Turkey: HIV-Positive Syrian refugee fights for access to treatment in Istanbul detention centre

HIV positive Syrian refugee ‘left for dead’ in İstanbul removal center

Ahmed Aaabo’s treatment has been disrupted by bureaucratic hurdles after his temporary protection status was removed, says his lawyer.

Ahmed Aabo was only 10 years old when his family left him at the Turkish border in 2011, seeking a safer life amidst the Syrian civil war.

Granted Temporary Protection Status upon entering Turkey, Ahmed’s life took a dramatic turn about eight months ago after he donated blood to the Turkish Red Crescent, which revealed he was HIV positive.

Ahmed began receiving treatment at Haseki Training and Research Hospital in Fatih, İstanbul, where he regularly took his medication. However, his situation worsened due to administrative decisions and bureaucratic barriers.

Losing protection status

His temporary protection status was deactivated under the G-78 restriction code, which is used for foreigners who are deemed to pose a public health threat due to infectious diseases. This deactivation prevented him from accessing his medications.

In an attempt to understand his situation and secure his medication, Ahmed visited the Kumkapı Foreigners’ Branch Directorate. There, he was detained and handcuffed for allegedly residing illegally and transferred to the Hadımköy Removal Center.

His lawyer, Hasan Kocapınar, filed a lawsuit to halt the deportation process. While awaiting the court’s decision, Ahmed was moved to the Adana Removal Center, where he could not access his medication, further deteriorating his health.

Kocapınar managed to get Ahmed transferred back to İstanbul, where he finally received his medication, but the interruption in his treatment had already severely affected his health.

Appeal to authorities

Kocapınar emphasized that denying Ahmed his right to treatment is a human rights violation. “Ahmed’s health has severely deteriorated due to the deprivation of his right to treatment and erroneous administrative actions. We will pursue all necessary legal avenues to restore his treatment rights,” he said.

He urged the authorities to honor international agreements and provide Ahmed with the care he needs, highlighting that sending Ahmed back to Syria would endanger his life, especially given his HIV status, which would make him a target for extremist groups.

Kocapınar also noted that Ahmed only has a three-month supply of medication left and emphasized the need for the Directorate General of Migration Management and the Directorate of Migration Affairs to resolve the issue. “Ahmed is currently held at the Arnavutköy Removal Center, where he does not have adequate access to his treatment. This is a human rights violation, and Ahmed’s right to health and life must be protected,” Kocapınar asserted.

G-78 Restriction Code

This code is applied to foreigners who carry infectious diseases that could threaten public health and safety, resulting in an indefinite ban on their entry to Turkey.

Peru: Venezuelan migrants in Peru face severe challenges in HIV care and basic services, report finds

Biobehavioral Survey (BBS) in Venezuelan Migrants living in Lima/Callao and Trujillo – Final report

Translated with Google translate – Scroll down for article in Spanish

The persistent and serious economic and social crisis that Venezuela is experiencing has led more than 5.5 million Venezuelans to leave their country in search of guaranteeing the right to health and life, access to basic services and job opportunities. Peru, with more than 1.57 million Venezuelan migrants, is the second country in Latin America with the most reception. This situation represents one of the largest migratory movements, comparable to that seen in war situations, such as in Syria or Afghanistan. From 2018 to date, changes have been observed in migratory dynamics, which could result in the modification of the conditions faced by migrants, and have an impact on their access to basic services.

Faced with this situation, different government bodies and some NGOs have created different channels to offer support to Venezuelan migrants in Peru. Despite the commitment and effort of the Peruvian government to support the refugee and migrant population, 91.5% of the Venezuelan population residing in the country does not have health insurance.[ 1] Many of them do not have the necessary legal and economic means to access these services and not having legal identification in the country, they do not have the national health insurance or Comprehensive Health Insurance (SIS).

The number of Venezuelan migrants living with HIV and residing in Peru has been increasing. In 2021, according to USAID figures through the LHSS (Sustainability of Local Health Systems Project) project, more than 8,000 migrants living with HIV were estimated, of which less than 50% received antiretroviral treatment. Worrying is the large percentage of migrants who stopped receiving treatment when leaving their country or during their journey to Peru, and who have encountered significant barriers to access to comprehensive HIV services during their stay.

National regulations ensure universal access to antiretroviral treatment to all people with HIV in the national territory, regardless of the country of origin, but research carried out by cooperation agencies reports that only 2% of migrants with HIV have Comprehensive Health Insurance (SIS) and that 23% of them arrive with or develop advanced stages of HIV or AIDS.

This document reports a prevalence of HIV of 1.01% in the Venezuelan migrant population in Lima/Callao and Trujillo, which is higher than the prevalence of 0.4% in the Peruvian adult population (15-49 years) [UNAIDS] and the prevalence of 0.5% in the adult population in Venezuela (15-49 years) [UNAIDS]. As in Peru, the HIV epidemic in the Venezuelan migrant population is concentrated in key population (gay men and men who have sex with other men-MSM, transgender women-MT, sex workers-TS and intravenous drug users), as well as in the young population. However, higher prevalence of HIV was found in the MSM population of Venezuelan migrants (15.6%) than the Peruvian MSM population (10%) [UNAIDS] and higher prevalence in Venezuelan male STs (43.39%) than Peruvians (3%) [10].

The findings of the cascade of the care continuum of migrants with confirmed HIV diagnosis that showed low levels of treatment initiation, continuation of care and virological suppression are worrying: 25% had started antiretroviral treatment, 20.6% reported receiving HIV care at the time of the study and 38.8% were on virological suppression. Virological suppression was higher among those with old diagnosis (85.7%) than in those with new diagnosis (17.4%). Figures well below the 95-95-95 targets of the Global AIDS Strategy 2021-2026.

The migrant population with HIV has multiple basic needs, and confronts different forms of discrimination based on their origin (xenophobia), gender expression and identity (transphobia), sexual diversity (homophobia or lesbophobia), age, or living with HIV (serophobia), which, when superimposed, determine an intersectional discrimination that, together with other social determinants, are barriers to access to health services, decent work, food and housing, and also present great difficulties in regularizing their migratory status and accessing a foreign identity card that would enable them to process the SIS. The main difficulties faced by the Venezuelan migrant population are financial (52.6%), food (21.6%) and housing (17.3%).

70.7% of migrants participating in this study report having had an experience of stigma or discrimination. With regard to the experiences of violence in the last 12 months during their stay in Peru, a total of 45.5% reported psychological violence, 47.7% physical violence, 48.7% reported having suffered forced sex and 44.2% reported having been sexually exploited in exchange for resources.

It is necessary to address these barriers through responses focused on and directed by the affected communities such as expanding the supply of diagnostic services and combined HIV prevention in the primary health care sector, which includes pre-exposure prophylaxis (PrEP) and self-testing in health services free of discrimination and with a gender equality approach.

The findings of this report provide solid evidence on the vulnerability factors and social and health determinants of the Venezuelan migrant community in Peru. It portrays the health situation of migrants in general and migrants living with HIV and identifies gaps in access to education, work, health, justice and equality for all. It is a resource for the generation of focused and differentiated policies for combined prevention, early diagnosis and timely treatment of HIV, the elimination of discrimination, the efficiency of investments in HIV, and the strengthening of other programs aimed at social welfare, food security and the elimination of poverty.

From UNAIDS we welcome the findings of this work that describes the HIV epidemic in this population in two of the Peruvian regions with the largest number of migrants and provides government decision-makers with the necessary evidence to sustain inclusive public policies aimed at eliminating the barriers to access to services, generated by the inequalities faced by the migrant population, with HIV and belonging to the key populations in Peru.

Joint United Nations Programme on HIV/AIDS (UNAIDS) – Equipo Peru

[1] [Proposal for Increasing Health Care Coverage for Venezuelan Refugees and Migrants Living with HIV. Update in Response to the COVID-19 Pandemic. PAHO/UNAIDS/CDE/COVID-19/21-0013 © PAHO/WHO and UNAIDS, 2021].
[10] Degtyar A, George PE, Mallma P, Diaz DA, Cárcamo C, Garcia PJ, Gorbach PM, Bayer AM. Sexual Risk, Behavior, and HIV Testing and Status among Male and Transgender Women Sex Workers and their Clients in Lima, Peru. Int J Sex Health. 2018;30(1):81-91. doi: 10.1080/19317611.2018.1429514. Epub 2018 Mar 27. PMID: 30224942; PMCID: PMC6138045.

The report in Spanish can be downloaded here: https://peru.iom.int/sites/g/files/tmzbdl951/files/documents/2024-01/oimreportefinal_es.pdf

Encuesta Bioconductual (BBS) en Migrantes Venezolanos que viven en Lima/Callao y Trujillo – Reporte final

La persistente y grave crisis económica y social que vive Venezuela ha llevado a más de 5.5 millones de venezolanos a abandonar su país en búsqueda de garantía al derecho a la salud y a la vida, acceso a servicios básicos y oportunidades laborales. Perú, con más de 1.57 millones de migrantes venezolanos, es el segundo país de Latinoamérica con mayor acogida. Esta situación representa uno de los mayores movimientos migratorios, comparable con el visto en situaciones de guerra, como en Siria o Afganistán. De 2018 a la fecha, se han observado cambios en la dinámica migratoria, que podrían traducirse en la modificación de las condiciones que afrontan los migrantes, y repercutir en su acceso a servicios básicos.

