South Africa: South Africa needs a healthcare system that is migration-aware and recognises mobility

HIV care for migrant women in South Africa: the gaps and 5 steps towards offering better services

Around 8.45 million people in South Africa live with HIV – an estimated 13.9% of the population. Of South African women aged 15-49, approximately 24% are HIV positive.

The roll-out of services to prevent mother-to-child transmission of HIV has been notably successful in reducing the rate of transmission.

But there are still gaps in the delivery of HIV treatment and prevention. A case in point is migrant women. People who move across national borders or between regions and provinces are particularly easy for healthcare systems to miss. And there’s no integrated system of tracking them. Nor is there any robust national data on how many migrant women, specifically pregnant migrant women, are on treatment and virally suppressed.

In 2020, it was estimated that there were 4 million migrants in South Africa, some of whom were women living with HIV. The public health system has struggled to respond yet alone integrate this mobile population.

The vulnerability of migrants was highlighted during the COVID-19 pandemic when restrictions affected people’s ability to travel to access treatment as well as the delivery of healthcare.

In a recent paper we explored the challenges of the COVID-19 pandemic for HIV prevention services in Johannesburg, South Africa’s economic hub. We interviewed healthcare providers and stakeholders in policy and programming. The aim was to understand the gaps in ensuring adherence to lifelong antiretroviral therapy for mobile populations.

The information we gathered shone a light on the country’s overburdened healthcare facilities and the shortcomings in the network of referral clinics in Johannesburg and across Gauteng province. We went on to draw from these insights to understand the systemic gaps in the delivery of antiretroviral treatment (ART) to migrant women. We identified five in particular. And we then identified possible solutions, including how technology could improve access to healthcare.

The gaps

The pandemic created new problems in healthcare delivery and exposed existing shortcomings. Five main themes emerged from our qualitative study.

First, women living with HIV and who were highly mobile feared going to healthcare facilities because they were scared of getting COVID. This interrupted their treatment and increased their risk of falling ill.

Second, some healthcare workers told us they felt overwhelmed by the added burden of the pandemic on providing HIV prevention services to pregnant women. For example, many reported that there was a lack of infrastructural resources to follow social distancing protocols. This disrupted their provision of care.

Third, migrant women faced a number of logistical barriers:

  • some who left Gauteng province and then tried to return to collect their medication couldn’t do so due to border and lockdown restrictions
  • some lost their jobs and income, and were unable to afford travel to collect their ART
  • some were denied care because they didn’t have documentation (though this should not have been a barrier).

These factors resulted in patients interrupting treatment.

Fourth, some individuals who sought treatment reported mistreatment and xenophobic attitudes from healthcare providers. Even some healthcare providers reported that their colleagues behaved negatively towards migrant women.

Time pressures were the fifth theme. Health workers said they needed more time to counsel patients. This helps build a rapport and strengthens the ability of patients to manage their health.

From these insights we drew up a list of interventions we think would improve antiretroviral services to migrant women in South Africa.

What can be done?

The first step is to dispense antiretrovirals for a longer duration of time to alleviate stress for individuals on the move and encourage retention in the ART programme.

Secondly, decentralise services and bring care to the community with pop-up delivery that can help remove logistical barriers like transport to clinics that are far away.

Thirdly, introduce virtual care platforms – like online HIV prevention of mother to child transmission services. It could help highly mobile individuals to interact with healthcare providers. This could help to improve the referral system between clinics and counsellors could follow up patients who had moved. The system could keep better patient records and send reminders for medicine collections. In addition, it should include translation services to help remove communication barriers between service providers and users. And it could better integrate communication of healthcare facilities – even those in other countries – so as to track patients.

Fourthly, healthcare providers need better opportunities to build closer relations with each other. This could create a better understanding of the changes in their work and the underlying issues that affect them. Greater understanding could help get to the root of where negative attitudes towards migrants stem from to improve behaviours towards patients.

In addition, healthcare facilities often improvise to come up with strategies and solutions that meet the requirements and changes to programmes. If these were better documented they could then provide knowledge translation and learning opportunities on a larger scale for other healthcare providers, facilities and programmes.

Fifth, government should evaluate healthcare environments before changing policies and programmes. Platforms such as working groups should be provided for collaboration with researchers, service providers and mobile patients to help direct policy and practices.

South Africa needs to take a more pragmatic approach to the delivery of antiretroviral treatment. It needs a healthcare system that is migration-aware and offers a service that recognises mobility – one that speaks to the realities of migrant women living with HIV in South Africa.

 

Thailand: Key population-led organisations deliver HIV prevention and treatment services to migrants

Thailand’s HIV policies benefit migrants, including Filipinos

In December 2021, Ed (not his real name), a migrant Filipino in Thailand suspected that he had contracted HIV due to symptoms such as herpes, fever, and weight loss. After conducting a quick Google search and reaching out to HIV advocates in the Philippines, he was referred to Rainbow Sky Association of Thailand (RSAT) in Ramkamhaeng, Bangkok. RSAT is a registered community organization that collaborates with people with sexual diversity in Thailand.

Like many in the LGBT community, Ed is aware that society is quick to condemn them due to their sexual and gender orientation, particularly among migrant Filipinos.

In earlier years, HIV was commonly referred to as the “OFW (Overseas Filipino Workers) disease” due to cases among seafarers and migrant Filipinos who were infected under different circumstances while abroad.  It was also seen as a “gay disease.”
In 2022, there were approximately 14.97 thousand reported cases of HIV/AIDS in the Philippines, the highest since 2016. According to aidsdatahub.org, the Philippines has an estimated 140,000 people living with HIV (PLHIV). On average, there were 42 newly diagnosed Filipinos in 2022, which was several times higher than the average of nine in 2012.

Although Thailand has had successful campaigns against HIV, there are still an estimated 520,000 people living with HIV (PLHIV) and 6,500 new infections in 2021, but it already fell 58% compared to previous years. The numbers include migrant workers seeking treatment or undergoing testing in clinics nationwide.

Filipino Migrants and HIV

With over 17,000 Filipinos in Thailand where an undisclosed numbers do not have an insurance or health care coverage under Social Security (SSO), seeking treatment for HIV maybe expensive.

