Italy: Legal issues and language difficulties restrict healthcare access for migrants in Southern Italy

Healthcare access in Southern Italy: the challenges faced by migrant communities

For many migrants in Southern Italy, protecting their health remains an uphill battle. The REACH OUT project, along with extensive field research, has revealed how access to care and the prevention of sexually transmitted infections are affected by a complex mix of social, cultural and economic factors.

Economic and legal difficulties, as well as language and cultural barriers, are among the primary obstacles preventing migrants in Southern Italy from accessing healthcare services.

Funded by the European Union and conducted in collaboration with Maastricht University and the University of Padua, the REACH OUT project has uncovered important data* on the health vulnerabilities of migrants in Southern Italy.

The project focuses on the prevention and access to care for HIV, hepatitis B and C, and other STIs, identifying real-world barriers that hinder the effective implementation of healthcare interventions in challenging contexts. One of the key findings is the role of Social Determinants of Health (SDH)– such as legal status, income, education level, and discrimination – which significantly impact healthcare access and infection risk.

Economic challenges are a major barrier: 67% of migrants interviewed live below the poverty line, with monthly incomes of less than 630 euros. Moreover, nearly half (48%) lack access to healthcare services, often due to limited awareness of their rights or complications in navigating administrative processes. This problem is especially severe in reception centers and informal settlements like Borgo Mezzanone, where healthcare registration is often absent.

Language and cultural barriers further compound the issue. Difficulties in translating sexual health information into various languages, combined with the stigma sorrounding STIs, create additional challenges in promoting preventive practices. While many migrants are aware of STIs and some prevention methods, shame and religious beliefs often prevent them from adopting protective behaviours.

Mental health data is equally concerning: 61.9% of migrants exhibited signs of psychological distress, while 30% reported having experienced intimate partner violence. Issues such as anxiety and depression are common, often stemming from prolonged stays in Italy without legal stability or social integration. Though these psychological factors do not directly block access to healthcare, they often isolate individuals, making them less likely to seek out healthcare services and support.

This research highlights the crucial need to improve communication about healthcare rights for migrants and to strengthen access to services for more inclusive protection. At INTERSOS, we are committed to using these insights to refine and expand our field initiatives, working closely with communities to build trust, provide targeted healthcare, and support long-term structural changes that enhance the quality of life for migrants in Italy.

*The data referenced here were gathered through three studies conducted by graduate researchers from Maastricht University and the University of Padua: Marije Pot, Martina Bugelli, and Antonia Laß.

New report documents key challenges for migrants on the move in the Darien region

PAHO Report Highlights Urgency of Improving Access to Health for Migrant Populations in Darien Region

Washington, DC (PAHO) – A report released today by the Pan American Health Organization (PAHO) documents the key challenges facing migrants in the Darien region and calls on countries in the Americas to collaborate to strengthen disease surveillance and improve policies and programs to ensure the health of migrants.

The new report, Challenges in access to health for migrants transiting the Darien region , reveals that migrants face significant health challenges as they cross the vast jungle territory between the Colombian and Panamanian border, including lack of access to emergency medical care, adverse environmental conditions, increased risk of violence and exploitation, and exposure to infectious diseases.

“In the Americas, millions of migrants continue to be disproportionately affected by health problems due to lack of access to care, and this is particularly the case in the dangerous Darien crossing,” said PAHO Director Dr. Jarbas Barbosa.

“It is essential that countries, partners and donors come together to address the number of variants that are hampering access to timely care for migrant populations,” he added.

Over the past two years, migration in the Darien region has continued to increase, with populations moving across borders from the south to the center and ultimately to North America. This phenomenon is not only due to political and economic instability in Latin America and the Caribbean, exacerbated by the COVID-19 pandemic, but also to conflicts and challenges in other parts of the world.

In the first three months of 2024, more than 135,000 people passed through this area, mainly from Colombia, Ecuador, Haiti, Peru and Venezuela, but also from Afghanistan, Angola, Bangladesh, China and India, to name a few.

While migrants are particularly vulnerable to health problems, caused by a lack of access to preventative care and medication for pre-existing conditions, the harsh terrain of the Darien region also exposes them to extreme weather, wild animals, violence and exploitation.

The report shows that levels of vulnerability among populations in transit have also increased in recent years due to an increase in the number of migrants with disabilities, women travelling alone, pregnant women and women with children under one year old, in addition to the number of unaccompanied children and adolescents.

Due to the lack of health care along the route, migrants are often deprived of vital antenatal care, as well as care for chronic diseases such as diabetes, hypertension and HIV. The lack of specialized services, including sexual and reproductive health, and mental health issues also compound migrants’ health problems.

Lack of access to health services, sanitation, basic hygiene and safe water, as well as consumption of unsafe and micronutrient-poor street foods and nights spent sleeping outdoors, have also increased the incidence of skin lesions, respiratory infections and foodborne diseases among children under five – the leading cause of death in this age group in both countries.