Ante esta situación, diferentes instancias gubernamentales y algunas ONG han creado distintos canales para ofrecer apoyo a los migrantes venezolanos en el Perú. A pesar del compromiso y el esfuerzo del gobierno peruano en apoyar a la población refugiada y migrante, el 91,5 % de la población venezolana residente en el país no cuenta con seguro de salud.[1] Muchos de ellos no cuentan con los medios legales y económicos necesarios para acceder a estos servicios y al no disponer de identificación legal en el país, no les corresponde el seguro nacional de salud o Seguro Integral de Salud (SIS).

El número de migrantes venezolanos que viven con VIH y reside en el Perú ha ido en aumento. En el 2021, según cifras de USAID a través del proyecto LHSS (Proyecto de Sostenibilidad de los Sistemas Locales de Salud) se estimaron más de 8,000 migrantes viviendo con VIH, de los cuales menos del 50% recibían tratamiento antirretroviral. Es preocupante el gran porcentaje de migrantes que dejaron de recibir el tratamiento al abandonar su país o durante su trayecto al Perú, y que han encontrado importantes barreras para el acceso a los servicios integrales de VIH durante su estancia.

La normativa nacional asegura acceso universal al tratamiento antirretroviral a toda persona con VIH en el territorio nacional, independientemente al país de origen, pero investigaciones realizadas por las agencias de cooperación informan que solo el 2% de los migrantes con VIH disponen de Seguro Integral de Salud (SIS) y que el 23% de ellos llegan con o desarrollan etapas avanzadas de VIH o SIDA.

El presente documento reporta una prevalencia del VIH de 1.01% en la población migrante venezolana en Lima/Callao y Trujillo, la cual es más alta que la prevalencia de 0.4% en población adulta peruana (15-49 años) [ONUSIDA] y que la prevalencia de 0.5% en la población adulta en Venezuela (15-49 años) [ONUSIDA]. Al igual que Perú, la epidemia de VIH en la población venezolana migrante está concentrada en población clave (hombres gay y hombres que tienen sexo con otros hombres-HSH, las mujeres transgénero-MT, las trabajadoras sexuales-TS y usuarios de drogas intravenoso), así como en población joven. Sin embargo se encontró mayor prevalencia de VIH en la población HSH de migrantes venezolanos (15.6%) que la población HSH peruana (10%) [ONUSIDA] y mayor prevalencia en TS masculinos venezolanos (43.39%) que peruanos (3%) [10].

Son preocupantes los hallazgos de la cascada del continuo de atención de las personas migrantes con diagnóstico de VIH confirmado que mostro niveles bajos de inicio de tratamiento, continuación de cuidado y de supresión virológica: 25% había iniciado tratamiento antirretroviral, 20.6% reportó encontrarse recibiendo atención en VIH al momento del estudio y el 38.8% se encontraba en supresión virológica. La supresión virológica fue mayor entre aquellos con diagnóstico antiguo (85.7%) que en aquellos con diagnóstico nuevo (17.4%). Cifras muy por debajo de las metas 95-95-95 de la Estrategia Global de Sida 2021-2026.

La población migrante con VIH presenta múltiples necesidades básicas, y confronta distintas formas de discriminación por su origen (xenofobia), expresión e identidad de género (transfobia), diversidad sexual (homofobia o lesbofobia), edad, o vivir con el VIH (serofobia), que al superponerse determinan una discriminación interseccional que junto con otras determinantes sociales, son barreras de acceso a servicios de salud, al trabajo digno, a alimentación y vivienda, y presentan además, grandes dificultades para regularizar su estatus migratorio y acceder a un carnet de extranjería que les habilitaría a tramitar el SIS. Las principales dificultades a las que se enfrenta la población migrante venezolana son financieras (52.6%), de alimentación (21.6%) y de vivienda (17.3%).

El 70.7% de los migrantes participantes en este estudio refiere haber tenido una experiencia de estigma o discriminación. Con respecto a las experiencias de violencia en los últimos 12 meses durante su estadía en el Perú, un total de 45.5% reportó violencia de tipo psicológica, 47.7% violencia física, 48.7% reportó haber sufrido sexo forzado y 44.2% reportó haber sido explotado sexualmente a cambio de recursos.

Es necesario abordar estas barreras a través de respuestas enfocadas en y dirigidas por las comunidades afectadas como son ampliar la oferta de servicios de diagnóstico y la prevención combinada del VIH en el sector primario de atención a la salud, que incluya la profilaxis preexposición (PrEP) y el auto testeo en servicios de salud libres de discriminación y con enfoque de igualdad de género.

Los hallazgos de este informe aportan evidencia sólida sobre los factores de vulnerabilidad y determinantes sociales y de salud de la comunidad migrante venezolana en el Perú. Retrata la situación de salud de las personas migrantes en general y de los migrantes viviendo con VIH e identifica brechas en el acceso a educación, trabajo, salud, justicia e igualdad para todos. Es un recurso para la generación de políticas enfocadas y diferenciadas de prevención combinada, diagnóstico temprano y tratamiento oportuno del VIH, la eliminación de la discriminación, la eficiencia de las inversiones en VIH, y el fortalecimiento de otros programas que apunten al bienestar social, la seguridad alimentaria y la eliminación de la pobreza.

Desde ONUSIDA saludamos los hallazgos de este trabajo que describe la epidemia del VIH en esta población en dos de las regiones peruanas con mayor número de migrantes y brinda a los tomadores de decisión del gobierno, la evidencia necesaria para el sustento de políticas públicas inclusivas y orientadas a la eliminación de las barreras al acceso a servicios, generadas por las desigualdades que enfrenta la población migrante, con VIH y pertenecientes a las poblaciones clave en el Peru.

Programa Conjunto de las Naciones Unidas sobre el VIH/SIDA (ONUSIDA) – Equipo Perú

[1] [Proposal for Increasing Health Care Coverage for Venezuelan Refugees and Migrants Living with HIV. Update in Response to the COVID-19 Pandemic. PAHO/UNAIDS/CDE/COVID-19/21-0013 © PAHO/WHO and UNAIDS, 2021].
[10] Degtyar A, George PE, Mallma P, Diaz DA, Cárcamo C, Garcia PJ, Gorbach PM, Bayer AM. Sexual Risk, Behavior, and HIV Testing and Status among Male and Transgender Women Sex Workers and their Clients in Lima, Peru. Int J Sex Health. 2018;30(1):81-91. doi: 10.1080/19317611.2018.1429514. Epub 2018 Mar 27. PMID: 30224942; PMCID: PMC6138045.

https://peru.iom.int/sites/g/files/tmzbdl951/files/documents/2024-01/oimreportefinal_es.pdf

HIV services expanded for displaced migrants in wake of Ukraine war and regional turmoil

Navigating HIV services during migration crisis in Eastern Europe and Central Asia

Countries affected by the migration crisis in Eastern Europe and Central Asia, prompted by the war in Ukraine and other turmoil in the region, have had to put in place measures so that all displaced people have access to essential HIV services.

 Key Figures: 

  • In 2022, Europe was confronted by the largest refugee crisis since World War II.
  • As of February 2024, nearly one-third of Ukraine’s population remains displaced, with 6.3 million Ukrainian refugees globally, primarily concentrated in Europe, 62% of them are women.
  • In 2022, around one million Russian citizens emigrated, with many choosing prolonged stays abroad.
  • Central Asian countries witnessed the biggest influx of international migrants since their independence.
  • Up to 300,000 Belarusians left their country since May 2020.
  • Migration from Central Asia to Russia surged in 2023, with notable increases in Uzbek, Kyrgyz, and Tajik nationals entering for work purposes. (ICMPD Migration Outlook Eastern Europe and Central Asia 2024)
  • The HIV epidemic is growing in Eastern Europe and Central Asia, with Russia, Ukraine, Uzbekistan, and Kazakhstan accounting for 93% of new infections in the region combined.

Surviving the devastating events of March 2022 in Mariupol, Ukraine, uncertain of what the future held, Svetlana fled her hometown.

“Mariupol was a scene of utter destruction. I had a packed suitcase, but I left it behind, only taking with me a dog and a cat,” recalls Svetlana. “With assistance, we managed to reach the Polish border, eventually finding refuge in Lithuania.”

Living with HIV since 2000, Svetlana relies on anti-retroviral treatment (ARV) to keep the virus at bay by taking a tablet a day. In haste, she had only taken one pill box.

Upon her arrival in Lithuania, she connected with an online organization that within days helped her to obtain her life-saving medicine from a doctor.

Svetlana is one of 70  participants in 6 countries in the Regional Expert Group on Migration and Health (REG) study that assessed the healthcare access for Ukrainian refugees using qualitative methods. According to Daniel Kashnitsky, the lead REG expert, “insights from specialists and service recipients revealed that all HIV-positive refugees had access to treatment across EU host countries.”

After recovering from the initial shock, the European Union activated the Temporary Protection Directive, establishing legal guidelines for managing mass arrivals, offering humanitarian aid, and ensuring access to life-saving antiretroviral treatment and basic HIV services to those in need.

Outside the EU, in countries like Moldova and Georgia, special regulations ensure free access to HIV services. Moldova’s National AIDS Coordinator, Yuri Klimaszewski, underscored that Moldova provided HIV services to refugees like it does for its citizens.

The study also revealed that some refugees struggled in host countries, leading to challenges maintaining treatment adherence. Tatyana (name changed) left Odessa along the Black Sea in April 2022.

But she returned home because she could not find adequate support under the opioid maintenance therapy program in Poland. She found it complicated to reach the service point, the language barriers prevented her from communicating her needs with medical staff, and she lacked community support.

