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.

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: Court finds refusal to let migrant woman stay in Russia because of her HIV status unlawful

Court in Krasnodar invalidates refusal to allow a foreigner with HIV to stay in Russia

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

The Krasnodar Territory Department of the Russian Federal Consumer Rights Protection and Human Health Control Service decided that Uzbek citizen X. was undesirable in Russia because of her HIV positive status. The Leninskiy Court in Krasnodar found the ban discriminatory and unlawful.

The foreigner went to court to challenge the decision to ban her from staying in Russia, pointing out that her parents, brother and sister reside in Russia and have Russian citizenship, and she has never violated the law. When Rosia appealed to Rospotrebnadzor to cancel the decision, they replied that the procedure for cancellation or suspension under this category was not regulated by law and that the contested decision could only be cancelled on the basis of a court decision.

The court found that under the law On the Prevention of the Spread of Disease Caused by HIV in the Russian Federation, foreigners and stateless persons with such status may stay in the country if they do not violate administrative and criminal law. The Russian Constitutional Court has also confirmed the illegality of such restrictions.

As a result, the Leninskiy Court in Krasnodar ordered the regional department of Rospotrebnadzor to reverse the decision on the undesirability of the Uzbekistani citizen, who is now allowed to enter the country.

Суд в Краснодаре признал незаконным отказ во въезде в Россию иностранке с ВИЧ

Управление Роспотребнадзора по Краснодарскому краю приняло решение о нежелательности нахождения в России гражданки Узбекистана Р.Р. из-за ее положительного ВИЧ-статуса. Ленинский суд Краснодара признал запрет дискриминационным и незаконным.

Иностранка обратилась в суд, оспаривая решение о запрете пребывания в России, указав: ее родители, брат и сестра проживают в России и имеют российское гражданство, она ни разу не нарушала законодательство. Когда Розия обратилась в Роспотребнадзор с требованием отменить решение, там ответили – порядок отмены или приостановления по этой категории законодательно не урегулирован и отмена оспариваемого решения возможна только на основании решения суда.

Суд установил, что по закону “О предупреждении распространения в Российской Федерации заболевания, вызываемого ВИЧ” иностранцы и лица без гражданства с подобным статусом могут находиться в стране, если не нарушают административное и уголовное законодательство. Незаконность такого ограничения подтверждает и Конституционный суд России.

В итоге Ленинский суд Краснодара обязал региональное управление Роспотребнадзора отменить решение о нежелательности пребывания гражданки Узбекистана, которой теперь разрешен въезд в страну.

Cyprus: Decision to deport HIV positive student on the grounds of “carrying an infectious disease” is reversed

Deportation of HIV student halted after uproar

The civil registry and migration department on Saturday responded to being lambasted for ordering the deportation of a third-country student because he was HIV positive, saying they would be issuing him a residence permit under certain health conditions.

The Aids Solidarity Movement earlier in the day condemned the deportation order, labelling it an act of “severe discrimination” and calling for the reversal of the decision.

According to the statement, the student was informed by the civil registry and migration department on March 16 by letter that he would be deported on March 21 on the grounds of “carrying an infectious disease”.

The movement said that this decision completely ignored letters of support from both the Gregorios treatment centre and the Solidarity Movement itself, as well as the guidelines of the World Health Organisation, which state “that when a person living with HIV has an undetectable viral load, due to the effective medication they receive, they cannot transmit the virus, even through unprotected sex”.

“The student has access to medication from his country, does not burden the state in any way in relation to his antiretroviral treatment or medical supervision, and does not pose a risk to public health,” the statement added.

Moreover, with the student’s written consent, the movement sent his medical results, along with a note from Doctor Ioannis Demetriades, the head of the Gregorios Clinic and the head of the ministry of health’s HIV and Aids programme, to the migration department’s acting director, asking that the student be allowed to complete his studies.

“We denounce this serious discrimination based on the HIV status of an individual and demand the immediate change of the decision from all the competent bodies of the state that support human rights,” the statement concluded.

Later on Saturday a statement from the migration department said it would in the end be issuing the residence permit after receiving a confirmation from the competent medical services of the state that the student was not contagious.

The condition of the permit is that the student receive regular health checks at the Gregorios Clinic.

It added that it had only been following the law, which “prohibit entry into the country, or carry out deportations for those persons who are carriers or suffer from communicable or infectious diseases and which are a danger to public health”.

Cyprus: Migration Department cancels deportation of undetectable HIV-Positive student after backlash

Deportation of HIV student halted after uproar (Updated)

The civil registry and migration department on Saturday responded to being lambasted for ordering the deportation of a third-country student because he was HIV positive, saying they would be issuing him a residence permit under certain health conditions.

The Aids Solidarity Movement earlier in the day condemned the deportation order, labelling it an act of “severe discrimination” and calling for the reversal of the decision.

According to the statement, the student was informed by the civil registry and migration department on March 16 by letter that he would be deported on March 21 on the grounds of “carrying an infectious disease”.

The movement said that this decision completely ignored letters of support from both the Gregorios treatment centre and the Solidarity Movement itself, as well as the guidelines of the World Health Organisation, which state “that when a person living with HIV has an undetectable viral load, due to the effective medication they receive, they cannot transmit the virus, even through unprotected sex”.

“The student has access to medication from his country, does not burden the state in any way in relation to his antiretroviral treatment or medical supervision, and does not pose a risk to public health,” the statement added.

Moreover, with the student’s written consent, the movement sent his medical results, along with a note from Doctor Ioannis Demetriades, the head of the Gregorios Clinic and the head of the ministry of health’s HIV and Aids programme, to the migration department’s acting director, asking that the student be allowed to complete his studies.

“We denounce this serious discrimination based on the HIV status of an individual and demand the immediate change of the decision from all the competent bodies of the state that support human rights,” the statement concluded.

Later on Saturday a statement from the migration department said it would in the end be issuing the residence permit after receiving a confirmation from the competent medical services of the state that the student was not contagious.

The condition of the permit is that the student receive regular health checks at the Gregorios Clinic.

It added that it had only been following the law, which “prohibit entry into the country, or carry out deportations for those persons who are carriers or suffer from communicable or infectious diseases and which are a danger to public health”.