“Medication can cost up to 10 thousand baht (USD 250) per month,” said Kao Kierati Panpet, Deputy Director for Bureau of Health Service Provision of RSAT.

The first month is free for foreigners, then they are referred to hospitals to seek further treatment.

RSAT has an average of 60 clients a day, of which 15-20 are PLHIV. The organization has over a hundred foreign clients some of whom are getting free treatments while others are referred to hospitals. However, due to stigmatization and discrimination their nationalities are undisclosed.

“We do not discriminate between undocumented and documented workers. We understand and accept cultural differences and gender roles. We are a society of people of different genders, races, ethnicity, classes, religions, sexual orientation, disabilities or socio-economic status. Rainbow is a safe place for them,” she said.

Ed has no insurance, yet he is able to avail of free services from RSAT.

“All my tests were done at RSAT. I was assisted by their staff and endorsed in a public health center,” Ed explained.

The Bangkok Metropolitan Authority (BMA), a partner of RSAT shoulders the medication of migrants who cannot afford the treatment.

Stigmatization and Discrimination

Dr. Jon Fontilla, former country coordinator of Australian Federation of AIDS Organization (AFAO-Bangkok) said that Thailand and the Philippines are tolerant to the LGBT rather than accepting, but it has limitations.

Thailand is more accepting of gender diversity, acknowledging that gender is not binary or just male and female. This is probably due to the different religious backgrounds of the two countries, with Buddhism being more gender-affirming than Catholicism, according to Dr. Fontilla.

In Thailand, society does not discriminate against the clothes people wear in public. It is also more common to see LGBTQI couples holding hands in public places.

But members of the community still experience discrimination.

Darel Magramo, a teacher, recalled being mocked by a group of teen boys in a male restroom in a Bangkok mall. Magramo wore a crop top, and their friend wore a sleeveless top. The boys began to groan and act like they were having anal sex when they noticed them approaching the restroom. Even after they left the restroom, the boys followed them and continued moaning, leaving them frightened and trembling.

Gay men, men having sex with men (MSM), and transgender women (TWG) are often stereotyped as promiscuous.

Due to stigma, which particularly affects the LGBTQI community, Ed’s situation wasn’t known to his family, friends, or even employer. He fears losing his job.

In a UNDP study in 2020 found out that stigmatization among TWG in Thailand are due to cultural beliefs such as karma and most TWG, if not all, are into sex work.

“While there are different laws on prostitution in both countries, sex work in Thailand seems to be more out in the open. This plays a part in HIV in that program people know and can easily reach these sex workers offering them health programs such as testing and PreP without stigma and discrimination. This encourages sex workers to use services and take better care of themselves. Some even promote their usage of condoms and PrEP (pre-exposure prophylaxis) in sex work and routine HIV testing, according to Dr. Fontilla,” Dr Fontilla explained.

PrEP is a daily medicine taken by an HIV-negative person to prevent contracting the virus.

Government policies and commitment

In the Philippines, the Philippine HIV and AIDS Policy Act of 2018 (RA 11166) includes provisions for minors to get HIV tests without parental consent, strengthening HIV/AIDS education to reduce stigma and discrimination, counseling for PLHIV families, increased protections against discrimination, expanding access to evidence-based prevention strategies, and improving HIV and AIDS care and treatment provisions. Under SDG-related benefits, PhilHealth insurance also covers HIV treatment.

The Commission on Human Rights (CHR) and the Department of Justice (DOJ) issued Joint Administrative Circular Order No. 1 in 2021 to establish uniform rules on redress mechanisms for PLHIV. As such, the Public Attorney’s Office (PAO) provides assistance to PLHIV relating to their labor concerns and others.

Thailand does not have specific laws on PLHIV, yet it has implemented several best practices to end AIDS, including legalizing over-the-counter sales of HIV self-test kits, scaling up same-day treatment initiation for newly diagnosed people, and successfully rolling out a pre-exposure prophylaxis (PrEP) program. This has become a mechanism for sustainable HIV response financing by significantly increasing investments in key population- and community-led health services. Key population-led services are now supporting 82% of HIV pre-exposure prophylaxis (PrEP) users. Key population-led organizations are delivering health services in Bangkok, and they are essential in providing access to HIV prevention and treatment services without fear of discrimination.

The Thai government has increased the budget for HIV and AIDS services each year. In 2021, the National Health Security Office (NHO) received around 3.67 billion baht to cover HIV and AIDS services under Universal Health Coverage (UHC). The Global Fund also signed USD 61 million for 2021–2023 in the fight against HIV and tuberculosis (TB) by reaching more people in key populations who bear a disproportionate burden of these diseases. The allocation of the national budget has increased over time to support community-led organizations working with PLHIV.

End inequalities, end AIDS

After a year and half of ART (anti-retroviral therapy), Ed has reached 20 copies per milliliter of blood which is now undetectable. Undetectable means that the virus can no longer be passed on, but he remains PLHIV.

Darel, meanwhile, always undergoes a routine HIV testing to reduce the stigma and to encourage the young people to have themselves tested not only for HIV but for other sexually transmitted diseases.

The UNAIDS launched the Global AIDS Strategy 2021-2026, called “End Inequalities. End AIDS.” This strategy aims to use an inequalities lens to close the gaps that are preventing progress towards ending AIDS. The Global AIDS Strategy prioritizes reducing inequalities that drive the AIDS epidemic and aims to get every country and community on-track to end AIDS as a public health threat by 2030.

France: Hôtel-Dieu hospital in Paris offers migrants free tests for STIs, hepatitis B and C and HIV

Free sexual health checks for migrants at Paris hospital

The Hôtel-Dieu hospital in Paris offers checks for sexually transmitted infections (STI) such as chlamydia, gonorrhea, syphilis, hepatitis B and C and HIV. The service is free and open to all, including undocumented migrants without healthcare coverage in France.

Herman, 27, just did a blood test in the Hôtel-Dieu hospital’s sexual health department, in the center of Paris. He will get the results in a week.

“My girlfriend asked me to do an HIV test,” says the young Guinean who has been in France for three years. “She lost her mother when she was very young, and she recently learned her mother died of AIDS. She did the test a month ago and it was negative. Now it’s my turn. None of my girlfriends were sick that I know of, but I prefer to check.” AIDS is the autoimmune disease one can develop after becoming infected with HIV.