To help address these issues, the report makes six recommendations:

  • Strengthen coordination and partnerships between countries to ensure a more coherent and rapid response to health situations;
  • Improving access to health services for migrants in transit, as well as for host populations;
  • Strengthen health surveillance and information management in accordance with the International Health Regulations (IHR);
  • Strengthening institutional and community capacities to combat preventable diseases and deaths;
  • Support countries in developing and strengthening policies, programmes and frameworks to address migrant health;
  • Help create plans to promote preparedness, response and recovery in the context of a migrant health crisis.

PAHO continues to work with countries in the Americas to support the development of migration response plans to improve access to health for migrant and local populations, improve health surveillance, and strengthen partnerships and networks.

The Organization also works with host countries to implement health promotion campaigns on issues related to dengue prevention, sexual and reproductive health and other health topics, as well as to develop campaigns to combat xenophobia, stigma and discrimination.

Peru: Congress approves exceptional health coverage for migrants and refugees with TB and HIV

Peru approves groundbreaking law to extend health coverage for migrants with HIV and TB

In a milestone decision, the Peruvian Congress has passed legislation that extends temporary health insurance coverage to migrants diagnosed with HIV and tuberculosis (TB). This law allows non-resident foreigners to access healthcare services through the public health insurance system (known by the Spanish acronym SIS) while they complete their immigration processes.

This law, which incorporates proposals from Law Bills 5253, 5554, and 7260, represents a significant step in reducing barriers for migrant populations, ensuring timely medical attention without the need for official residency documentation. Now, migrants affected by HIV or TB can receive vital healthcare services, including medical consultations and diagnostic exams, regardless of their immigration status.

The legislative breakthrough follows over two years of advocacy led by the Grupo Impulsor, a coalition that includes UNAIDS, alongside partners such as USAID’s flagship initiative Local Health System Sustainability Project (LHSS), IOM, UNHCR, the Peruvian Observatory of Migration and Health of the Peruvian University Cayetano Heredia (OPEMS-UPCH), Colectivo GIVAR, VENEACTIVA, the Peruvian TB Social Observatory, and Partners in Health.

Likewise, providing timely treatment for migrants with HIV or TB not only improves their quality of life but also reduces the risk of transmission, making it a crucial public health measure benefiting everyone. It also saves money: early care is far more cost-effective, preventing advanced cases that strain the health system.

A cost-benefit analysis reveals that Peru could save around 5 million soles ($1.33 million USD) annually by preventing new infections and another 54 million soles ($14.58 million USD) through avoiding productivity losses linked to AIDS and TB-related deaths.

Migrants living with HIV in Peru remain among the most discriminated groups in the country, with 70.7% reporting stigma, according to the Ministry of Justice and Human Rights. They also face heightened vulnerability due to xenophobia, violence, and exploitation—nearly half of them have experienced physical violence or sexual exploitation. Accessing healthcare is a major challenge, with only 2% of migrants with HIV covered by public health insurance, leaving the rest to pay out-of-pocket costs that many cannot afford.

“By extending health insurance to migrants, Peru is not only addressing these barriers but also aligning with global commitments, like the Sustainable Development Goals (SDGs), aimed at eradicating epidemics such as AIDS and TB by 2030”, says Luisa Cabal, UNAIDS Regional Director for Latin America and the Caribbean. “This legislative victory not only marks a turning point in health policy but also sets a precedent for future reforms, ensuring a more inclusive and equitable healthcare system for all.”

Protecting everyone’s rights protects public health.

Netherlands: Study explores factors influencing the uptake of HIV testing among heterosexual migrants

Barriers and enablers that influence the uptake of HIV testing among heterosexual migrants in the Netherlands

Background

Heterosexual migrant men and women in the Netherlands often face barriers to accessing health services, including HIV testing, that may lead to late-stage HIV diagnoses. This study explored factors of influence in the usage of HIV testing among heterosexual migrants.

Methods

Qualitative evaluation with semi-structured interviews at the Amsterdam-based AIDS Healthcare Foundation (AHF) Checkpoint and one focus group discussion (FGD) conducted during June-July 2023 with 19 participants: interviews with 12 heterosexual migrants from low- or middle-income countries (LMICs) and FGD (n = 5) and interviews (n = 2) with 7 key informants from the (public) health sector. Recorded interviews were transcribed and thematically analyzed, using the framework of Andersen’s Expanded Behavioral Model of Health Services Use.

Results

In total, 55 themes emerged from the interviews and the FGD. Examples include insufficient availability of information on HIV and testing services, and difficulty in accessing these services (e.g. the barrier of the online appointment system of the Centre for Sexual Health (CSH)). HIV test participants expressed free, rapid testing, no appointment required, and a positive experience during their HIV test as enablers to test in the future. Results from key informants showed that poor health literacy and lack of clarity on the healthcare system’s guidelines were barriers for heterosexual migrants in accessing information on HIV and testing services. It also revealed past initiatives and interventions that were successful in reaching at-risk groups such as the integration of HIV testing into sexually transmitted infection (STI) testing, but that were subsequently discontinued due to financial constraints.

Conclusion

Factors contributing to a low HIV test uptake were participants’ perception of limited accessibility of CSH facilities, insufficient available information on HIV (testing) services, and low perception of HIV risk. Unclear policies on accessing HIV/STI testing services at CSHs, and potential missed opportunities for HIV testing at general practitioners were contributing factors identified by key informants.