“Despite the unprecedented support shown by European countries to Ukrainian refugees, systemic issues, particularly bureaucratic complexities, require proactive intervention by social workers, community organisations and volunteers to effectively address these challenges,” said Mr Kashnitsky. Additionally, he added, “there is a pressing need to tackle the stigma faced by people living with HIV and other key populations, such as people who use drugs.”

Uladzimir, who left Belarus for Poland in the first days of the war in Ukraine, needed about a month to start receiving ARV treatment. First, he had to obtain “international protection”, then confirm his HIV status and wait for an appointment with a doctor. But once all that was cleared, he had access to all the necessary services. For many accessing services is not as straightforward as it is for Ukrainian refugees, according to the REG study “Forced migrants with HIV status: social psychological and medical aspects of adaptation”

Legislation in some countries makes accessing HIV prevention and treatment for migrants challenging. And in some cases, national healthcare systems may lack resources to meet the influx of people and their needs.

As the Russian Federation continues to deport migrants living with HIV, those who remain in Russia due to the inability to return home or for family reasons are compelled to stay in the country illegally. They are deprived of HIV treatment and health services. Some have succeeded by receiving treatment remotely (ARVs sent to them with the help of countries of origin).

Recommended strategies, as outlined by the REG study, include improving the system of informing people about potential risks and available HIV services abroad, establishing health insurance protocols, and supporting community organizations that provide HIV services.

Removing legal provisions that discriminate against migrants living with HIV will also reduce barriers to accessing antiretroviral therapy, resulting in significant improvements for public health in the region.

Eamonn Murphy, UNAIDS Regional Director for Asia Pacific and EECA regions, praises the collaborative efforts involving various stakeholders, including governments of countries of origin and host countries, community organizations, the Joint UN Programme on AIDS, and donors.

However, he says more needs to be done. “There is an urgent need to work on the legalization and standardization of such approaches to ensure all people on the move can access essential services and remain on treatment wherever they are.”

The Golondrinas strategy connects HIV positive migrants to medical care in LAC region

Golondrinas’ project seeks to guarantee care for migrants with HIV

Translated with Deepl.com; For original article in Spanish, please scroll down.

It is a strategy for people arriving in another country to continue with the necessary treatment.

A person with HIV who leaves his or her country may experience difficulties with treatment or care elsewhere. While anyone can access the Universal Health Insurance (SUS) in Bolivia, the issue is made difficult due to forms and other issues; however, access to medicines for migrants carrying the virus has been achieved, according to the head of Health and Human Rights Projects at the Institute for Human Development (IpDH) in Cochabamba, Karina Rojas.

The ‘Golondrinas’ strategy seeks to ensure health care for migrants with HIV in the countries through which they pass or stay.

The Americas and Caribbean Platform of Coalition Plus held its annual meeting earlier this year in Cochabamba. The director of the Institute for Human Development (IpDH), Edgar Valdez, explained that the Platform’s members are Colombia, Guatemala, Argentina, Dominican Republic, Canada, Ecuador and Bolivia.

The meeting is a space to address issues such as policies, human rights in each country, budgets and how to work together on this issue, as each country has differences and similarities regarding access to treatment, the vulnerability of people with HIV, stigma and discrimination.

Another issue that stands out is related to migration and the ‘Golondrinas’ strategy.

The head of IpDH’s Health and Human Rights Projects explained that the ‘Golondrinas’ project was born in one of the meetings of the Platform of the Americas and the Caribbean, because it is a necessity for this vulnerable population; migrants with HIV.
‘People who migrate, sometimes do so irregularly and, therefore, it is very easy to violate their rights’.
She said that, in response to this situation, they submitted a project to the French Development Agency, which is currently providing funding. It consists of providing sexual health services along the route taken, in the case of Bolivia, by people arriving from Venezuela, as well as Haiti, Peru, Colombia and other countries.
Valdez explained that the project is integrated between French Guiana, Ecuador, Guatemala, Colombia, Bolivia and Argentina.

‘In other words, we want to provide health care and their rights as immigrants. It is a health support to all people with HIV, to all migrants of sexual diversity and to all women who also come here to Bolivia. In general, they are in transit, but some of them also stay. So there is legal support.

She added that there are organisations, such as Caritas and the government, which also work on other aspects.
‘We are seeing how we can articulate how to respond to this population that is extremely vulnerable because of their migrant status, because of the discrimination they may suffer and the stigma. So it is a space for them to consult, receive care and, of course, medicines.

Rojas described how they have seen cases where it has been possible for people with HIV from other countries to access treatment.

‘By advocating and explaining that health comes before the legal situation, people with HIV who need treatment have been able to access and collect from Cdevir (Centro Departamental de Vigilancia y Referencia para casos de VIH), for example.
In Cochabamba, Bolivia, there is still not much progress. But there is a need.
‘We are contacted by people who migrate, who have HIV; they have contacted us because they want to pick up their retroviral treatment or they don’t want to stop taking their medication.

He stressed that the right to health comes before documents.

The director of the Red Somos de Colombia Community Medical Unit, Jhon Ramirez, said that his country receives Venezuelan migrants who are in transit through Colombia to South or Central America.

‘The project consists of being able to approach migrants, identify their HIV status, get them into treatment and, if they are passing through, refer them to the organisations that are part of the Americas and Caribbean Platform of Coalition Plus, which have resources from the Golondrinas strategy.

The risk in ‘survival sex’ practices
For a migrant person, in their need to move from one place to another, to have sex with a trailer driver, as an example, is a survival sex practice.

The director of the Red Somos de Colombia Community Medical Unit, Jhon Ramirez, explained that there are also known cases of migrants agreeing to sex in exchange for food or a room with a bathroom or other basic necessities.
Valdez described that countries such as Colombia and the Dominican Republic receive migrants from Haiti; in addition, people from Venezuela also arrive in Colombia and Ecuador. However, in most cases they are in transit to Chile, Argentina and others.

‘We are also trying to see if there are people who want to stay in Bolivia; we protect their rights to see how they can be legal, what Bolivian laws protect these people.

Karina Rojas, head of IpDH’s Health and Human Rights Projects, stressed the importance of offering sexual health services, that is, that they can access HIV testing, ‘women can access family planning’, and treatment for sexually transmitted infections.
‘As they are a vulnerable population, sometimes they do sex work. We want to partner with other organisations that work on migration from another point of view; for example, Caritas here in Cochabamba has a shelter, so we can refer them to the shelter and they can refer us to the health services.

The IpDH director explained that ‘Golondrinas’ is related to access, above all, to universal health care.
‘We focus specifically on people with HIV, sexual diversity and, of course, sex workers as well, so everything related to sexuality, violence (…). We are always reflecting on these issues, the issue of migration.
For Ramírez, there are complex issues.

‘But the most complex part of the situation is that people do not have access to condoms, access to antiretrovirals, access to combined prevention strategies, such as access to PREP (pre-exposure prophylaxis), access to post-exposure therapy, and this is closely linked to issues of survival sex practices,’ he said.

Aiming for a single international code for patient access to treatment
The director of the Red Somos de Colombia Community Medical Unit, Jhon Ramirez, said that the ‘Golondrinas’ strategy aims to ensure that migrants with HIV have access to a single code that allows them access to treatment in other countries, if they leave their own.

‘The strategy is to let the migrant population know that in Bolivia there is the IpDH, that here they can access prevention services, that they can access medical treatment, counselling; this is the most important thing we have to do (…), so that the person knows that on the route to South America they will find Kímirina in Ecuador, the IpDH in Bolivia and the Fundación Huésped in Argentina’.
These organisations will be able to guarantee some kind of medical support in their migratory transit, in order to be able to successfully refer people.
‘The idea is to have a referral and counter-referral system so that, if I give a doctor in Colombia, in Ecuador they can see what medication this person has and there are no barriers to access.
The aim is to have a system at international level, and that each person has a unique code to be used at the time of the interview with the doctor or nurse in the programmes.
‘The code will be for the professional to access their medical history, so that the doctor in Colombia can see the treatment in Bolivia, to continue the same treatment, because they can sometimes open the entire clinic; and also so that the person has a reference code so that they can access this information.

DATA IN COLOMBIA Ramírez explained that in his country there are 7 million Venezuelan migrants. Of these, according to Colombian immigration data, two million have a vocation to stay, and the rest are migrants who are passing through to other countries in the region.

‘We seek to address 3,700 migrants and refer them to sexual health, reproductive health and HIV prevention services, as a strategy to control indicators of public health interest in our countries. An important part of the Golondrinas strategy is to establish the needs of the migrant population in terms of sexual health, reproductive health and other pathologies.
He added that it is estimated that in Colombia there are around 22,000 Venezuelan migrants who could be living with HIV.
‘We have identified 4,500, who are in the health system in Colombia. We still need to look for another 18,000 people who may be living with HIV and do not know it at the moment.

She added that a study carried out with George Hawkins University showed an HIV prevalence rate of 0.9% and 5% for syphilis.
The head of IpDH’s Health and Human Rights Projects explained that in Cochabamba there are still no statistics available.
‘We have also tried to incorporate this nationality data, for example, into the Simone (Computer System for Monitoring and Evaluation of the National HIV Programme), which is the monitoring system of the Ministry of Health, but there is still no data that we can reflect,’ said Rojas.

However, he assured that the doors of the IpDH are open for those who need antiretroviral treatment if they have HIV; for those who had risk situations, sexual violence; for testing and others referred to sexually transmitted infections.
‘What we want is that they don’t cut off the health services they need along the way.