In this health center of the Paris hospital network, STI checks are free and anonymous. “We accept all, without conditions,” says Dr. Florence, co-administrator of the center. There is no need to have healthcare coverage to get treated here. Undocumented migrants have as much of a right to access to this service as other people.

Free with or without an appointment

The center has a phone translation service, allowing it to welcome foreigners who do not speak French.

“People can get an appointment by email (in French and in a foreign language) or on Doctolib, or come here without an appointment,” says Dr. Florence.

In the center, a team made up of a dermatologist, gynecologist, a psycho-sexologist, nurse, a couple’s counsellor and a social worker offer STI checks and treatments to prevent infections. They can prescribe Pre-Exposure Prophylaxis (PrEP), a pill which can prevent one from getting HIV. They also offer specialized medical consultations, but those are not always free.

Keeping Hepatitis B under a close watch

The center can give treatment for syphilis, hepatitis B and C, and HIV.

“The number of hepatitis B cases is more significant in Sub-Saharan Africa and South-East Asia,” says Dr. Delphine Mattei, who does day consultations. Migrants coming from those regions are particularly exposed to those infections.

Blood tests are useful to know if the patient was infected with hepatitis B and healed from it, or if they are chronically ill, so that they can be followed or simply kept under watch if the disease is dormant. “One should not hesitate to ask their partner to get vaccinated [there is a vaccine against hepatitis B],” adds Dr. Mattei.

Self-testing kits for HIV detection

According to French health statistics, many migrants get infected with HIV after arriving in France, after unprotected sex.

Traditional blood test or rapid tests at the center are ways to detect the virus. “We also have self-testing testing kits [from a blood drop] that people can take home to for their partner, relatives or friends to do it from their homes,” adds Dr. Florence.

Last year, some 37 HIV cases were detected in the center, a quarter of which were pregnant women. The women were tested during their pregnancy check-ups.

The center is next to a pregnancy center (centre de protection maternelle (CPM) Cité) where many pregnant women experiencing poverty or homelessness seek medical, psychological, and social care.

Migrant women are particularly at risk of being infected with HIV in France. Economic precarity makes them particularly vulnerable to sexual violence in France, which multiplies their risk of contracting HIV by four, according to a 2018 study.

The sexual health center staff is also trained to recognize violence and can offer psychological help if need be.

HIV remains taboo among African migrants

In some cases, when pregnant women are accompanied by their partner, the partner also accepts to get tested. But the medical staff wish they would do that more often. “HIV is still taboo for some people, especially in Africa. People are afraid of being stigmatized and rejected in their family, so they do not get tested,” says Dr. Florence.

“Today, many people live healthy lives with the virus without transmitting it to their partner thanks to medical treatment,” says the doctor. “If people do not get tested, the virus can worsen, and they risk transmitting it to others.”

“There’s no shame in getting an STI when one has an active love life,” says Dr. Florence. The most important is to wear a condom with the new partner from the beginning to the end of intercourse and to get tested regularly when you change sexual partners.”

Other less well-known STIs such as chlamydia and gonorrhea are also often detected and treated at the sexual health center.

Those STIs do not always provoke symptoms, such as urinary pain or a burning sensation or unusual yellow discharge for women. Nevertheless, those two STIs need to be taken seriously because they can cause infertility for women and testicular infections for men. They are detected by sampling urine and swabbing the vagina, throat, or anus.

One can get STI tested and treated for free in France at any CeGIDD, and in many other places. Here is a website where you can find a place near you.

Hôtel-Dieu’s sexual health center

Phone: 0142348300 / Email : css.paris.htd@aphp.fr

Hours : From 9 am to 7 pm from Monday to Friday, excepted Tuesday (open from 1:30 pm to 7 pm) with or without an appointment

Address : Hôtel Dieu, 1 place du Parvis Notre-Dame (6th floor – galerie A1), Paris. Metro stop : Cité (line 4) / Hôtel de Ville (lines 1 and 11) / Châtelet (lines 1, 4, 7 et 14).

Russia: Laws that restrict migrants with HIV and deny them medical care increases the burden on the health care system

Legal barriers to migrants with HIV are not working

Automated translation via Deepl.com. For original article in Russian, please scroll down.

Laws that restrict the stay of foreign nationals with HIV, as well as the denial of free medical care, may be one of the causes of a hidden epidemic, writes the EECA Regional Platform.

The Regional Expert Group on Migrant Health conducted research in two EECA countries, Armenia and Uzbekistan. The aim was to identify the legal barriers to HIV faced by citizens of the countries who have returned from migration.

Challenges for migrants with HIV

Social isolation and stigmatization, lack of permanent relationships, language barriers, unstable material resources, and limited access to health care services are the main challenges faced by labour migrants with HIV.

Inability to obtain a legal patent because of HIV infection leads to administrative offences:

  • Among migrants: illegal labour activities, commercial sex services
    Among the citizens of host countries: illegal sale of patents and HIV certificates etc.

The problem with getting ARV treatment leads to resistance and a general deterioration of the health of migrants living with HIV. This ultimately increases the burden on the health care system: patients’ opportunistic infections need to be intensified, ART regimens need to be changed, etc. Moreover, returning migrants contribute to the spread of HIV in their home countries.

Currently, the Russian Federation, which receives the largest number of migrants from the EECA region, is one of 19 countries that restrict the stay of foreign nationals with HIV. People living with HIV entering Russia specify visiting relatives, tourism/travel or medical treatment as the purpose, rather than employment.

At the end of 2021, a law came into force in the Russian Federation which requires foreign nationals to be tested for HIV, banned substances and dangerous infectious diseases every 3 months. But foreign business associations, as well as the media, have reacted quite sharply to the Russian law. The business community sent a letter to the Russian Government asking it to simplify the rules and not to subject highly qualified specialists to testing.

Законодательные барьеры для мигрантов с ВИЧ не работают

Законы, которые ограничивают пребывание в стране иностранных граждан с ВИЧ, а также отказ в бесплатной медицинской помощи, могут быть одной из причин скрытой эпидемии, пишет Региональная Платформа ВЕЦА.

Региональная экспертная группа по здоровью мигрантов провела исследование в двух странах ВЕЦА — Армении и Узбекистане. Целью было определить правовые барьеры в связи с ВИЧ, с которыми сталкиваются граждане стран, вернувшиеся из миграции.