For the full text of the study, see: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0311114

 

France: New government wants to reform the law that gives free medical assistance for immigrants after three months

New French interior minister announces plan for tougher immigration policy

France’s newly appointed interior minister Bruno Retailleau signalled a rightward shift for French interior policy on Monday at his first public speech in office. Addressing police unions at the Cour de l’Hôtel de Beauvau, he vowed to end “illegal” migration and “restore order” in the country.

Concerning immigration, the senior senator with The Republicans (Les Républicains) party called for a much tougher policy in an interview on national TV, proposing to regularize as few people as possible while deporting as many as possible. He also urged legislative changes, such as a reform to the law that gives free medical assistance for immigrants after three months in the country, aiming to replace it with a much-reduced protection regime. Beyond this, he is targeting the “Circulaire Valls,” a law instated in 2012 under former President François Hollande which ended the criminal offense of illegal residence, preventing law enforcement from taking individuals in an irregular situation into custody. This would be contrary to decisions by the Court of Justice of the European Union (CJEU) on the Return directive and subsequent Cassation Court decisions.

Another proposed change consists of revoking a 1968 bilateral agreement with Algeria, signed in the context of decolonization, which grants special status and benefits for Algerian immigrants to France. However, the fact that the agreement is governed by international law, not French law, might make it more difficult to make it void. A cancellation would immediately affect Algerians and their rights in France. Moreover, Retailleau called for bilateral agreements with Maghreb countries to better retain migrants outside of Europe, following the examples of Italy’s agreement with Albania and the agreement between the EU and Tunisia.

Retailleau is a senior politician with plenty of experience who was first elected to the National Assembly in 1994, represented the Vendée department for the past 20 years and finally served as president of the LR senatorial group since 2014. He is part of France’s recently elected government following a snap general election in response to President Macron’s loss of support in public polls.

Vietnam: Vietnam and IOM sign MoU to promote migrant inclusion in National Health Systems

IOM and Ministry of Health sign partnership to promote migrants’ health

The International Organisation for Migration (IOM) and the Ministry of Health (MoH) on Wednesday afternoon strengthened their collaboration in promoting the health and well-being of migrants.

HÀ NỘI — The International Organisation for Migration (IOM) and the Ministry of Health (MoH) on Wednesday afternoon agreed to strengthen their collaboration in promoting the health and well-being of migrants by signing a new Memorandum of Understanding (MoU).

Under the MoU, they also agreed to promote migrants’ inclusion in national health systems and policies.

The MoU reflects nearly 40 years of collaboration between IOM and MoH, which began in the early 1980s.

Over the years, this partnership has grown from IOM health assessment programmes for populations moving to destination countries to public health efforts that facilitate better access to healthcare services for migrants and strengthen cross-border disease control and public health emergency response and preparedness.

Việt Nam has become a significant source of migrants, particularly those seeking employment opportunities abroad.

Recent data shows a resurgence in international labour migration, with approximately 155,000 Vietnamese citizens securing employment abroad last year alone, equivalent to nearly a third of the new workers entering the labour market.

Similar to other countries in the ASEAN region, the burden of health issues in Việt Nam remains complex, including infectious diseases, occupational health hazards and injuries, mental health challenges, non-communicable diseases such as cardiovascular disease and diabetes and maternal and child health problems.

Infectious diseases like human immunodeficiency virus (HIV), acquired immunodeficiency syndrome (AIDS), tuberculosis (TB) and malaria continue to be significant concerns.

Achieving Universal Health Coverage (UHC) remains a challenging goal and presents an even greater challenge for migrants.

Recent studies conducted by IOM in the region have highlighted the challenges faced by cross-border migrants in accessing healthcare, including language barriers, discrimination, financial constraints, lack of health insurance across borders and lack of official cross-border referral mechanisms for migrant patients.

They can be made even more vulnerable in pandemic situations due to inadequate access to needed health care and services, as shown during the COVID-19 pandemic.

Park Mi-Hyung, Chief of Mission of IOM in Việt Nam, stressed the importance of this collaboration to ensure the health and well-being of migrants, aligning with the goals of the Global Compact for Safe, Orderly, and Regular Migration (GCM) and the Sustainable Development Goals (SDGs).

“In a world where an increasing number of people are on the move, collaborations and partnerships are crucial to enhance the health and well-being of migrants. Healthy migrants contribute to healthy communities,” she said.

Nguyễn Tri Thức, Deputy Minister of Health, said that in recent years, the MoH and IOM have actively cooperated in many areas related to ensuring the health of migrants, including raising awareness of migrants’ health, strengthening bilateral cooperation in cross-border tuberculosis control and preparing for and responding to public health emergencies.

In addition, he said, IOM supported enhanced regional cooperation last year through regional workshops on migration and migrant health.

Goal 3 of the United Nations Sustainable Development Goals is good health and well-being.

“I hope we will continue to promote closer cooperation to successfully implement the United Nations Sustainable Development Goals,” said Thức. — VNS

Australia: Criminalisation fuels healthcare disparities for migrants living with HIV

HIV in Australia: shades of injustice remain

Elimination is the goal, but migrants living with the virus experience a criminalised environment that thwarts access to care.