Proyecto ‘Golondrinas’ busca garantía de atención a migrantes con VIH

Se trata de una estrategia para que las personas que llegan a otro país puedan continuar con los tratamientos necesarios.

Una persona con VIH que deja su país puede atravesar dificultades en torno a su tratamiento o atención de salud en otros lugares. Si bien, cualquier persona puede acceder al Seguro Universal de Salud (SUS) en Bolivia, el tema se dificulta debido a los formularios y otros; sin embargo, se ha conseguido el acceso a medicamentos para migrantes que portan el virus, según describió la responsable de Proyectos de Salud y Derechos Humanos del Instituto para el Desarrollo Humano (IpDH) en Cochabamba, Karina Rojas.
La estrategia ‘Golondrinas’ busca que se garantice la atención en cuanto a salud a personas migrantes con VIH en los países por donde pase o permanezca.

La Plataforma de las Américas y el Caribe de Coalition Plus realizó su reunión anual en días anteriores, en Cochabamba. El director del instituto para el desarrollo Humano (IpDH), Edgar Valdez, detalló que son miembros de la Plataforma los países de Colombia, Guatemala, Argentina, República Dominicana, Canadá, Ecuador y Bolivia.
El encuentro es un espacio para abordar temas como las políticas, los derechos humanos en cada país, los presupuestos y cómo trabajar de manera conjunta frente a esta problemática, ya que cada país tiene diferencias y semejanzas respecto al acceso al tratamiento, a la vulnerabilidad de las personas con VIH, al estigma y discriminación.
Otro de los temas que resalta es el relacionado con la migración y la estrategia denominada ‘Golondrinas’.
La responsable de Proyectos de Salud y Derechos Humanos del IpDH expuso que el proyecto ‘Golondrinas’ nació en una de las reuniones de la Plataforma de las Américas y el Caribe, porque es una necesidad para esta población vulnerable; los migrantes con VIH.
“Las personas que migran, lo hacen, a veces, irregularmente y, por lo tanto, es muy fácil vulnerar sus derechos”.
Dijo que, ante esa situación, presentaron un proyecto a la Agencia Francesa de Desarrollo y, en la actualidad, otorga financiamiento. Consiste en dar servicios de salud sexual a lo largo del recorrido que hacen, en el caso de Bolivia, personas que llegan de Venezuela, además de Haití, Perú, Colombia y otros países.
Valdez detalló que el proyecto está integrado entre Guyana Francesa, Ecuador, Guatemala, Colombia, Bolivia y Argentina.

“Es decir que, queremos brindar atención de salud y sus derechos como inmigrantes. Es un apoyo de salud a todas las personas con VIH, a todas las personas migrantes de diversidad sexuales y a todas las mujeres que vienen también aquí a Bolivia. En general, son en tránsito; pero, algunas se quedan también. Entonces hay un apoyo jurídico”.

Agregó que existen organizaciones, como Cáritas y la Gobernación, que también trabajan en otros aspectos.
“Estamos viendo cómo articulamos para responder a esta población que es extremadamente vulnerable por su condición migrante, por la discriminación que pueden sufrir y el estigma. Entonces, es un espacio para que ellos puedan consultar, recibir atención y, por supuesto, los medicamentos”.
Rojas describió que atendieron casos en los que fue posible que personas con VIH de otros países accedan a sus tratamientos.
“Haciendo incidencia y explicando que antes que la situación legal está la salud, las personas con VIH que necesitaban tratamiento, han podido acceder y recoger del Cdevir (Centro Departamental de Vigilancia y Referencia para casos de VIH), por ejemplo”.
En Cochabamba, Bolivia, todavía no existen muchos avances. Pero, hay necesidad.
“Nos contactan personas que migran, que tienen VIH; nos han contactado porque quieren recoger su tratamiento retroviral o no quieren dejar de tomar sus medicamentos”.
Remarcó que por encima de los documentos está el derecho a la salud.
El director de la Unidad Médica Comunitaria Red Somos de Colombia, Jhon Ramírez, expresó que su país recibe migrantes venezolanos, que van de tránsito por Colombia hacia Suramérica o Centroamérica.
“El proyecto consiste en poder abordar a las personas migrantes, identificar su estatus serológico a VIH, entrarlos en tratamiento y, si van de paso, poderles referenciar a las organizaciones que hacen parte de la Plataforma de las Américas y el Caribe de Coalition Plus, que cuentan con recursos de la estrategia Golondrinas”.

El riesgo en las “prácticas de sexo por supervivencia”
Que una persona migrante, en su necesidad de traslado de un lugar a otro, tenga relaciones sexuales con un conductor de un trailer, como ejemplo, es una práctica de sexo por supervivencia.

El director de la Unidad Médica Comunitaria Red Somos de Colombia, Jhon Ramírez, explicó que también se conocen de casos de personas migrantes que acceden a relaciones sexuales a cambio de comida o de una habitación con baño u otros enseres o elementos básicos.
Valdez describió que países como Colombia y República Dominicana reciben migrantes de Haití; además a Colombia y Ecuador también llega gente de Venezuela. Aunque, en la mayoría de los casos son de tránsito a Chile, Argentina y otros.

“Nosotros estamos también tratando de ver si hay alguna persona que quiere quedarse en Bolivia; le protegemos sus derechos para ver cómo puede ser legal, cuáles son las leyes bolivianas que le protegen a esas personas”.
La responsable de Proyectos de Salud y Derechos Humanos del IpDH, Karina Rojas, remarcó la importancia de ofrecer servicios de salud sexual, es decir, que puedan acceder a pruebas de VIH, “las mujeres a planificación familiar”, tratamiento de infecciones de transmisión sexual.
“Como es una población vulnerable, a veces, hacen trabajo sexual. Entonces, es un riesgo también de violencia sexual en ese trayecto (…). Queremos asociarnos a otras organizaciones que trabajan la migración desde otro el punto de vista; por ejemplo, Cáritas de aquí de Cochabamba tiene un albergue; entonces, nosotros podemos referir al albergue y ellos pueden referirnos a los servicios de salud”.
El director del IpDH explicó que ‘Golondrinas’ tiene relación con el acceso, sobre todo, a salud a nivel universal.
“Nosotros nos concretizamos de manera específica en las personas con VIH, en las diversidades sexuales y, por supuesto, las trabajadoras sexuales también; entonces, todo lo relacionado a la sexualidad, la violencia (…). Siempre estamos reflexionando en esas temáticas, el tema de migración”.
Para Ramírez, existen temáticas complejas.
“Pero, lo más complejo de la situación es que las personas no tienen en su tránsito migratorio acceso a condones, acceso a antirretrovirales, acceso a estrategias de prevención combinada, como el acceso a la PREP (profilaxis previa a la exposición), el acceso a la terapia postexposición, y esto va ligado mucho a temas de prácticas de sexo por supervivencia”, sostuvo.

Apuntan al código único internacional para acceso al tratamiento de pacientes
El director de la Unidad Médica Comunitaria Red Somos de Colombia, Jhon Ramírez, expresó que la estrategia ‘Golondrinas’ apunta a que las personas migrantes con VIH tengan acceso a un código único que les permita el acceso a tratamiento en otros países, si es que sale del suyo.

“La estrategia es poder que la población migrante sepa que en Bolivia está el IpDH, que aquí pueden acceder a servicios de prevención, que pueden acceder a tratamientos médicos, a orientaciones; es lo más importante que tenemos que hacer (…), para que la persona sepa que dentro de la ruta hacia Suramérica va a encontrar en Ecuador a Kímirina, en Bolivia al IpDH y en Argentina a la Fundación Huésped”.
Estas organizaciones en su tránsito migratorio podrán garantizar algún tipo de soporte médico, para poder referenciar de manera exitosa a las personas.
“Se trata de tener un sistema de referencia y contrarreferencia que, si yo lo medico en Colombia, en Ecuador puedan ver qué medicación tiene esta persona y no tenga barreras de acceso”.
El objetivo es contar con un sistema a nivel internacional, y que cada persona tenga un código único para ser utilizado al momento de la entrevista con el médico o enfermero en los programas.
“El código será de acceso del profesional a su historia clínica, para que pueda ver el doctor de Colombia el tratamiento en Bolivia, para continuar el mismo tratamiento, porque pueden hacer apertura, a veces, de toda la clínica; y también que la persona tenga a la mano un código de referencia para que puedan acceder a esa información”.
DATOS EN COLOMBIA Ramírez detalló que en su país hay 7 millones de personas venezolanas migrantes. De ellos, según datos de inmigración Colombia, 2 millones tienen vocación de permanencia, y el restante son migrantes que van de paso hacia otros países de la región.
“Buscamos poder abordar 3.700 migrantes y poder referenciarlos hacia servicios en salud sexual, salud reproductiva, prevención del VIH, como una estrategia de control de los indicadores de cifras de interés en salud pública en nuestros países. Algo importante que tiene la estrategia Golondrinas es poder establecer las necesidades de la población migrante en cuanto a salud sexual, salud reproductiva y también en otras patologías”.
Agregó que se estima que en Colombia hay alrededor de 22 mil personas migrantes venezolanas podrían estar viviendo como VIH.
“Tenemos identificadas 4.500, que están ingresadas al sistema de salud en Colombia. Nos falta buscar esas otras como 18 mil personas que pueden vivir con VIH y en el momento no lo saben”.
Acotó que un estudio realizado con la Universidad de George Hawkins mostró una prevalencia para VIH en el 0.9%, para sífilis, un 5%.
La responsable de Proyectos de Salud y Derechos Humanos del IpDH explicó que en Cochabamba todavía no se cuenta con estadísticas.
“Hemos tratado también de incorporar este dato de nacionalidad, por ejemplo, al Simone (Sistema Informático de Monitoreo y Evaluación del Programa Nacional de VIH), que es el sistema de monitoreo del del Ministerio de Salud, pero todavía no hay datos que podamos reflejar”, expresó Rojas.
Sin embargo, aseguró que las puertas del IpDH están abiertas para quienes necesiten el tratamiento antirretroviral si tienen VIH; para quienes tuvieron situaciones de riesgo, violencia sexual; para hacerse pruebas y otros referidos a infecciones de transmisión sexual.
“Lo que queremos es que no corten los servicios de salud que necesitan en el trayecto”.