Проблемы мигрантов с ВИЧ

Социальная изоляция и стигматизация, отсутствие постоянных отношений, языковой барьер, нестабильный материальный уровень, ограниченный доступ к медицинским услугам — основные проблемы, с которыми сталкиваются трудовые мигранты с ВИЧ.

Невозможность получения легального патента из-за наличия ВИЧ-инфекции ведет к административным правонарушениям:

  • среди мигрантов: незаконная трудовая деятельность, коммерческие секс-услуги;
    среди граждан принимающей страны: нелегальная продажа патентов и сертификатов об отсутствии ВИЧ-инфекции и т.д.

Проблема с получением АРВ-терапии приводит к резистентности и общему ухудшению здоровья мигрантов, живущих с ВИЧ. Это в конечном итоге повышает нагрузку на систему здравоохранения: необходимо усиливать лечение оппортунистических инфекций пациентов, менять схему АРВТ и т.д. Более того, вернувшиеся домой мигранты способствуют распространению ВИЧ в своих странах.

В настоящее время Российская Федерация, принимающая наибольшее количество мигрантов из региона ВЕЦА, является одной из 19 стран, которые ограничивают пребывание иностранных граждан с ВИЧ. Люди, живущие с ВИЧ, въезжая в Россию, указывают в качестве цели не трудоустройство, а посещение родственников, туризм/путешествие или лечение.

В конце 2021 года в РФ вступил в силу закон, согласно которому иностранные граждане обязаны каждые 3 месяца сдавать анализ на ВИЧ, запрещенные вещества и опасные инфекционные заболевания. Но зарубежные бизнес-ассоциации, а также СМИ достаточно остро отреагировали на российский закон. Бизнес-сообщество направило письмо в Правительство РФ с просьбой упростить правила и не подвергать проверке высококвалифицированных специалистов.

Russia: Migrants are forming a “hidden epidemic” because they are afraid to seek help

Why are migrants living with HIV being deported from Russia?

Automated translation – For article in Russian, please scroll down.

Russia is one of 19 countries that deport migrants living with HIV. Migrants, in turn, prefer not to return to their homeland and remain in the country illegally. For fear of being discovered, they do not seek medical attention until they feel very sick. Experts believe that in this way migrants not only risk their health, but also exacerbate the situation with HIV in the country, writes RIA Novosti.

Where it all started

In 1995, the Law on Preventing the Spread of HIV was passed, stating that migrants who have been diagnosed with HIV should be deported. In 2015, the law was amended: it is forbidden to expel from the country foreigners whose relatives are Russian citizens.

Despite the fact that it is possible to take a status test in Russia anonymously, migrants who want to obtain citizenship or a patent in order to work officially must provide the results of an HIV test. The data is automatically sent to Rospotrebnadzor, then the relevant commission makes a decision on the “undesirability of stay”, after which the foreign citizen must leave the country within one month.

In this regard, the number of migrants who have decided to “lay low” in order not to return to their homeland is growing: many have jobs here, a stable income, families and relatives.

Hidden epidemic 

In February, Russian Deputy Prime Minister Tatyana Golikova announced that there were 1.1 million people living with HIV in Russia. According to Rospotrebnadzor, migrants, who make up almost 2 million, account for more than 39,000 cases. Most of them are citizens of Tajikistan, Ukraine and Uzbekistan. These are only official statistics. According to Vadim Pokrovsky, with existing methods of fighting infection, the number of people living with HIV by 2030 could double.

Experts believe that migrants are forming a “hidden epidemic”: many are in the country illegally, do not accept treatment, because they are afraid to seek help. They try not to leave Russia, because they will not be allowed back because of their status.

According to Vadim Pokrovsky, under current methods of combating infection the number of people living with HIV by 2030 can grow by half.

Expert opinion

Daniil Kashnitsky, Academic Relations Coordinator of the Regional Expert Group on Migrant Health, believes that the law passed in 1995 is long out of date. Over the past few decades, drugs have been developed that allow people living with HIV to live full lives, have an undetectable viral load and have healthy babies. And because of the existing discrimination, migrants “hide” and do not have access to quality medicine. Many of them are ready to purchase treatment at their own expense, but due to being on the “unwanted list”, they cannot legally stay in Russia.

Experts from the Regional Expert Group on Migrant Health are confident that this problem can be solved by refusing deportation and reaching certain agreements with the CIS countries.

Почему из России депортируют мигрантов, живущих с ВИЧ?

Россия является одной из 19 стран, которые депортируют мигрантов, живущих с ВИЧ. Мигранты, в свою очередь, предпочитают не возвращаться на родину и остаются в стране нелегально. Из страха быть обнаруженными они не обращаются за медицинской помощью до тех пор, пока не станет совсем плохо. Специалисты считают, что таким образом мигранты не только рискуют своим здоровьем, но и усугубляют ситуацию с ВИЧ в стране, пишет РИА Новости.

Откуда все началось

В 1995 году был принят закон «О предупреждении распространения ВИЧ», сообщающий, что мигранты, у которых выявили ВИЧ, должны быть депортированы. В 2015 году закон был скорректирован: запрещено высылать из страны иностранцев, у которых родственники являются гражданами России.

Несмотря на то, что пройти тест на наличие статуса в России можно анонимно, мигранты, которые хотят получить гражданство или патент, чтобы работать официально, должны предоставить результаты анализа на ВИЧ. Данные автоматически попадают в Роспотребнадзор, затем соответствующая комиссия принимает решение о «нежелательности пребывания», после чего иностранный гражданин должен покинуть страну в течение одного месяца.

В связи с этим растет количество мигрантов, которые решили «залечь на дно», чтобы не возвращаться на родину: у многих здесь работа, стабильный доход, семьи и родственники.

Скрытая эпидемия 

В феврале вице-премьер РФ Татьяна Голикова сообщила о том, что в России зафиксировано 1,1 млн людей, живущих с ВИЧ. По данным Роспотребнадзора, на мигрантов, которые составляют почти 2 млн, приходится более 39 000 случаев. Большую часть составляют граждане Таджикистана, Украины и Узбекистана. Это только официальная статистика. По словам Вадима Покровского, при существующих методах борьбы с инфекцией количество людей, живущих с ВИЧ, к 2030 году может вырасти вдвое.