Health Minister Mark Butler painted a largely rosy picture of the progress towards elimination of HIV in Australia today, speaking on the second morning of the ASHM HIV/AIDS Conference in Sydney.

A legal academic, however, said people with HIV in Australia were still living under a pall of criminalisation, none more so than migrants.

Mr Butler praised the Australian response to the epidemic, especially in NSW, which was most affected in the early days.

“Since HIV was first detected more than 40 years ago in Australia, Australia’s response has been one to be proud of,” he said.

“When you go back to those early years, AIDS was highly feared here as it was around the world. There was huge stigma, misinformation, homophobia and such loss and so much grief for communities.

“But Australia’s response early on was characterised by partnership and collaboration: governments, people living with HIV, communities affected by HIV, non-government organisations, health professionals and academics all came together and worked together.”

He said HIV notifications were declining in Australia, at one of the fastest rates in the world – “but as you have all heard, I’m sure, transmission has also gone up in 2023, reminding us there is always more work to be done”.

“Eliminating transmission of HIV here in Australia is ambitious, but I am absolutely assured it is now achievable,” he said today, citing inner Sydney – once the epicentre of the epidemic – as a place that had effectively achieved elimination.

Mr Butler set up the HIV Taskforce last year with a goal to “virtually” eliminate transmission by 2030. The Ninth National HIV Strategy covers from last year to 2030, continuing the work of the Eighth – whose goal was virtual elimination by 2022.

He said transmission rates had grown “among temporary residents who are here in Australia on work or study visas”.

“So we will provide subsidised access to PrEP to make healthcare more equitable for people who don’t have access to Medicare … We will make sure that at-risk populations can get free HIV self-testing kits through an expansion of the national HIV self-test mailout program [run by the National Association of People with HIV Australia (NAPWHA)] as well as HIV self-testing vending machine programs,” said Mr Butler.

For David Carter, Scientia Associate Professor at the faculty of Law & Justice at UNSW, the necessary changes for people on visas won’t be found in any vending machine but in immigration policy.

Professor Carter, who leads the Health+Law Research Partnership for social justice for people living with HIV or hepatitis B, walked through the history of “unjust and unhelpful” HIV criminalisation in Australia – a public policy environment that includes but is not limited to action by law enforcement and courts. It begins with the creation of a “suspect population”.

He quoted the very first National HIV Strategy in 1987, which warned of the “temptation” of criminalisation measures, including “universal or selective testing, closure of gay venues, criminal penalties for transmission, compulsory notification of HIV infection and restrictions on freedoms of infected people through limitations on employment, quarantine or compulsory detention”, and noted these would jeopardise health measures to prevent transmission.

A working party in 1992 concluded that “even in the face of decisions by individuals that generate harm, it was the wrong decision to restrict the free choice of individuals in modern society, as draconian measures would merely alienate people at risk of infection and deter them presenting for counselling, testing and treatment”.

While pressure to enforce such measures may have been largely resisted, and the situation for Australians has greatly improved, migrants living with HIV are still experiencing an alienating and hostile environment, said Professor Carter.

Characterising them as posing potential harm to Australians “establishes an adversarial relationship between the person living with HIV and the state” and compromises health care by promoting defensive behaviour.

He and his team have interviewed migrants in Australia living with HIV over the past two years, for whom “criminalisation is indeed very active, and it is producing serious, negative health and other impacts of individuals or communities and respects”.

He quoted one interviewee, “Sergio”, who told the team: “I don’t have to face any court, but I did have to prove that I wasn’t a bad person just because I have HIV.”

Others spoke of experience going through the migration process as being “subject to an unending interrogation”.

“Laurence” told his interviewer: “It’s like a tattoo on your mind. The government will treat you different for every single step of your life from here on out.”

“Manish”, who was on a temporary visa, avoided getting tested for 10 months after beginning to suspect he had HIV, for fear of having his visa revoked. His health deteriorated during this time.

“The elevated threat levels produced by the interaction of migration law and public health law … significantly harmed Manish’s health, caused psychological distress and steered him towards coping responses that denied him the testing and treatment, access to medical care and other supports that he deserves and that we all collectively affirm are essential and are his right,” said Professor Carter.

“Manish said to us: ‘I feel like if I had reassurance that nothing’s going to happen to me if I tested positive for this, I would not have been afraid to go and get a test for HIV’.”

Others described feelings of “hopelessness and depression, because there is no hope for us to stay permanently while living with HIV” (in fact there are pathways for permanent migration despite living with HIV). These people would go for weeks without medication in a form of self-sabotage “because they just don’t have hope for their future anymore”.

For these and other people like them, the Australian environment “is just a set of undifferentiated threats to autonomy, wellbeing and safety, to which they are forced to respond with adaptation, distancing and adopting a posture of self-defence”.

Professor Carter concluded that “it may be different today [from the 90s], but it is not over, and it won’t be over here or elsewhere until the stigma of HIV, unconventional sexuality and drug use are gone”.

The HIV/AIDS Conference is running in Sydney this week back-to-back with the 25th IUSTI World Congress.

