provided with HIV voluntary counseling and testing services. If found to be HIV positive, they should be referred to available community HIV care and support. Efforts should also be made to protect those returning with HIV or with AIDS from stigma and discrimination. At a very minimum, confidentiality about HIV status on return should be strictly maintained. Associations of people living with HIV/AIDS and other community care and support efforts in countries of destination and of return should be encouraged to reach out to and include migrants and mobile people affected by HIV/AIDS.

Improving laws and regulations

Human rights law and some international and regional laws protect the rights of migrants and mobile people. National and local laws may also contain protective provisions. However, national laws and regulations should be reviewed to ensure that the rights of migrants and mobile people are protected in the following areas:

-- protection of family unity including the ability to bring spouses and children to the destination country

-- legal access to local health care services

-- protection against discrimination

-- application of local labor protection to migrants and mobile populations, including minimum wage and the right to organize

-- availability of legal process and legal support, including in the context of deportation

-- protection of confidentiality of HIV status

-- access to basic social security during transit and at destination

-- ratification of the International Convention on the Protection of All Migrant Workers and Members of their Families, as well as other international instruments that protect migrants and seasonal workers.

Including migrants and mobile people in strategic planning and AIDS plans

Almost all countries are affected by migration and by population mobility - as sending or receiving countries and/or because of population movement within their borders. This population mobility could be a major factor driving the HIV epidemic in a country, and yet neither the mobility itself nor the migrants and mobile people involved are usually addressed in strategic planning or in national AIDS plans. In national and community strategic planning, any mapping of the epidemic and the factors driving it should include attention to migrants and mobile people, their realities, and their vulnerabilities. Where relevant, national AIDS programs should give population mobility, migrants and mobile people special attention in national and community AIDS responses, and allocate sufficient funds to address the needs involved.

At the same time, regional and international bodies must use their institutional advantages to promote effective responses to migration, mobility and HIV/AIDS. Finally, resources must be increased and/or shifted to deal more strategically with the issues involved. Communication and sharing of knowledge must occur between regions and between programs.

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