Эксперты считают, что мигранты формируют «скрытую эпидемию»: многие находятся в стране нелегально, не принимают лечение, так как боятся обратиться за помощью. Они стараются не выезжать из России, потому что обратно их не пустят из-за статуса.

По словам Вадима Покровского, при существующих методах борьбы с инфекцией количество людей, живущих с ВИЧ, к 2030 году может вырасти вдвое.

Мнение экспертов

Даниил Кашницкий, координатор по академическим связям Региональной экспертной группы по здоровью мигрантов, считает, что закон, принятый в 1995 году уже давно устарел. За последние несколько десятилетий разработаны препараты, которые позволяют людям, живущим с ВИЧ, жить полноценной жизнью, иметь неопределяемую вирусную нагрузку и рожать здоровых детей. А из-за существующей дискриминации мигранты «прячутся» и не имеют доступа к качественной медицине. Многие из них готовы приобретать лечение за свой счет, но из-за попадания в «нежелательный список», они не могут легально находиться в России.

Специалисты из Региональной экспертной группы по здоровью мигрантов уверены, что эту проблему можно решить, отказавшись от депортации, и достигнув определенных договоренностей со странами СНГ.

Israel: Undocumented migrants living with HIV receive drugs no longer administered to Israelis

Undocumented HIV carriers in Israel receive treatment ‘worse than third world countries,’ if any at all

Those treated by the Health Ministry program speak of severe side effects, and doctors note drugs they receive are no longer administered to Israelis.

Hundreds of undocumented HIV carriers in Israel receive inadequate treatment and outdated medications that sometimes cause severe side effects. Moreover, they are unable to access treatment for their condition and related infections or receive sufficiently close monitoring. Carriers are admitted to the Health Ministry’s treatment program only after their condition deteriorates, and their immune system is already dysfunctional.

One source familiar with the situation said the plan suffers from “quality of treatment and a management level worse than third world countries.”

According to the latest Health Ministry data from 2019, 130 out of 430 new carriers diagnosed that year were undocumented and without health insurance.

Doctors and professionals in the field say the treatment regimen for undocumented HIV carriers is very narrow, and far removed from the quality provided to Israeli carriers, who enjoy treatment that is among the most advanced in the world. As a result, physicians often find themselves helpless when treating patients.

D., 50, is an undocumented migrant who arrived in Israel from Ethiopia about 25 years ago. She was diagnosed HIV-positive 19 years ago, when she was five months pregnant. In 2016, after years of being treated on a voluntary basis, she started to receive treatment from the Health Ministry, in the course of which, she said, she was given medications that weren’t suitable for her and caused multiple side effects.

“My body does not react well to the pills,” she related. “They cause me pains, exhaustion and an accelerated heartbeat. When I take them I am afraid to leave the house and I simply prefer to forgo that on certain days.”

D. said that she asked for medications appropriate for her but her request was denied because they are not included in the program. “I was told that if I want to buy them privately it will cost me 6,000 shekels [$1,850] a month. I don’t have that amount.” Now she is being treated irregularly. “The doctor gave me what there is, what she manages to get hold of,” she said, referring to the more expensive medications. “I don’t know which medication I will be receiving in another month or two. Sometimes I just switch treatment.”

D. is also ineligible for regular follow-ups. Undocumented persons are entitled to a test that monitors their immune system activity only once a year, whereas Israeli patients are entitled to a quarterly test. In the meantime, neither D. nor her attending physician know how effective the treatment is. In addition, she is not entitled to treatment to be treated for for side effects and accompanying complications.

“I don’t have a regular job and have no way to pay for private treatments,” she said. “I go to clinics in Jerusalem’s Old City because it’s cheaper there. I want to live, but I am not getting what I need.”

“It’s not just a difference between life and death. It’s a difference between life and death in agony,” said Dr. Itzik Levy, director of the AIDS clinic at Sheba Medical Center, Tel Hashomer. “The treatments currently given to undocumented carriers are ones that are no longer used – not even in third world countries.” In 2016, after a protracted struggle, the Health Ministry decided to offer treatment to undocumented HIV carriers. “The problem is that the quality of care and its administration is worse than in third world countries,” Levy claimed.

Levy said undocumented carriers are only entitled to outdated drugs that cause a long list of side effects, absent in the latest medications. “These are drugs that are not currently administered to any Israeli carriers – drugs with lower efficacy that lead to many side effects, such as anemia, weakness, increase in blood lipids, diabetes, and neuropsychiatric symptoms,” he asserted.

In addition, the program does not cover treatments for other complications and AIDS-related illnesses, which are caused by the disease or the side effects of its treatment. “They do not receive other drugs, including preventive ones. If you need to prevent disease or administer complex antibiotics – they aren’t eligible,” he said. “I face patients I cannot help. I have carriers who have fallen ill because of the drugs’ side effects or other reasons and had nothing for them. Their immune system deteriorated. In one case, a patient had a stroke and remained disabled for life. Another patient had lymphoma and died. These are things that could have been prevented with better treatment for HIV suppression.”

Dependent on leftovers

In 2016, the National Program for the Treatment of Undocumented HIV Carriers was launched, led by the Health Ministry’s department of tuberculosis and AIDS, designed to handle immigrant carriers, many of whom come from endemic countries, including refugees and migrant workers from Africa and carriers from the former Soviet-Union who overstayed their tourist visas and became undocumented migrants in Israel.

The program is designed and budgeted for the treatment of about 400 HIV carriers aged 18 and over who are in Israel for at least six months and lack health insurance. Candidates for the program were required to appear before a medical committee. S., 60, emigrated from Ethiopia in 1995 and was diagnosed HIV positive three years later. In 2006, he also fell ill with tuberculosis and a brain infection. He suffers from neural and bone damage. In his case, too, the treatment he’s getting through the program is insufficient.

“My treatment depends on what the doctor can get hold of,” he said. “The other medications I buy myself, costing me about a thousand shekels a month.”

K. 70, arrived in Israel from Ethiopia about a decade ago and was diagnosed as a carrier shortly afterward. She said that one of the two medications she receives as part of the program causes severe side effects. “The medication causes vomiting, loss of appetite, exhaustion and a serious rash all over the body,” she said. “That’s in addition to a chronic lack of iron. The new medications are better and don’t produce side effects, but I don’t know which medication I’ll get, or in what quantity. The pills will run out in another month and a bit, and I’m already stressed. I don’t know what will happen.”