India: India’s informal migrant workers face challenges accessing HIV and social protection services

Reaching Unreached Migrants In Unorganised Workforce With Health Services – OpEd

By

According to the Ministry of Labour and Employment of Government of India, the workers in the unorganised sector constitute about 93% of the total workforce in the country. A lot of them are informal migrant workers who live in difficult conditions and are most likely to be left behind when it comes to accessing healthcare and social protection services.

“My humble submission is that unorganised sector workers should be put first for serving their healthcare and social protection needs,” said Syed Mohammad Afsar, who leads the global HIV/AIDS programme for ILO (International Labour Organization). ILO is one of the oldest United Nations agencies which focusses on social and economic justice by advancing labour standards.

“Gujarat is an Indian state that receives many migrant workers – they include those coming from neighbouring states as well as those who come from different districts of Gujarat. These migrants work in the informal sector and face a lot of hardships and challenges- such as violence, inadequate income, or vulnerable situations where their rights may not be protected. That is why since the last almost three years now, we have focussed on Gujarat to promote HIV testing among informal sector workers,” added Afsar. Addressing gender-based violence, income disparities which make people vulnerable to HIV, and other vulnerabilities is also vital.

India, along with other countries, has promised to end AIDS as a public health threat by 2030. Scientific evidence shows that if a person living with HIV is receiving lifesaving antiretroviral treatment and remains virally suppressed, then he/she/they can live normal healthy full lives and the risk of any onwards spread of HIV from that person is zero. At the same time, all others should have full access to HIV combination prevention options in an evidence- and rights-based manner.

Afsar shared that ILO intervention in Gujarat has been developed together with the government’s Ministry of Labour and Employment, local employers and trade unions, and other partners to address both: HIV and TB among informal sector workers. Ending discrimination and building capacities is so key, says Afsar. Community-based HIV testing was one of the hallmarks of these efforts.

GAP is filling the gap in health service coverage of unorganised workforce

One such project of ILO was implemented by organisations like GAP (Gujarat AIDS awareness and Prevention unit – GAP – which is part of the International Society for Research on Civilization Diseases and on Environment – ISRCDE).

“GAP has reached out to those who were unreached,” said Afsar while speaking with CNS founder head Shobha Shukla on the sidelines of world’s largest AIDS conference this year (25th International AIDS Conference or AIDS 2024). “It is critically important to reach the first HIV target – which is to ensure that at least 95% of people living with HIV should know their status. People need to get diagnosed to receive the lifesaving treatment.”

GAP-led initiative found that the HIV rate in the informal sector workers they served was 0.36%, which is higher than the national average of 0.23%.

GAP leaders Jogendra Upadhyay and Pankaj Patel both spoke to CNS. They also serve on the leadership of INN – a pan-India network of over 350 groups working on issues related to HIV/AIDS- and were among the distinguished presenters at AIDS 2024.

“Well-planned targeted interventions of National AIDS Control Organisation (NACO) of the government of India also serve the migrant workforce. But it has perhaps not reached everyone, such as construction workers, small scale industry workers, farm workers, agriculture market informal workers, fruit and vegetable market workers, quarry workers, among others. We have to reach them with full cascade of comprehensive health and social protection services so that no one is truly left behind,” said Jogendra Upadhyay.

“Put human being first is a mantra of our founder late Dr Radium Bhattacharya as our first accountability is to the people we serve who are our first stakeholder too,” said Pankaj Patel.

GAP took the challenge of serving those who are left behind

“One problem is that migrant workers in unorganised or informal workforce change every year. They work for a few months and then go back to their native place because of ‘seasonal migration’. One example is of those who work in cold storage warehouses in Gujarat. Cold storage warehousing involves the storing of perishable or other temperature sensitive goods like food, at a specific temperature range to maintain their shelf-life and quality. About 10,000 workers from eastern Uttar Pradesh, Bihar, Odisha, and other states, work in cold storages in Gujarat for six months. Next year, all those who turn up to work could be different. This increases vulnerability to HIV, TB, sexually transmitted infections (STIs), and also breaks the continuum of care,” said Jogendra.

GAP engaged employers and employers’ associations at local and state level, along with trade unions, district TB offices (DTOs), Gujarat State AIDS Control Society of the government, and other partners who could help provide comprehensive care to the workers. “Engaging the local contractor who hires labour workforce is also very important,” points out Jogendra.

GAP organised over 15 meetings of all those who had a role to play in helping support the initiative to reach the unreached informal sector workers.

“First step was to survey over 1,200 people from labour workforce for a range of vulnerability-related factors,” said Pankaj. “20% of them reported to have multiple sexual partners. We could also connect with few who reported to be gay men and other men who have sex with men or female sex workers. These were hidden communities,” rightly says Pankaj and Jogendra of GAP as these people were not able to benefit from the existing interventions for migrants.

Four-Fifths did not go to health centre so as not to lose their daily wage

“Our survey shows that 78% of these persons did not go to the health centres of integrated counselling and testing centres of the government as they did not want to lose their daily wages – and rather preferred if such a service was available at their workplace,” said Jogendra.

“That is why, all programmes of GAP are done at the workplace of workers,” emphasised Jogendra.

Community-based HIV and TB screening, community-based HIV testing, linkage to HIV and TB care services, and a range of comprehensive support services are key elements which makes GAP’s intervention at workplaces of migrant workers so successful.