Poland: Ukrainian refugees struggle with stigma and treatment gaps

Ukrainian refugees with HIV adjust to care abroad

On top of housing, work and schooling, Ukrainian refugees with HIV face an additional, urgent difficulty: how to access the antiretroviral medicines they need to suppress the virus. In Poland, they face a particular stigma, causing many HIV positive refugees to conceal their health status.

When Anna Aryabinska fled from Kyiv in March 2022 with her ex-partner’s children, she had little idea that she would end up supporting not only his family, but many HIV-positive Ukrainians in Poland. Until Russia’s full-scale invasion, Aryabinska had been an activist for the Ukrainian organisation Positive Women, supporting women with HIV. Now she is one of a group of volunteers assisting fellow Ukrainian refugees to keep taking medication for HIV, as well as integrate into healthcare systems in European countries which have very different epidemic profiles and standards of treatment.

Ukraine has the second-largest HIV epidemic in Europe after Russia, with an estimated 260,000 people living with the disease. Over six million Ukrainians are now refugees from Russia’s full-scale invasion, according to the UNHCR. In Poland, the top destination, 1.6 million Ukrainians have applied for temporary protection schemes (the vast majority are women and children as martial law bans most men aged 18 to 60 – like Aryabinska’s ex-partner – from leaving Ukraine). On top of issues around housing, work and schooling, people with HIV face an additional, urgent difficulty: how to access the antiretroviral (ARV) medicines they need to take every day to suppress the virus.

Difficult adjustment

Anna Aryabinska left Kyiv in March 2022, when Russian forces were just a few kilometres from the city. Better prepared than many, she took a three-month supply of ARVs and a medical note from Kyiv doctors with her. When she reached Poland she registered right away at the local AIDS centre. Since then, she has been guiding others through a similar process as part of an online service, HelpNow, supported by the Ukrainian NGO Alliance for Public Health.

‘People are in such a panic,’ she says. ‘And they have no one else to ask.’ HelpNow has set up hubs in Poland, Germany and the Baltic states, and has helped Ukrainian refugees in 47 countries with online support, as well as in-person assistance in major refugee hubs like Warsaw. HelpNow volunteers teamed up with local NGOs to help refugees baffled by practical issues like finding translators for medical records or doctor’s appointments, receiving necessary documentation, or simply reaching the nearest AIDS clinic – there are only 16 in Poland, compared to 300 in Ukraine.

Botswana: Following free ARV programme for non-citizens, adverse birth outcomes improve

Free antiretroviral therapy for non-citizens in Botswana: a further step towards the elimination of HIV

Following the expansion of antiretroviral therapy to migrants and non-citizens in Botswana, gaps have narrowed in the uptake of antenatal care and antiretroviral therapy during pregnancy between citizens and non-citizens living with HIV. Disparities in adverse birth outcomes were no longer observed after the change in policy, according to a report in the Journal of the International AIDS Society.

In Botswana, approximately 25% of female citizens aged 15 to 49 are living with HIV. Back in 2002, the government of Botswana launched a free universal antiretroviral therapy programme, which has proven to be very successful, including by improving birth outcomes of infants born to women with HIV. However, access to this programme was restricted to citizens of Botswana only, although non-Botswanan citizens represent as high as 7% of the country’s total population. Many are migrants from neighbouring countries with large HIV epidemics, such as Zimbabwe, Zambia and South Africa, with 13%, 11% and 19% HIV prevalence, respectively.

Only 29% of migrants in Botswana had personal health insurance or could afford to pay for HIV care, and research has shown that migrants had worse health outcomes than citizens of Botswana. Evidence has also shown that stigmatisation by healthcare and security staff in medical facilities were barriers to receiving care. Furthermore, pregnant non-citizens were less likely to receive antenatal care and more likely to receive care later in pregnancy, deliver at home and experience adverse birth outcomes than pregnant citizens of Botswana.

At the end of 2019, the government of Botswana drastically shifted its policy by authorising the free distribution of antiretroviral therapy to non-citizens living with HIV.

Dr Christina Fennel from Harvard University, with colleagues in Botswana and the US, evaluated the impact of this major policy change on antenatal care, antiretroviral therapy use and adverse birth outcomes among infants. For this, they compared outcomes in infants born to citizens and non-citizens living with HV, before (2014-2019) and after (2019-2021) the policy change. They used data from the Tsepamo Surveillance Study, a large birth outcomes surveillance programme that collects data from maternity sites in Botswana, including about 72% of all births in the country.

More specifically, the impact analysis was based on data from maternal records. Adverse birth outcomes analysed were preterm delivery, very preterm delivery, stillbirth, neonatal death, small for gestational age (babies smaller than usual for the number of weeks of pregnancy) and very small for gestational age. Because multiple births may be associated with adverse birth outcomes, only singleton births were included in the analyses of adverse birth outcomes.

Results

During the entire analysis period – 2014 to 2021 – there were 47,576 live deliveries and stillbirths among pregnant women with HIV recorded in the Tsepamo study, including 47,443 with known citizenship status – 45,917 (97%) Botswanan citizens and 1,516 (3%) non-citizens.

The proportion of non-citizens with unknown HIV status decreased significantly in the post-expansion period, from 6% to 1% (p < 0.001), whereas it remained the same (0.5% vs 0.4%; p = 0.02) for citizens.

The proportion of non-citizens with HIV attending antenatal care increased from 79% in the pre-expansion period to 87% following expansion, whereas attendance among citizens with HIV remained constant through both periods at approximately 96%. (Non-citizens can attend antenatal care by paying a modest fee, which did not change through the study period).

In the pre-expansion period, 65% of non-citizens received antiretroviral therapy, of whom only 7% had a dolutegravir-based regimen. After 2019, the proportion on antiretroviral therapy increased significantly to 90%, narrowing the gap with citizens (97%). Also, the proportion of non-citizens and citizens receiving dolutegravir almost equalised (42% vs 44%), showing a decrease in the use of old antiretrovirals such as nevirapine, which have a higher risk of adverse birth outcomes.

Regarding adverse birth outcomes, in the pre-expansion period infants born to non-citizens with HIV had significantly greater risks of preterm delivery (aRR = 1.28; 95% CI: 1.11, 1.46), very preterm delivery (aRR = 1.89; 95% CI: 1.43, 2.44) and neonatal death (aRR = 1.69; 95% CI: 1.03, 2.60) when compared with infants born to citizens with HIV. For reasons that are not clear, non-citizens had a reduced risk of having an infant who was small for gestational age (aRR = 0.75; 95% CI: 0.62, 0.89).

After the expansion of antiretroviral therapy, none of the adverse birth outcomes were significantly higher among infants born to non-citizens with HIV than infants born to citizens with HIV.  Also, there were declines in adverse birth outcomes among infants born to non-citizens, including preterm delivery (23% in 2014-2019 vs 14% in 2019-2021) and stillbirth (4% vs 3%). At the same time, no changes in birth outcomes for HIV-negative non-citizens were observed.

According to Fennel and colleagues, their findings suggest that greater access to antiretroviral therapy – including modern regimens – may have reduced adverse birth outcomes. They also underscore the substantial decrease of the proportion of pregnant non-citizens with unknown HIV status, as well as increased linkage to HIV therapy and antenatal care after the policy change.

In 2022, Botswana was praised for reaching, ahead of the 2025 target, the UNAIDS goals of 95% of all people living with HIV to be aware of their status, 95% of those aware of their status to receive sustained antiretroviral therapy, and 95% of people receiving this therapy to achieve viral load suppression. The results of this study further confirm that Botswana has become a model for other countries that may still hesitate to scale-up access to antiretroviral therapy and HIV care for all minorities, including migrants, not to mention those countries that might be tempted to introduce new restrictions.

References

Fennell C et al. The impact of free antiretroviral therapy for pregnant non-citizens and their infants in Botswana.Journal of the International AIDS Society 2023, 26:e26161 (open access).

https://doi.org/10.1002/jia2.26161

 

US: Find out where to go for free, or low-cost, HIV services, regardless of immigration status

Free Healthcare and Support for Immigrants Living with HIV/AIDS in New York

In New York, care for HIV and AIDS is free or low-cost for anyone, regardless of immigration status.

In New York, care for HIV and AIDS is free or low-cost for anyone, regardless of immigration status. People from the age of 12 can have walk-in free HIV tests in services at NYC sexual health clinics.

Only two clinics, Fort Greene Express at 295 Flatbush Extension in Brooklyn and Chelsea Express at 303 Ninth Avenue in Manhattan, offer appointment scheduling. You can schedule an appointment in one of these two locations. Parental consent is not necessary for tests and assistance.

The NYC Health Department asks for a fee for sexual health services given to adults (age 19 and over). They can use their insurance plan to pay for the visit. Those without health insurance or who don’t want to use it will be asked to pay a sliding scale fee based on their family size and yearly income. They will not be asked for proof of family size or yearly income.