One of the drugs that treats a significant proportion of undocumented carriers is called Zidovudine (AZT), approved for use in 1987. Another drug used on this group of patients is efavirenz (Stocrin). Both drugs cause severe and often fatal side effects. For these reasons, these drugs have been discontinued in most countries, including Israel.

“These are drugs with a lot of side effects that Israeli carriers have not received for more than a decade. Israeli carriers are treated with new-generation drugs that have almost no side effects, are effective against resistant viruses, but are more expensive,” said Levy. “This situation is forcing me to perform poor medicine. I have a patient in her sixties for whom I found a donation of two boxes of medicine that she needs and is not entitled to. Once she runs out her fate will be sealed unless we find more.”

Other senior AIDS physicians identified with the situation described by Levy.

“Treatment for Israeli citizens is second to none, including in Europe. Israeli carriers receive the most advanced, expensive, and unlimited treatment. We are talking about drugs that cost between NIS 4,000 and NIS 5,000 per month per patient. Cost is certainly a consideration,” said Dr. Hila Elinav, director of the AIDS medicine unit at Hadassah, and a board member of the Israeli AIDS Society. “Most patients do fine with the old drugs, but some have severe side effects or have developed resistant strands. We have no solution for them.”

She said this situation creates the need to source leftovers from Israeli patients. “This is a very problematic method, and I am constantly under pressure,” she said. In cases in which they don’t manage to obtain the right medications, she said, “I have to change the treatment, and that is absolutely not good.”

Other sources agreed that the existing treatment is problematic, but stressed that before the program got underway undocumented carriers received no treatment at all.

According to Dr. Dan Turner, Director of the AIDS Center at Ichilov Hospital, and Chairman of the Israeli AIDS Society, “The treatments given to undocumented carriers are the same treatments given to Israeli patients previously. We are talking about a relatively large number of pills and with a very high percentage of side effects.”

Looking back, he said, many Israeli patients who received the obsolete treatment survived and coped with the side effects. “Our big problem is the fact that a few dozen patients can’t receive the old treatment, whether due to resistance or because of various side effects, and we have no solution for them,” he said. “In some cases this reaches a condition that poses an immediate danger to their life.”

‘Scandalous’ threshold

Another problem professionals point out is the entry threshold to the program. Unlike Israeli carriers who are treated upon diagnosis, an undocumented carrier who tests positive will only be monitored and treated after their immune system activity falls below the set threshold. “The threshold for entering the program is a scandal and that is something that must change,” Elinav said. “It’s not just that people are at risk of developing a disease. They can infect others and this counters the goal of lowering the overall morbidity. Beyond that, untreated carriers come to hospitals with AIDS, and then their condition is much more difficult.” According to Turner, research shows that the earlier the treatment of carriers begins, the more their life expectancy increases, and the more AIDS-related illnesses and comorbidities decrease.

And yet, some professionals believe the program should be judged more broadly. “It is true that there is criticism of the program, but it should also be welcomed. The situation before was terrible. Today, the program helps most patients but needs improvements,” Turner added. “The program is welcome but there is still a lot to do.” According to the Ministry of Health, more than 500 carriers have been treated to date under the program. There are now about 350 people in the program, only a few of whom are being monitored, as they do not yet meet the criteria.

“The program is vital and helps hundreds of HIV carriers a year receive life-saving treatments. The number of undocumented carriers being treated has more than doubled since it was launched,” said Noga Oron, chairwoman of the Committee for the Struggle Against AIDS. “There is an urgent need to add new generation drugs to the program for those patients whose drugs don’t suit their needs.” A more effective program will reduce the burden on the health system because of unnecessary infections and hospitalizations. It is also proven that the HIV carrier that is treated optimally is not contagious at all, and therefore it is recommended that every person who is HIV-positive be treated as soon as possible,” said Oron.

The Health Ministry commented: “The use of medications other than those stipulated in the guidelines would raise the cost of the program by several million more shekels or would bring about a significant decrease in the number of patients who can benefit from the program. Israel is one of the few countries in the West that provides free antiviral monitoring and treatment for non-citizens without health insurance. The program operates on a strictly medical and humanitarian basis only. The medications are those recommended by the World Health Organization.”

It added: “At the same time, there is a small number of carriers whose treatment in the program is unsuitable (due to resistances), and they receive the medications in other tracks. This year again, the tuberculosis and AIDS department requested a special budget for which authorization has not yet been received. All told, the program is essential, both in terms of public health and on humanitarian grounds. However, the program is operating under challenging budgetary constraints, especially in the past few years.”

Andorra: People refused entry to the country for a variety of health reasons, including HIV

A doctor’s complaint against the Andorran government for the ‘grave violation of human rights’ of immigration medical services

Translated from Spanish via Deepl.com; Scroll down for the original article in Spanish.

Ricardo Villanueva, a doctor who worked for three years in a hospital in Andorra, has filed a complaint against the government of the Principality. The doctor claims that people have been refused entry to the country for various health reasons: HIV, hepatitis, diabetes, myopia, obesity, anxiety and deafness.

‘The objective is purely economic, as vulgar as that’, he denounces, adding: “an HIV-positive patient is going to be an economic burden for them in the future, and for an obese patient the capacity to develop illnesses is going to be much greater, which is going to have repercussions on their coffers”.

In this sense, the doctor highlights a fact: ‘The average life expectancy in Andorra is 90 or 91 years, more than anywhere else in Europe, this is due to the fact that “sick, no thanks”’. ‘When they have an illness or whatever, the Andorran service automatically takes away their residence permit, and if they don’t have a residence permit, they have to go to their country of origin,’ he laments.

Moreover, Villanueva assures that ‘this situation has not changed nowadays’, according to what he has heard ‘from doctors who continue to work in Andorra’, to which he adds that ‘what has happened is that there is better surveillance in the flow of data referring to these problems’.