Game: Ladder signifies Do’s – and Snakes signify Don’ts

GAP not only uses flipcharts for raising awareness, but also uses the widely popular ‘snakes and ladders’ board game, but with a difference: ladder is for those who give the right answer (they move upwards in the game), and snake is for those who give a wrong one (they go downwards in the game).

Games help us engage people more and convey important messages related to HIV (and STIs, TB, hepatitis) prevention, testing and treatment in a more effective way, says Jogendra.

Agrees Afsar of ILO: “I have seen how GAP volunteers use ‘snakes and ladders’ game to engage people at workplaces. If you give the right answer, you go upwards, and if you give the wrong answer, you go downwards. These are inter-educational approaches that need to be leveraged upon to enhance health seeking behaviour.”

GAP’s impact

In a span of three years, GAP (via its community-based intervention), has screened almost 40,000 migrant workers for HIV and TB at the workplace of informal or unorganised workforce in few districts of Gujarat. Out of those screened and tested, 87% were first-time testers for HIV in their lifetime, informed Jogendra.

Thanks to GAP’s important work in bridging the divide between the reached and unreached with services, 116 people were diagnosed with HIV and 37 with active TB disease (and one worker with drug-resistant form of TB, HIV and cervical cancer) – and all of them were linked to the nearest government-run treatment and care services.

“It is important to note that 96% of those diagnosed with HIV were asymptomatic – they had no symptom. Worksite interventions help find people early and link them with public care services,” said Jogendra.

Once found positive for HIV (or active TB disease), every person is linked to the government-run programmes without any delay. We link those with HIV to the nearest centre which provides antiretroviral treatment, and those with active TB disease to the district TB programme, said Jogendra.

“In addition, we also help them avail of the benefits from government-run social protection schemes, such as e-Shram Card (for labour and employment) and Ayushman Bharat Card (for health coverage),” said Jogendra.

Community-based services are critical to reach the unreached

Afsar shares that “Community-based HIV testing was an important part of migrant workers testing project – they got rapid test kits from Gujarat State AIDS Control Society of the government. These kits were given to community volunteers after proper training, so that they could take those test kits and offer a test in communities.”

Jogendra reflects: “Our next step is testing family members (spouse, children, or others) for HIV and TB – and linking them to care as needed. But our project is a humble initiative whereas India is a large and diverse nation. There is an urgent need to scale up interventions to reach the unreached workers of informal or unorganised sector in every other state and ensure continuum of care.”

GAP partners with local district TB office of the government’s National TB Elimination Programme, which trains them in doing community-based TB screening (looking for classical TB symptoms), collecting sputum samples and handing them to laboratory of primary health centre or sub-centre for TB testing. If active TB disease is detected, then GAP supports the person through the TB treatment and ensures completion. GAP also ensures that the person is availing government-support schemes such as those that provide INR 500 per month of financial support (directly in the bank account of the patient) during treatment. GAP also provides supplementary nutritional support like protein powder, vitamin syrup, or other local nutritious food.

Over 96% of people screened for HIV were also screened for TB voluntarily, says Jogendra. Many were also screened (and referred as indicated) for hepatitis and a range of STIs.

One recent example of a person-in-need supported by GAP is of a female labour worker of a cold storage warehouse. She was diagnosed with HIV, multidrug-resistant TB, and cervical cancer. She received her treatment through local government-run antiretroviral clinic, treatment for drug-resistant TB through local government-run TB clinic, and referred to a gynaecologist for cervical cancer management, informed Jogendra. “Her son was linked to government-run scholarship programme for education in Gujarat state.”

Comprehensive care is vital, feel Jogendra and Pankaj. For instance, they also screen people for diabetes and blood pressure. Diabetes can heighten risk for TB as well as complicate outcomes of HIV care.

Every six months a person with HIV is offered a TB test.

No wonder that ILO has recognised GAP’s work several times as a best practice example, share Jogendra and Pankaj – for helping make a difference and doing justice to the legacy of Dr Radium Bhattacharya and GAP.

Do we know how to reach those who are currently unreached?

We are aiming to reach 95% of people living with HIV by 2025 so that they can know their status, and 95% of those who know their status should receive the treatment, and 95% of those on treatment should be virally suppressed. But do we have the right programmatic mix to reach those we are leaving behind- the unreached?

GAP’s intervention, supported by ILO and many other partners, provides some insights.

“We must reach the places where we have not reached earlier – such as places where migrant workers sit, work or live. They often do not have time to go to a health facility and get tested – if they go there then there is an opportunity cost – they do not get the daily wage for that day – therefore we have to take the services where they are,” reemphasises Afsar.

“A large number of people have been tested (for HIV), and those who are found positive are put on treatment. These are the people who were asymptomatic and a lot of them were young people, who are now on treatment and virally suppressed so that they can lead happy and productive lives,” rightly says Afsar.

Awareness or health literacy is key

We have to enhance risk perception for both TB and HIV so that people consider taking a TB test or HIV test and linkage to public services. “That is why in our workplace programmes we take help of peer educators, who go and create awareness, and enhance risk perception – this cannot be done in a lecture-driven or PPT driven approach,” said Afsar.