But, without insurance and money, you will still get services. Payments are not collected at the clinics. Get more information about the billing fees.

What kind of AIDS and HIV-related services do New York City sexual health clinics provide?

  • HIV post-exposure prophylaxis (PEP)
  • Individuals who have received an HIV diagnosis and wish to commence HIV treatment for the first time can initiate their treatment.
  • People who suspect they may have HIV-related symptoms can receive a medical evaluation to determine their condition.
  • Medical evaluation for people who might have or have been exposed to HIV
  • Individuals aged 12 and above can have HIV testing, even with no symptoms.
  • HIV pre-exposure prophylaxis initiation and counseling are available by appointment only through the NYC Sexual Health Clinics hotline at 347-396-7959

NYC Sexual Health Clinics in New York:

Morissania Sexual Health Clinic

1309 Fulton Avenue, Bronx

Monday through Friday, 8:30 a.m. to noon, and 1 p.m. to 3:30 p.m.

Jamaica Sexual Health Clinic

90-37 Parsons Boulevard, Queens

Monday through Friday, 8:30 a.m. to noon, and 1 p.m. to 3:30 p.m.

Corona Sexual Health Clinic

34-33 Junction Boulevard, Queens

Monday through Friday, 8:30 a.m. to noon, and 1 p.m. to 3:30 p.m.

Fort Green Sexual Health Clinic

295 Flatbush Avenue Extension, Second Floor, Brooklyn

Monday through Friday, 8:30 a.m. to noon, and 1 p.m. to 3:30 p.m.

Fort Green Express Clinic

295 Flatbush Avenue Extension, First Floor, Brooklyn

Monday through Friday, 8:30 a.m. to noon, and 1 p.m. to 3:30 p.m.

Chelsea Sexual Health Clinic

303 9th Avenue, Manhattan

Monday to Friday, 8:30 a.m. to 3:30 p.m.

Chelsea Express Sexual Health Clinic

303 9th Avenue, Manhattan

Monday through Friday, 8:30 a.m. to 3:30 p.m.

These clinics are closed on the last Thursday of every month. They are open at 10 a.m. on the third Tuesday of every month. They may close early on other days once capacity is reached.

Visit NYC Health Map to find the provider nearest to you by clicking here. You can also text “CARE” to 877-877, to find a provider close to your location.

Contact New York State HIV/AIDS Information Hotline: 800-541-2437

Free self-test kits:

To request free HIV self-test kits, you can contact an agency participating in the Community Home Test Giveaway program. You will find them on the NYC Health Map. Click on Sexual health services, HIV testing, and on free self-test, click yes.

Housing programs for people living with HIV and AIDS in New York:

The NYC Health Department runs housing programs for low-income people living with HIV and AIDS in New York and their families. The Housing Opportunities for Persons with AIDS (HOPWA) provides permanent housing and supportive services through congregate or scattered-site apartments for people with HIV and AIDS. HOPWA also offers long-term rental assistance and housing placement assistance to help individuals maintain stable housing and improve their quality of life. Find a HOPWA near you.

The Ryan White Part A Housing Program offers short-term and transitional housing opportunities, rental assistance, and placement assistance for eligible people with HIV and AIDS to maintain access to medical care and treatment. The program provides short-term supportive housing through congregate facilities or scattered-site apartments, time-limited rental assistance, and permanent housing placement through counseling, referral services, and additional support.

Organizations with free assistance for people living with HIV and AIDS: 

The Institute for Family Health

Manhattan

The Institute for Family Health

230 West 17th Street (between 7th & 8th Avenues)

New York, NY 10011

(212) 206-5200

Family Health Center of Harlem

1824 Madison Avenue

New York, NY 10035

(212) 423-4500

Bronx

Urban Horizons Family Health Center

50 E 168th St, Bronx, NY 10452

(718) 293-3900

Hudson Valley

Kingston Family Health Center

1 Family Practice Dr, Kingston, NY 12401

(845) 338-6400

Ellenville Family Health Center

6 Healthy Way, Ellenville, NY 12428

(845) 647-4500

Catholic Charities Services

People living with HIV and AIDS in New York can benefit from transportation services to medical care services, peer support groups; job coaching, basic internet and computer skills, housing, and stabilization services.

87 North Clinton Avenue

Rochester, NY 14604

(585) 546-7220

1099 Jay Street

Building J

Rochester, NY 14611

(585) 339-9800

ccfcs@fcscharities.org

Caribbean Equality Project

Members of the Caribbean LGBTQ+ community living with HIV/AIDS in New York will find free assistance and services at the Caribbean Equality Project. These services include free testing, sex education, condoms, and PrEP and PEP referrals.

Email: info@CaribbeanEqualityProject.org

Phone: (347) 709-3179

CAMBA

A nonprofit organization that provides multiple services to help people enhance their quality of life. Camba has prevention services for people with HIV/AIDS and populations at risk of HIV transmission.

Address: 1720 Church Avenue

Brooklyn, NY 11226

Phone: 718-287-2600

Email: info@CAMBA.org

Haitian immigrants with HIV/AIDS will find Haitian Creole services and assistance in these organizations.

Caribbean Women’s Health Association

CWHA provides programs that enhance individual well-being, strengthen families, and empower communities. These programs are designed to provide comprehensive, integrated, culturally appropriate, and coordinated services that are easily accessible to those who need them.

Address: 3512 Church Ave, Brooklyn, NY 11203

Phone: (929) 399-8070

Diaspora Community Services

Diaspora Community Services has been serving low-income residents, immigrants, and individuals with chronic illnesses in Brooklyn since its establishment in 1981. The organization offers various culturally sensitive services and support programs to meet the community’s needs. Here are some of the services immigrants will find at DCS:

Address: 921B East New York Avenue, Brooklyn, NY 11203

Phone: (718) 399-0200

Email: info@diasporacs.org

France: Foreign nationals with HIV in France face precarity and legislative hurdles

Access to healthcare for foreigners with HIV is fraught with pitfalls

Translated with Deepl.com – Scroll down for text in French

While foreign nationals account for more than half of all HIV-positive patients in France, their access to healthcare is an obstacle course. And the Immigration Bill currently before the French National Assembly could complicate this even further.

Will the goal of ending the global HIV/AIDS epidemic by 2030 be achieved? In France, the health authorities are welcoming some ‘encouraging’ data with six years to go. Santé publique France’s annual report shows that the number of tests carried out last year exceeded pre-Covid levels, with 6.5 million HIV serologies compared with 6.34 million in 2019. Another reason for satisfaction is that the number of people who will have discovered their HIV status in 2022 has been estimated at between 4,200 and 5,700, lower than in 2019.

However, the epidemic situation varies from one population to another. While the number of HIV-positive discoveries continues to fall among MSM (men who have sex with men) born in France, it continues to rise among those born abroad. Fifty-six per cent of these new discoveries concern people born abroad, according to Santé publique France. The figure was 51% last year.

A study by ANRS-Emerging Infectious Diseases of men who have sex with men who are HIV-positive and were born abroad shows that 40% of them contracted the virus after arriving in France. This dispels the myth that the virus is ‘imported’ by migrants. It establishes a direct link between the risks of HIV contamination and the conditions of migration, to which are added the precariousness and insecurity of the first years of life in France.

There are a number of schemes that provide medical care for these people: state medical aid (aide médicale d’État – AME), available to any illegal foreign national who has been in France for at least three months and whose income is less than €810 per month; the urgent and vital care scheme (dispositif de soins urgents et vitaux – DSUV), for those who have been in France for less than three months or who are not eligible for state medical aid; and universal health protection (protection universelle maladie – Puma), the general scheme available to asylum seekers who have been in France for at least three months.

Then there is the right to reside in France for medical reasons. Introduced in 1998 following the mobilisation of those involved in the fight against HIV/AIDS, it is aimed at seriously ill foreign nationals ordinarily resident in France who are unable to seek treatment in their country of origin. This guarantee of residency is essential for the treatment of chronic and potentially severe illnesses. For people in very precarious situations, particularly administrative ones, health generally takes second place. ‘They have a wide range of day-to-day concerns that have a knock-on effect on their medical care, with consultations not always guaranteed and medicines not taken regularly,’ explains Professor Nicolas Vignier, an infectious diseases specialist at the Avicenne hospital in Bobigny.

An obstacle course

However, access to these devices is fraught with obstacles. This is due to the lack of information available to foreign nationals arriving in France, as well as a host of administrative hurdles. Starting with proof of accommodation or identity, which is sometimes impossible for people in precarious situations to produce. Another obstacle is the lack of counters open to initial AME applications, as highlighted by a recent survey of primary health insurance offices in the Île-de-France region carried out by several associations.

It also points out that some departmental health insurance agencies make the submission of applications conditional on making an appointment. Matthias Thibeaud, Technical and Advocacy Advisor at the NGO Médecins du Monde, sees this as ‘a form of zeal’ faced by people ‘whose emergency is to survive from day to day’. Not to mention the discouraging delays, the lack of interpreting facilities, and incomplete or even erroneous information provided by some officials… As a result, an Irdes study published in 2019 showed that only half of those eligible were receiving state medical aid. Even after five years or more of presence on French territory, 35% of foreigners in an irregular situation do not have AME, it found.

The picture is not necessarily any brighter when it comes to asylum seekers’ access to the general scheme, which has been subject to a three-month waiting period since 2019. ‘Before 2019, people could open up their entitlement to universal health protection when they submitted their application. Now they have to wait three months, which means that many of them miss the boat’, complains Matthias Thibeaud.