La denuncia de un médico al Gobierno de Andorra por la “grave violación de los derechos humanos” de los servicios médicos de inmigración

Ricardo Villanueva, un médico que trabajó tres años en un hospital de Andorra, abandera una denuncia contra el Gobierno del Principado. El doctor asegura que han denegado la entrada al país por diferentes cuestiones de salud: VIH, hepatitis, diabetes, miopía, obesidad, ansiedad o sordera.

“El objetivo es meramente económico, así de vulgar”, denuncia, tras lo que añade: “un paciente seropositivo va a ser para ellos el día de mañana una carga económica y para un paciente obeso la capacidad de desarrollar enfermedades va a ser mucho más amplia, con lo que eso va a repercutir en sus arcas”.

En este sentido, el doctor destaca un dato: “El promedio de vida en Andorra son 90 o 91 años, más que en ninguna parte de Europa, esto es debido a que ‘enfermos, no gracias'”. “Cuando tienen una enfermedad o lo que sea, automáticamente el servicio de Andorra les quita el permiso de residencia, y si no tienen permiso de residencia, tienen que irse a sus países de orígenes”, lamenta.

Además, Villanueva asegura que “esta situación no ha cambiado en la actualidad”, según lo que le llega “por parte de médicos que siguen trabajando en Andorra”, a lo que apostilla que “lo que ha ocurrido es que hay una mejor vigilancia en los flujos de datos que hacen referencia a estos problemas”.

Nepal: How critical HIV medicine reached a traveler stranded in Nepal during the pandemic

Stranded in Nepal without HIV medicine

Wang Tang (not his real name) had never been to Nepal before, but at the end of March 2020 it was one of the few countries that had not closed its borders with China. Since he was desperate to get away from Beijing after having had to stay at home for months after the coronavirus outbreak spread throughout China, he bought a ticket.

But days after he arrived, while he was staying in Pokhara, the fourth stop on his trip, the local government announced that the city would be shut down. He heard that the lockdown would not last longer than a month.

As someone who is living with HIV, he had brought along enough HIV treatment to last for a month. However, he soon learned that the re-opening of the city was to be postponed, which meant that he was at risk of running out of the medicine he needed to take regularly in order to suppress his HIV viral load and stay healthy.

Mr Wang swallowed hard while counting the remaining tablets. He had no idea how to get more.

As the lockdown dragged on, it seemed that no end was in sight. Mr Wang started to take his medicine every other day so that his supply would last a little bit longer.

He contacted his friends back at home, hoping that they could send medicine to Nepal, but they couldn’t. The country was under lockdown—nothing could be imported.

Then, Mr Wang contacted his friend Mu-Mu, the head of Beijing Red Pomegranate, a nongovernmental organization providing volunteer services for people living with HIV. It was with Mu-Mu’s help that Mr Wang learned how to obtain HIV treatment after he was diagnosed as living with HIV. Having known each other for many years, Mu-Mu had the trust of his friend. Mu-Mu contacted the UNAIDS Country Office for China to see if it was possible to deliver medicines to Mr Wang. A UNAIDS staff member quickly got in touch with the UNAIDS Country Office for Nepal.

Everything happened so quickly that Mr Wang was shocked when he received a message from Priti Acharya, who works for AHF Nepal and had been contacted by the UNAIDS Nepal office, saying that she would bring the medicine to him.

The next day, Ms Acharya rode her motorbike for 15 km on a dusty road before reaching the place where she would meet Mr Wang. When he came down from the mountains to meet her, Ms Acharya, drenched in sweat, was waiting under the midday sun.

“I was so happy and thankful for her hard work. She gave me a sunny Nepalese smile in return, as well as detailed instructions on the medicine’s dosage,” said Mr Wang.

They took a photograph together, then Mr Wang watched Ms Acharya as she left on her motorbike. Her image, disappearing in the distance, is carved into his memory. To attend the five-minute meeting, Ms Acharya had to ride a round trip of more than 30 km.

“For half a month or so, I had been suffering from pain and anxiety almost every day due to the lack of medication and the loneliness of being in a foreign country on my own. I could not believe that I got the HIV medicine in such a short time,” said Mr Wang. After the trip, he wrote to thank Ms Acharya, explaining how important the medicine he now had in his hand was: “it’s life-saving.”

At the end of his stay in Nepal, Mr Wang wanted to do something for UNAIDS. As he is an experienced photographer, he volunteered to carry out a photo shoot for UNAIDS’ Nepal office.

The subject he chose was former soccer player Gopal Shrestha, the face of an HIV charity in Nepal and the first person living with HIV to reach the summit of Mount Everest. After his HIV diagnosis in 1994, Mr Shrestha launched the Step-Up Campaign and spent many years climbing mountains worldwide, hoping to give strength and hope to people living with HIV.

In 2019, Mr Shrestha reached the peak of the world’s highest mountain, Mount Everest, recording a historic breakthrough for people living with HIV. “If 28 000 people have already climbed Mount Everest, why can’t I?” he said. “By climbing the highest mountain in the world, I want to prove that we are no different from anyone else and that we can all make a difference.”

“The moment I saw him, I could tell he was a sophisticated man,” said Mr Wang. Without instructions, Mr Shrestha posed naturally in front of the camera. He displayed confidence and charm. His eyes, content and clear, reflected nature’s beauty. “The eyes surely are the window to the soul,” Mr Wang said.

Mr Wang is looking forward to his next trip to Nepal. After the pandemic, Pokhara’s lakeside will be flooded with tourists, and he looks forward to seeing the mountain town bustling with people like it used to.

Egypt: UNAIDS helps non-nationals in Egypt to get supplies of antiretroviral therapy

UNAIDS supporting people stranded in Egypt to access HIV treatment

Hundreds of thousands of people around the world have been stranded abroad due to the bans on flights and border closures imposed to stop COVID-19. As elsewhere, thousands of non-nationals have been stranded in Egypt indefinitely.

Travel restrictions have had many repercussions on the daily lives of non-nationals, putting significant economic pressure on them and potentially putting their well-being at risk.

The UNAIDS Country Office for Egypt has been working on COVID-19 from the start of the pandemic in the country, establishing a direct line of communication with the National AIDS Program and working with it to ensure the continuation of HIV treatment by everyone on it and to help non-nationals in Egypt to get supplies of antiretroviral therapy.