“We never impose HIV (or TB) testing. Testing is not the first step. First step is awareness generation – and do it in an environment where people’s rights are protected. That is why we engage and sensitise the employers and government agencies too along with other stakeholders to give confidence to workers that if they are found positive (for HIV or TB) they will not risk losing their job. Instead, they will get support, care and treatment to live healthy and well,” said Afsar.

Health justice in a socially unjust world

We all have to strive for health justice, and eventually social justice, which is ecologically sustainable. HIV, TB, hepatitis or STIs responses are part of this overarching approach. Let us hope GAP continues to bridge the gap in access to healthcare and social protection for those in informal or unorganised sector – and such people-centred approaches get scaled up everywhere.

US: City initiative aims to combat rising STIs rates among vulnerable populations

NYC to launch STD outreach program for uninsured New Yorkers, migrants

The city is launching a new outreach program to try to curb sexually transmitted diseases among uninsured New Yorkers, including migrants, The Post has learned.

Health Department officials reported a significant 36% spike in syphilis cases among women and an 11% jump in the gonorrhea rate among men in the city in 2022 — when a tidal wave of migrants began flooding the Big Apple, according to the most recent data available.

For both sexes combined, the city saw a 3% increase in syphilis cases that year compared to 2021, a 3% increase in chlamydia cases and 10% increase in gonorrhea cases.

“Assuring comprehensive and timely screening and treatment for STIs [Sexually Transmitted Infections], including chlamydia, gonorrhea, and syphilis, is critical for preventing … infertility, increased susceptibility to HIV, and congenital syphilis—as well as preventing onward spread to sex partners,” the department said in a pitch to potential bidders to run the program.

“Those who have immigrated to the US face barriers including insurance ineligibility (for undocumented and DACA recipients), delays in eligibility to access public health insurance programs (for documented immigrants), and barriers in understanding eligibility standards,” it added.

More than 212,000 migrants have sought assistance since arriving in the city starting in mid-2022, with 63,000 currently in the Big Apple’s shelter system, Mayor Eric Adams said Tuesday.

Last year, Health Commissioner Ashwin Vasan raised the alarm that half the migrants entering the city had not been tested for the contagious and potentially deadly polio virus.

Most low-income citizens have access to health insurance such as Medicaid to be screened and treated for sexually transmitted infections including chlamydia, gonorrhea, syphilis and HIV.

But the department said it’s more difficult to reach the hundreds of thousands of uninsured New Yorkers, including asylum-seekers, undocumented migrants here illegally and other young people.

Residents who lack insurance are unlikely or unable to self-pay for treatment out of pocket or may resist testing on their own, too, officials said.

“Lack of insurance and financial instability are among the frequently noted barriers to STI care, and they are often correlated,” the department said in its “concept paper” explaining the outreach.

Younger residents, LGBT individuals, blacks and Latinos and the unemployed who are uninsured or underinsured are also less likely to get screening, officials added.

Reported STI cases in the city have risen steadily since 2018, the department said.

But officials said the increase may partially reflect the resumption of STI screening services that were suspended or postponed during the COVID-19  pandemic.

Such services were impacted by lockdown protocols and restrictions and nationwide shortages in testing supplies.

The department said it is seeking  up to three contractors to provide STI-related services to uninsured New Yorkers in neighborhoods with the highest rates of chlamydia, gonorrhea, and syphilis.

The services would include screening and treatment as well as providing vaccines for hepatitis A, hepatitis B, HPV, and mpox.

“The purpose of this RFP [request for proposals] is to ensure that these individuals have equitable access to STI services,” the proposal said.

The Health Department had no immediate comment on how much the initiative would cost or how much each contractor would be paid and over how many years.

Tajikistan: Migrants can get tested and access treatment for HIV anonymously and free of charge

Where to get an anonymous HIV / TB test and free treatment in Tajikistan

HIV and tuberculosis are two complex diseases that require a multi-faceted approach that includes medical, social and educational interventions. It’s crucial to tackle these diseases not only to reduce the number of infections but also to improve the quality of life of people living with them.

 The number of people living with HIV among migrants is increasing

In Tajikistan, one in three people with HIV is a labour migrant. Over the past five years, 5,463 cases of HIV infection have been identified, according to data from the Republican Centre for Prevention and Control of HIV/AIDS. Migrants make up 22% of the infected. While in 2019 migrants accounted for only 17% of those infected, by 2023 this figure had increased to 32.5%.

Balajon Davlatov, a specialist in the dispensary department of the Republican HIV Centre, strongly recommends taking a free test at one of Tajikistan’s HIV prevention and control centres immediately after arrival.

“If migrants have doubts about their HIV status, they should be tested when they back home,” Balajon Davlatov said.

According to his words, more than 300 migrants are already on the dispensary registration of the Republican HIV Center. The identity and test results are not disclosed to third parties.

“Any information about each individual should be confidential. You can obtain rapid tests that report a patient’s HIV status within 15 minutes by analyzing saliva – completely anonymously,” says Balajon Davlatov.

HIV tests are available free of charge at one of the 67 state HIV prevention and control centres in all regions of Tajikistan.