The lack of medical cover makes it difficult to access screening, prevention and treatment. With potentially tragic consequences. If you cut off access to primary care, you delay diagnosis,’ says Professor Nicolas Vignier. You’re going to have people who don’t know they’re carrying a virus that they’re at risk of transmitting. Then, months or years later, they’ll fall seriously ill and have to be hospitalised, sometimes in intensive care, with a life-threatening or functional prognosis. This will have led to costly treatment and, above all, we will have allowed these people’s state of health to deteriorate to the worst.

New restrictions

Access to healthcare is likely to be further complicated by the Immigration Act, currently being examined by the National Assembly’s Law Commission. Although state medical aid, which had been transformed by the senators into emergency medical aid, has finally been withdrawn from the bill, healthcare professionals remain on alert, awaiting the conclusions of the evaluation report commissioned by Prime Minister Elisabeth Borne, which is due on Monday 4 December.

Another cause for concern, a very real one this time, is the restrictions placed on the right to stay in France for treatment purposes, which until now has been conditional on the absence of effective access to treatment in the country of origin, and which will now be refused if treatment is available. ‘For an HIV-positive person, this means that all it would take to be refused a residence permit in France is for antiretroviral drugs to be available in a private clinic in the capital of the country of origin. This is despite the fact that we know that there is a great deal of discrimination against HIV-positive people in France and other countries when it comes to effective access to treatment. It’s a semantic change in the text, but one that has dramatic consequences’, says Matthias Thibeaud of Médecins du Monde.

Professor Nicolas Vignier sees these restrictions as a purely symbolic measure that will have no impact on migration figures, despite the fact that the right of residence for medical reasons accounts for only 0.6% of all residence permits issued. Will MEPs approve them? The text will be debated in Parliament from 11 December.

Pour les étrangers porteurs du VIH, un accès aux soins semé d’embûches

Alors que les étrangers représentent plus de la moitié des malades séropositifs en France, leur accès aux soins relève du parcours du combattant. Et la loi Immigration, actuellement examinée à l’Assemblée nationale, pourrait compliquer ce parcours davantage.

L’objectif de mettre fin à l’épidémie mondiale de VIH/sida d’ici 2030 sera-t-il atteint ? En France, les autorités sanitaires saluent en tout cas certaines données “encourageantes” à six ans de la date butoir. Le bilan annuel de Santé publique France montre ainsi que le nombre de dépistages effectués l’année dernière a dépassé ses niveaux d’avant Covid, avec 6,5 millions de sérologies VIH contre 6,34 millions en 2019. Autre motif de satisfaction : le nombre de personnes ayant découvert leur séropositivité en 2022 a été estimé entre 4 200 et 5 700, des chiffres inférieurs à ceux de 2019.

Mais l’évolution de la situation épidémique est contrastée selon les populations. Si le nombre de découvertes de séropositivité ne cesse de diminuer chez les HSH (hommes ayant des rapports sexuels avec des hommes) nés en France, il continue d’augmenter chez ceux nés à l’étranger. Cinquante-six pour cent de ces nouvelles découvertes concerne des personnes nées à l’étranger, relève Santé publique France. Le chiffre était de 51% l’an passé.

Une étude de l’ANRS-Maladies infectieuses émergentes conduite auprès d’hommes ayant des relations avec des hommes porteurs du VIH et nés à l’étranger montre que 40% d’entre eux l’avaient contracté après leur arrivée en France. De quoi tordre le cou au mythe d’un virus “importé” par les migrants. Elle établit un lien direct entre les risques de contamination par le VIH et les conditions de migration, auxquelles s’ajoutent la précarité et l’insécurité des premières années de vie en France.

Des dispositifs permettant la prise en charge médicale de ces personnes existent : l’aide médicale d’État (AME), ouverte à tout étranger en situation irrégulière présent sur le territoire français depuis au moins trois mois et dont les ressources sont inférieures à 810 euros par mois ; le dispositif de soins urgents et vitaux (DSUV), pour ceux présents en France depuis moins de trois mois ou qui ne sont pas admis à l’aide médicale d’État ; et la protection universelle maladie (Puma), le régime général auquel ont accès les demandeurs d’asile présents sur le territoire français depuis au moins trois mois.

À cela s’ajoute le droit au séjour pour soins. Instauré en 1998 après la mobilisation d’acteurs engagés contre le VIH/sida, il s’adresse aux étrangers gravement malades résidant habituellement en France, qui ne peuvent pas se soigner dans leur pays d’origine. Cette garantie de séjour est essentielle dans la prise en charge de pathologies chroniques et potentiellement sévères. Car chez les personnes en situation de grande précarité, notamment administrative, la santé passe généralement au second plan. “Elles ont des préoccupations quotidiennes multiples qui vont déteindre sur leur suivi médical, avec des consultations qui ne sont pas toujours assurées, des médicaments qui ne sont pas pris régulièrement…”, éclaire le professeur Nicolas Vignier, infectiologue à l’hôpital Avicenne de Bobigny.

Un parcours d’obstacles

L’accès à ces dispositifs est cependant un parcours semé d’embûches. En cause, le manque d’information dont disposent les étrangers arrivant en France, mais aussi de multiples barrières administratives. À commencer par des justificatifs d’hébergement ou d’identité parfois impossibles à produire par un public précaire. Autre obstacle : le manque de guichets ouverts aux premières demandes d’AME, comme le relève une récente enquête menée par plusieurs associations auprès des caisses primaires d’Assurance maladie d’Île-de-France.

Celle-ci pointe par ailleurs que certaines agences départementales de l’assurance maladie conditionnent le dépôt des demandes à une prise de rendez-vous. Matthias Thibeaud, référent technique et plaidoyer au sein de l’ONG Médecins du monde, y voit “une forme de zèle” auquel se heurtent des personnes “dont l’urgence est de survivre au jour le jour”. Sans compter des délais décourageants, l’absence de dispositif d’interprétariat, des informations incomplètes, voire erronées, délivrées par certains agents… Résultat : une étude de l’Irdes publiée en 2019 indiquait que seules la moitié des personnes qui y étaient éligibles bénéficiaient de l’aide médicale d’État. Même après cinq ans ou plus de présence sur le territoire français, 35% des étrangers en situation irrégulière ne possèdent pas l’AME, constatait-elle.

Le tableau n’est pas forcément plus glorieux en ce qui concerne l’accès des demandeurs d’asile au régime général, soumis depuis 2019 à un délai de carence de trois mois. “Avant 2019, les personnes pouvaient ouvrir leurs droits à la protection universelle maladie au moment de leur dépôt de leur demande. Désormais, il faut attendre trois mois, ce qui conduit nombre d’entre eux à rater le coche”, déplore Matthias Thibeaud.

L’absence de couverture médicale rend difficile l’accès aux dispositifs de dépistage et de prévention, et au traitement. Avec des conséquences potentiellement tragiques. “Si vous coupez l’accès aux soins primaires, vous retardez le diagnostic, développe le professeur Nicolas Vignier. Vous allez avoir des personnes ignorant être porteuses d’un virus qu’elles risquent donc de transmettre. Et des mois ou des années plus tard, qui vont tomber gravement malades, qui vont devoir être hospitalisées, parfois en réanimation, avec un pronostic vital ou fonctionnel engagé. Cela aura entraîné des soins coûteux et surtout, on aura laissé l’état de santé de ces personnes se dégrader jusqu’au pire.”

De nouvelles restrictions

Or cet accès aux soins risque d’être encore un peu plus compliqué par la loi Immigration, actuellement examinée par la commission des lois de l’Assemblée nationale. Si l’aide médicale d’État, transformée par les sénateurs en aide médicale d’urgence, a finalement été retirée du texte, les acteurs de santé restent sur le qui-vive, suspendus aux conclusions du rapport d’évaluation commandé par la Première ministre Elisabeth Borne qui doivent être rendues lundi 4 décembre.

Autre motif d’inquiétude, bien concret celui-ci : les restrictions apportées au droit au séjour pour soins, jusqu’alors conditionné par l’absence d’accès effectif au traitement dans le pays d’origine et désormais refusé en cas de disponibilité du traitement. “Pour une personne séropositive, cela signifie qu’il suffirait qu’il y ait des antirétroviraux disponibles dans telle clinique privée de la capitale du pays dont elle est originaire pour se voir refuser un titre de séjour en France. Et ce alors qu’on sait qu’il existe de nombreuses discriminations, en France mais aussi dans d’autres pays, à l’encontre des personnes séropositives pour l’accès effectif au traitement. C’est un changement sémantique dans le texte, mais qui a des conséquences dramatiques”, dénonce Matthias Thibeaud, de Médecins du monde.

Alors que le droit de séjour pour soins ne représenterait que 0,6% de l’ensemble des titres de séjour, le professeur Nicolas Vignier voit quant à lui dans ses restrictions une mesure purement symbolique qui n’aura aucun impact sur les chiffres migratoires. Les députés les valideront-ils ? Le texte sera débattu dans l’Hémicycle à partir du 11 décembre.

Italy: Resident foreigners to be charged €2,000 to use the national health service as part of the 2024 budget

Government to charge foreigners to use health service

The Italian government will charge foreigners who live in Italy a €2,000 fee to use the national health service. The costs will be adopted as part of the 2024 budget. There will be an unspecified discount for those with legal residency, as well as foreign students and au pairs.

