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.”

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”.