In addition to blood testing at AIDS Centres, self-testing using near-blood fluid is now available. Self-testing kits are available in Dushanbe, Rudaki, Khujand and B.Gafurov via online ordering at hivtest.tj.

The order process involves filling out a simple form with a few questions. The platform helps people confidentially know their HIV status and provides up-to-date information on protection and prevention methods.

Those who tested positive for HIV can learn more about their result and get a second confirmatory test at the AIDS Centre.

In Tajikistan, there is an example of an HIV-positive mother who gave birth to two healthy children by stopping the virus from growing in her organism:

“We had a case of an HIV-positive woman. After she was treated with antiretrovirals, she gave birth to two healthy children who were HIV-negative. She’s now based in the Russian Federation and we send her the necessary medication and support. This shows that people infected with HIV can have children who are healthy and lead a full life”, says Balajon.

HIV is a human immunodeficiency virus that attacks the immune system. Most people do not experience any symptoms when they are infected. Sometimes a flu-like condition develops a few weeks after infection. But if abandoned and left untreated, HIV can develop into the final stage, AIDS, when the body is so weak it cannot protect the body from various infections and diseases.

Infecting another person with HIV is a Crime

However, a positive HIV status can bring certain risks, not only related to the state of health, if a person knows that he/she has a positive HIV status, but hides it from his/her sexual partner, within the framework of article 120 of the Code of Administrative Offenses of the RT, he or she may be fined from 720 to 1440 somonis.

Avoiding treatment for HIV or other infectious diseases is also subject to a fine from 1440 to 2160 somoni. This responsibility is stipulated in Article 119 of the Administrative Offenses Code of the RT.

If an individual intentionally infects another person with HIV, he or she can be punished by up to 3 years’ restriction of freedom or up to 2 years’ imprisonment. When a person infects another person with HIV knowing their HIV status, they can face 2 to 5 years in prison. The prison term can be longer – from 5 to 10 years in case more than one person was infected or the victim was a minor. This punishment is stipulated in Article 125 of the Criminal Code of Tajikistan, which characterises these actions not as an ordinary offence, but as a criminal act.

Therefore, it is crucial to have regular tests and status checks, especially if a person is at risk of infection.

How to recognise TB in the early stages

Having an HIV diagnosis, however, a person is not only at risk of committing offences but is also at risk of contracting serious infectious diseases, such as tuberculosis. We should also talk about this disease in more detail since the working conditions of many labour migrants can contribute to the infection of tuberculosis and its progression to more severe stages. Moreover, TB infection may have no connection with the presence or absence of HIV in a person. It is a separate disease that is also prevalent among different population groups, including labour migrants. In 2023, 4,048 TB patients were registered in Tajikistan.

In its initial stages, TB can easily be mistaken for the common flu, making it difficult to diagnose. However, several symptoms may indicate the presence of the disease:

  • Cough that lasts for more than 3 weeks.
  • The cough may be dry or with sputum that may contain blood.
  • Feeling tired for no apparent reason, even a rest.
  • Appetite loss and weight loss for no apparent reason.
  • Slight fever (up to 37-38°C), in the evening or at night.
  • Heavy sweating during sleep, even in a cool room.
  • Chest pain, which may increase with coughing or deep breathing.
  • Decrease in performance and shortness of breath with minor physical exertion.

Farkhod Dzhumayev, a phthisiologist, said the flu is not as exhausting: symptoms last 1-2 weeks, while TB is treated for 6 months to 2 years. Tuberculosis is treated with TB drugs, but without treatment, it can lead to death. Discontinuing medication prematurely or without consulting a doctor is dangerous, as it can lead to drug resistance of the pathogen.

To keep your family safe, if you suspect you are at risk of TB, you can contact one of the 69 public TB diagnostic and treatment centres. This service is provided free of charge by the state in Dushanbe, DRS, Sughd, Khatlon and GBAO.

“A patient who lives in a large family of 8 people in a 3-room apartment approached us,” says the doctor. “He went to hospitals, where he was prescribed treatment for flu, which did not relieve the patient from high fever, cough, exhaustion and headache. Fortunately, on the recommendation of the family doctor, he had a sputum test, which enabled us to detect tuberculosis in time and prescribe effective treatment.”

As Farhod Dzhumayev recalls, during the 2 months when the patient didn’t know his true diagnosis, his family also managed to get infected with TB:

“We checked his family, tested their sputum, conducted chest X-rays, and took a Mantoux immunologic test, and those who had active TB were prescribed TB treatment,” says the phthisiologist.

It’s easier to prevent the disease

HIV and tuberculosis are not a verdict. You can live a normal life with proper treatment like others.

In addition, advances in modern medicine make it possible to hope for a complete recovery from tuberculosis in a relatively short time. Scientists are also close to obtaining a cure for HIV. They are still at the testing stage, and it takes time to study their actions and potential risks. However, likely, HIV will soon move from being an “incurable” disease to a treatable one.

At this point, despite the availability of current or potential treatment, it is important to make efforts to prevent infection with serious diseases such as HIV and tuberculosis, because in any case, it is easier to prevent the disease than to spend energy, time and resources on recovering health.

Read more for addresses of treatment and testing centres in Tajikistan: https://asiaplustj.info/en/node/339434