Italy’s Economy Ministry announced in a statement on Monday (October 16) that it intends to charge foreigners from outside the EU who live in Italy a fee to use the public health service. The costs are expected to amount to €2,000 per year.

The charges, reported the news agency Reuters, will be adopted in the 2024 budget. There will also be an unspecified discount for those who possess legal residency papers, as well as foreign students and au pairs, the agency added.

According to the ministry’s online statement, the budget covers the period 2024-2026. Finance and Economy Minister Giancarlo Giorgetti said that the new budget was “in line with a prudent approach, that is responsible and realistic.”

he minister stated that his government had been concentrating on the “extra deficit, and wanted to give some kind of relief to the medium to lower earners and their dependants.” Giorgetti added that Italy had been “feeling the weight of the heightened interest on the public debt,” and that some things were not negotiable at the moment, like the price of energy.

Additional funding for health

In order to achieve their aims, one of the measures included in the budget, explained Giorgetti, are changes to health provision. As well as the charges, the government intends to add funding to the health service “equivalent to €3 billion per year in 2024 … this will add to the money already set aside to support the Sicilian region and as part of the National Plan for Recovery and Resilience (PNRR) as well as €4.2 billion from 2026.”

Bonuses will be offered to health care providers who manage to reduce the waiting list time. And resources will also be allocated in the year 2025 to help regional health providers appoint more employees.

However, although Italy provides free public healthcare and extends this not only to Italian nationals, but also foreign workers, job seekers and asylum seekers, as well as unaccompanied minors, there are some categories of foreigners who already have to pay certain costs. For instance, diplomats and foreign students can use the Italian health service but for a variable fee, dependent on their annual income.

Reuters reported that student charges are capped at €150 per year but for higher earners, fees can reach as much as €2,800 per year.

Proposal has ‘kicked up some dust’

A spokesperson from Italy’s biggest trade union CGIL, Giordana Pallone, told the Italian news agency Adnkronos that depending on what the details turned out to be, the reform could fall foul of the Italian constitution which guarantees free medical care for the poor.

“We’ll have to wait to see how the law is written, because as it is reported today, it has no value or basis compared to the system and regulations that we have,” explained Pallone. Writing in the financial news portal Qui Finanza, one journalist said that the government’s proposals had “kicked up some dust.”

During the press conference, according to Qui Finanza, Giorgetti explained that the charges would not apply to those who are registered in Italy and are working, unaccompanied minors and those who are waiting for their residence permits to arrive.

The new changes will follow in the footsteps of provisions made in a 1998 law, reports Qui Finanza. Here, the law stated that foreigners who are registered in Italy and are there for longer than three months are not obliged to sign up for the national health service, but they are obliged to make sure they are covered with some kind of medical insurance, which means effectively they need private health insurance or they sign up for the national health service and are charged a fee.

Potential increases

Even with the discounts the new costs could rise by around 470% for some people, from say €149 per year for foreign students resident in Italy to around €700 per year, writes Qui Finanza. People working as au pairs could be asked to start paying €1,200 per year instead of the current €219, which amounts to an increase of 547% stated the financial news portal.

Italy’s Order of Doctors (Ordine dei medici) released a statement following the news, noting that “Article 32 of the constitution protects the rights of the individual and the collective. The article underlines that medical help must be offered for free to those too poor to pay for it. If non-EU foreigners do not have any money, then they must be helped free of charge. Here we are not talking about citizens but individuals. So in our opinion, the right to free health care is guaranteed over and above whether anyone can pay for it.”

Although these charges are not directly related to migrants and asylum seekers, and cover all foreigners in the country, critics of the proposals see the charges as another way that the right-wing government is attempting to make it harder to be in Italy without the correct papers.

Last month, for instance, the government proposed charging migrants around €5,000 if they wanted to avoid detention while their request for protection was being processed, reported Reuters and several other news agencies.

Healthcare in Italy

A study by the Society of Medical Sciences (SISMED) in Italy in 2022 found that although health provision is provided free in Italy — since 1982 — Italians have been paying for certain services via a ticket system. You can see a general practitioner for free but if you have a specialized medical visit, you will need to pay. Diagnostic tests and laboratory tests often come at a cost, as well as non-urgent care and non-emergency care that do not need a recovery period in hospital. If you want to visit a thermal spa, you will also need to pay.

However, some patients can get some of these treatments without paying: If you have a chronic or a rare disease, if you have diabetes, cardiopathy, are disabled, have a fast-growing tumor, are pregnant or if you want to do an HIV test.

Despite these exceptions, the national daily paper Corriere della Sera reported at the beginning of 2023 that some Italian families were forgoing medical care because of fears of the costs involved.

South Africa: Fear of deportation forces HIV-positive migrants in South Africa to seek illegal drug supply

The drug smugglers keeping HIV patients alive in South Africa

Antiretroviral drugs are free in South Africa – but thousands of undocumented HIV-positive migrants dare not seek them out.

The decision to leave Malawi was an easy one for McLean Nyirenda. He could either languish in poverty at home, as he had done for his whole life, or depart in search of work that would support both himself and his family.

He settled upon South Africa, the continent’s most advanced country, one full of opportunity and adventure – yet in leaving for the Rainbow nation, the 27-year-old’s life has since been placed in grave danger.

Nyirenda is one of thousands of HIV-positive Malawians living in South Africa as an undocumented migrant. Because of his illegal status, he dares not visit a hospital to access – for free – the antiretroviral drugs which are needed to keep him alive.

Across the country, non-South African citizens are frequently denied antiretroviral therapy at public health care institutions, and Nyirenda fears he would not only meet the same fate, but be reported to law enforcement and deported back home.

In desperation, the young man, who works as a watchman at the house of a wealthy South African businessman, has turned to a syndicate of drug smugglers who supply the precious antiviral medication to irregular Malawians at an exorbitant price.

“I depend on smuggled antiretrovirals for my health, and this is the only way for most of us here to live longer and achieve what we came here for,” says Nyirenda.

It’s estimated there were at least 2.9 million immigrants residing in South Africa in 2020, but rising unemployment challenges and the impacts of natural disasters across the continent have likely further increased this number.

The Malawi High Commission in South Africa estimates there are more than 140,000 undocumented Malawians living in the country, of whom 30 per cent are believed to be HIV positive.

Despite antiretroviral services being free of charge for anyone in South Africa, most irregular migrants do not access the medicine via local hospitals because of their illegal status.

This creates opportunity for Malawi drug smugglers, who typically masquerade as drivers or businessmen, but it can also lead to patients skipping their antiretroviral therapy.

These drugs are needed to suppress the HIV virus within an infected individual; without them, the pathogen has the opportunity to replicate within the body and, over time, Aids can develop.

Death by ‘drug defaulting’

A Malawi High Commission official, who spoke on the condition of anonymity for fear of reprisals, said the situation in South Africa is culminating in a rise in Aids-related deaths among Malawian patients.

“At the moment we don’t have statistics to share with you but I can confirm that a number of deaths and dead bodies being repatriated to Malawi are HIV related and mostly caused by drug defaulting,” the official said.

Nyirenda has yet to meet the same fate, thanks to his mother Grace who has managed to source his medication through drug smugglers and a local hospital in Malawi.

“I was worried to hear that he was not able to go to hospital and access the antiretrovirals because he doesn’t have legal documents for his stay there,” she tells the Telegraph. “I felt my son will die due to lack of treatment.

“Then, I approached one of the health workers at Nyungwe rural hospital [in northern Malawi] who managed to sell me each bottle of antiretroviral drugs at MWK 5,000 [the equivalent of $5] and I sent him them through the drug smugglers.”

When she is unable to buy the antivirals from the local hospital, Grace turns to the Malawian drug syndicate, which charges $50 for three months’ worth of supplies. She says the smugglers always have the medication in stock.

“They charge MWK 15,000 [$15] for transportation if I source it myself and MWK 50,000 [$50] when they are supplying it themselves.”

One of the smugglers, a Malawian bus driver called James who travels back and forth to South Africa, said there is high demand for HIV patients living in the country, adding that, like Grace, he buys the medication from health workers in government hospitals at $5 a bottle.

However, James said, the reason the smugglers charge “exorbitant prices” to patients is because they need to bribe security forces at border crossings and road blocks.

“We know it’s illegal, but we can’t do otherwise because we have to save the lives of our colleagues,” he adds.

Mathews Ngware, a medical doctor and chairperson of the Malawi Parliament committee on health, says the problem in accessing antiretrovirals via public hospitals is common to irregular immigrants across the continent.

“This is a big issue across Africa because it involves undocumented migrants who fear to be identified if they go to public health facilities to access the drugs,” he says. “We have similar cases of Malawians travelling back home from Botswana, Zimbabwe and other countries to get their antiretrovirals.”

He added that the phenomenon of drug defaulting among patients – “which may give chances of new infections if they engage in unsafe sex with others” – threatens to undermine the global target of ending HIV as a public health threat by 2030.

The strategy, adopted by UNAIDS in 2021, seeks to eliminate new HIV infections and Aids-related deaths by 2030.

To combat the issue of drug defaulting, Malawi National Aids Commission has launched a new programme which provides HIV-positive Malawians living outside of the country with six months’ worth of medication at a time.

It’s hoped such an approach will ensure treatment consistency and stop people like Nyirenda from missing out on their drugs.

“We are informing all those living outside the country to come and identify themselves as irregular immigrants so that they can collect drugs in large volumes,” says Karen Msiska, a spokesperson for the Commission. “Through this initiative we hope we can end issues of defaulting due to the unavailability of the drugs.”