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

Golondrinas’ project seeks to guarantee care for migrants with HIV

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

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

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

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

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

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

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

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

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

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

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

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

He stressed that the right to health comes before documents.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Poland: Ukrainian refugees struggle with stigma and treatment gaps

Ukrainian refugees with HIV adjust to care abroad

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

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

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

Difficult adjustment

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

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

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

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

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

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

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

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

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

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

Results

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

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

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

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

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

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

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

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

References

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

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

 

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

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

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

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

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

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

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

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

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

NYC Sexual Health Clinics in New York:

Morissania Sexual Health Clinic

1309 Fulton Avenue, Bronx

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

Jamaica Sexual Health Clinic

90-37 Parsons Boulevard, Queens

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

Corona Sexual Health Clinic

34-33 Junction Boulevard, Queens

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

Fort Green Sexual Health Clinic

295 Flatbush Avenue Extension, Second Floor, Brooklyn

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

Fort Green Express Clinic

295 Flatbush Avenue Extension, First Floor, Brooklyn

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

Chelsea Sexual Health Clinic

303 9th Avenue, Manhattan

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

Chelsea Express Sexual Health Clinic

303 9th Avenue, Manhattan

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

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

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

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

Free self-test kits:

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

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

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

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

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

The Institute for Family Health

Manhattan

The Institute for Family Health

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

New York, NY 10011

(212) 206-5200

Family Health Center of Harlem

1824 Madison Avenue

New York, NY 10035

(212) 423-4500

Bronx

Urban Horizons Family Health Center

50 E 168th St, Bronx, NY 10452

(718) 293-3900

Hudson Valley

Kingston Family Health Center

1 Family Practice Dr, Kingston, NY 12401

(845) 338-6400

Ellenville Family Health Center

6 Healthy Way, Ellenville, NY 12428

(845) 647-4500

Catholic Charities Services

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

87 North Clinton Avenue

Rochester, NY 14604

(585) 546-7220

1099 Jay Street

Building J

Rochester, NY 14611

(585) 339-9800

ccfcs@fcscharities.org

Caribbean Equality Project

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

Email: info@CaribbeanEqualityProject.org

Phone: (347) 709-3179

CAMBA

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

Address: 1720 Church Avenue

Brooklyn, NY 11226

Phone: 718-287-2600

Email: info@CAMBA.org

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

Caribbean Women’s Health Association

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

Address: 3512 Church Ave, Brooklyn, NY 11203

Phone: (929) 399-8070

Diaspora Community Services

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

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

Phone: (718) 399-0200

Email: info@diasporacs.org

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

Access to healthcare for foreigners with HIV is fraught with pitfalls

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

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

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

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

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

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

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

An obstacle course

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

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

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

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

New restrictions

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

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

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

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

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

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

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

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

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

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

Un parcours d’obstacles

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

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

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

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

De nouvelles restrictions

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

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

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

Iraq: Majority of Kurdistan’s new HIV cases are foreigners, now facing deportation

KRI’s MoH records 72 new cases of HIV/AIDS during 2023

Shafaq News / The Ministry of Health of the Kurdistan Region (KRI) announced on Friday the registration of 72 new cases of HIV/AIDS, confirming that the majority of them are from outside the Region.

In a statement released on the occasion of World AIDS Day, the ministry indicated that “the concerned authorities in the Region, as part of the 2023 control program, conducted 598,000 tests for the HIV virus, especially for foreigners before granting residency, blood donation, marriage, employees in tourist places, as well as detainees, prisoners, and individuals with thalassemia and viral hepatitis.”

The statement added that “the ministry recorded 72 new cases of HIV/AIDS during the current year, with the majority being foreign nationals,” stating that “measures have been taken against them, and they will be repatriated.

The ministry emphasized that “new cases among KRI’s citizens are under medical care and prevention measures, including continuous medical examination, treatment provision, and ongoing medical instructions.”

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.