Sophia Bianchi (not her real name) is an Italian tourist stranded in Sharm El Sheikh. “I ordered my antiretroviral treatment in late April from Italy via a courier service. Unfortunately, the shipment was stuck at the airport customs in Cairo for weeks. I contacted UNAIDS and they have been very helpful, following up daily with the Egyptian Ministry of Health and Population to get approval for releasing the shipment and checking on me and my health. They kept pushing through the Eid holidays and it all got resolved in two weeks. It was a stressful time but now I am relieved,” she said.

Antiretroviral therapy is available in Egypt free of charge to all nationals and registered refugees. However, as there is no community-based dispensing, nor private market purchase of antiretroviral medicines, gaps remain in ensuring that non-nationals can access treatment. For this reason, UNAIDS’ work during the COVID-19 pandemic has been essential in bridging the gaps.

There are strict rules on the dispensing of antiretroviral therapy in Egypt—only close family members are able to collect it from the dispensing centre. For Fatima Ahmed (not her real name), a refugee from Yemen who because of chronic illnesses that put her at higher risk from COVID-19 cannot leave her house, this was a significant barrier to accessing her HIV treatment. UNAIDS got in contact with the Egyptian Ministry of Health and Population to get an exceptional approval to dispense her medicine through a nongovernmental organization.

“I have not left the house for more than three months. My family has not been able to support me financially, so I was left without revenue. Thanks to the support of the National AIDS Program and MENA Rosa, a nongovernmental organization, peer supporters have delivered three months of antiretroviral treatment to my doorstep,” said Ms Ahmed.

However, much still remains to be done in reaching out to the most in need in Egypt. UNAIDS in Egypt has been advocating for the right to health and universal health coverage for everyone and is working in partnership with the Egyptian Ministry of Health and Population to ensure treatment for all nationals and non-nationals in the country.

“We believe in the absolute right of everyone to have access to their basic right to health. Ensuring access to antiretroviral therapy during these exceptional times is therefore our upmost priority. We are working relentlessly with our governmental and nongovernmental partners to build long-term policies to ensure treatment and care services for people living with HIV during times of emergency,” said Walid Kamal, the UNAIDS Country Director for Egypt.

South Africa: African migrants face dual challenge of navigating HIV care and social stigma

The social management of HIV: African migrants in South Africa

HIV is the most common chronic illness in South Africa. One in every five is infected and one in every 13 takes antiretroviral drugs daily. Managing HIV medically has become more of a part of normal life.

Amid this public health emergency, some 2.5 million foreign-born African immigrants live in South Africa. They largely come from countries with the highest HIV prevalence rates in the world, such as Lesotho. Yet their access to health care and services is limited, because they are vulnerable in various ways. Though entitled to inclusion and care in South Africa, they may face deportation, xenophobia, exploitation, language barriers, cultural estrangement and social isolation.

In spite of these challenges, migrants do manage HIV medically. But we do not really know how they manage socially in communities where the stigma of the disease affects all dimensions of life. HIV is often referred to today as a “manageable” chronic illness, but it is not just a medical condition. It is also very much a social condition as living with HIV comprises both clinical features of care and experiences of stigma and social angst.

Understanding how migrants manage this social dimension of their condition matters because it shapes the landscapes and outcomes of their care. It directly influences when and where people seek treatment, and how well they adhere to it if they do. This in turn affects critical issues such as drug resistance and prevention of transmission.

In a recent journal article, I unravel complexities of stigma and perceptions of HIV in Mozambican migrant communities. My research exposes layers and shades of stigma across different social networks and locations, which influence how HIV is managed socially. It shows how an individual’s HIV status determines how other community members are regarded and interacted with in daily life.

Perceptual contrasts

Nowhere in South Africa is the migrant population as dense as in inner-city Johannesburg. In their urban enclaves, community members inevitably lead lives entwined with those of people receiving care for HIV, whether aware of their infection or not.

HIV is spoken of here in ways that acknowledge, perpetuate and replicate stigma. For instance, Mozambicans may allude to HIV as “stepping on the mine”, as “being poisoned” or as “getting stung”. Open conversation about HIV is avoided, which in turn creates an anxiety that motivates secrecy. This is so because disclosure of HIV serostatus may put social life at risk.

I explore perceptions of HIV among two groups of Mozambican migrants in Johannesburg: one consisting of patients receiving care for HIV in a hospital; and the other of community members unaware of their own serostatus.

The contrast between how these two groups perceive of each other is staggering. The patients apprehensively conceal their status for fear of what others might think of them. But these others express mostly empathy and understanding for their condition.

I identify two reasons for such stark perceptual contrasts. The first lies in a transformation of identity, which results in a division between an “us” and a “them”, between the HIV-positive and the HIV-negative.

This process creates a schism between “patienthood” and “personhood”. When a person tests positive for HIV, fears of physical death in the future transform into fears of social disruption in the present. Loneliness and isolation then result from the person keeping her HIV status secret.

As the identity of a community member shifts from personhood to patienthood, as she receives counselling and care, she comes to associate disclosure with her own (and others’) social death. Her serostatus then becomes a secret in her life, while her notion of others’ perceptions of HIV becomes confined to the realm of the suspected and nervously anticipated. Expecting social misfortunes should others learn of her status, she opts for concealment as a strategy of survival in the community.

Secondly, I find that stigma is tied to location, because of the ways in which location is tied to social networks. In different social networks such as family at home, friends, work colleagues, acquaintances in the community or the nightlife, the stakes of disclosure vary considerably.

For instance, one focal point of stigma is the local HIV clinic. It is supposed to care for its patients, but at the same time it also estranges them, because others might recognise them there and so become antagonists rather than fellow patients.

In fact, Mozambicans largely prefer to avoid clinics in South Africa and go home to Mozambique for treatment. The stakes of disclosure, involving livelihoods, partners and identities, are far too high to risk being seen receiving care in South Africa. Disclosure may be less hurtful in certain locations where social networks are more sympathetic.

This may further complicate the therapeutic journey of migrants in terms of costs, retention in treatment or simply having to explain away the true purpose of one’s absence.

Medicalised, not socialised

HIV may have become easier to manage medically, but stigma continues to cause distress and remains severely challenging to manage. This is also a challenge for health care provision, as it sways choices of when and where to seek care: a South African clinic, for example, or a distant, socially safer treatment option.

HIV may have been medicalised, yes, but not socialised.