AIDS action Issue 44 Page 1 2
Issue 44 April - June 1999
People on the move
Many people live away from their homes and communities. Worldwide, about 125 million people are migrant workers, immigrants or refugees living outside the country where they were born. Many more people move within their country, often from rural to urban areas, in search of education, employment or safety. Some make their living along the roads, railways and rivers as traders or transport workers. For others, for example, sex workers and soldiers, their work involves moving from place to place.
Migrants and refugees can be particularly vulnerable to sexually transmitted infections (STIs) including HIV. This is because it is often harder for people to practise safer sex if they are living in difficult circumstances. For example, the level of HIV infection among transport workers in India is twenty times as high as the level of HIV in the general population. The communities left behind are also very vulnerable to HIV.
This issue of AIDS Action looks at some practical approaches to HIV prevention with people on the move. A project in Niger describes its work with migrant peer educators. For workers on the move, a national programme can help improve health services. A programme in India explains how it provides STI treatment and health information for truck drivers. Effective HIV programmes for people on the move should also include activities with the communities they originally come from. A project from South Africa explains how they do this. Refugees have particular needs. This issue includes some of the lessons learned from HIV prevention programs with refugees in Tanzania and Mozambique.
Mobility and HIV
People on the move can be particularly vulnerable to HIV. AIDS Action looks at practical interventions and approaches to HIV prevention with mobile populations.
When large numbers of people move, diseases often spread too. In West Africa, for example, the highest levels of HIV are found in areas with high migration rates. Migrants and refugees can be particularly vulnerable to HIV, because often (but not always) they live in situations where:
they are likely to be having sex with different people, some of whom are also having sex with more than one person
they lack the information, skills or resources to practise safer sex.
Poverty and lack of rights
Refugees or people who move to cities to work often have to live in poor areas with little privacy. They may have poor working conditions and earn little, especially if they are illegal migrants.
They may rely on sex work for money. Poor migrants, such as domestic workers, can be very vulnerable to sexual violence and abuse. During wars, many people, both women and men, may be raped. Refugees and prisoners of war can be particularly vulnerable. Some countries insist that migrants have an HIV test before they enter the country and deport them if they are HIV positive – often without any counselling.
Away from home
People often behave differently when they are away from home. They are out of their usual environment but may not fit into the community they have moved to, because of differences in languages and culture, and because of discrimination. They may lack support and friendship. The people they do make contact with are often marginalised themselves.
Sex can be one of the few ways people on the move can enjoy themselves. They may have sex with more people than they would if they stayed at home. They may have sex with different kinds of people. They may have sex at a younger age. For instance, some sailors start sexual relationships with a number of partners along the routes they travel; young people in refugee camps lack guidance and support from adults and peers and often start sexual relation-ships at a younger age than normal; men living in all male communities such as mining camps or prisons often have sex with male or female sex workers or with male peers.
Lack of access to sexual health information and services
Sexual health services include STI diagnosis and treatment, and condom distribution. Where these are available, migrants and refugees might not know where to find them, they might speak a different language from the service providers, or they might be too poor to pay. Some groups, such as illegal immigrants, sex workers, and men who have sex with men, may find it particularly difficult to use or pay for services. Services also vary from place to place, and it may be difficult for people on the move to continue treatment or care that they have started elsewhere.
People on the move – who are they?
Migrants are people who move voluntarily to another country or to a different area within their own country. Some migrants move permanently (immigrants). But many, for instance miners, long-distance truck drivers, traders, fishermen, sailors and soldiers, move regularly between their place of work and home. About 16 million people migrate each year from rural to urban areas of developing countries (excluding China). Between 2 and 4 million people migrate internationally each year.
Refugees are people who move involuntarily to another country because of war, civil unrest or persecution. Some people are also refugees from natural disasters. About 18 million people are refugees.
Internally displaced people are refugees within their own country. About 20 million people
HIV prevention and care programmes can become more responsive to the needs of migrants and refugees by listening to their concerns and prioritising their needs. For instance, migrants may see their living conditions as their main concern, not HIV, but addressing social issues can have an enormous impact on reducing HIV transmission. It is also important to actively involve employers, trade unions and relevant community support organisations where possible. Programmes with migrants also need to look at the needs of the migrants' sexual partners, including their partners at their place of origin, if they are to be effective.
Listening and involving
The CARAM (Coordination of Action Research on Mobility and AIDS) network in South-East Asia involves migrant workers as interviewers and outreach workers. It uses focus group discussions to look at migrants' concerns. Its Malaysian representative, the organisation Tenganita, found that this leads to a better understanding of migrants' circumstances and more appropriate local health interventions. Training peer educators is another approach. The Niger project on page 4 gives an example of how peer educators can work.
Improving living conditions
Some large employers, such as plantations and mines, provide family accommodation and health services for migrant workers. A multinational rubber plantation in Côte d'Ivoire employs about 3,000 migrant workers from Burkina Faso. In response to the high rate of HIV infection among its workers, it has built villages on the plantation which include a group of family houses, a school and a health centre. Many workers now come with their families and stay several years before returning home.
Access to information and
Migrant labourers who
live and work together can be easy to reach
with sexual health information, condoms and clinical
services for STIs. Some organisations have recognised this opportunity. The
World Bank, for example, made the provision of sexual health services a
condition for awarding the contract for constructing an oil pipeline
between Chad and Cameroon.
Improving people's rights
Work with migrants can be used for advocacy. In Tanzania, information from a study with child domestic workers and their employers has been used to inform the emerging national debate on the situation of female domestic workers. In Malaysia, Tenganita has found that involving migrants in their own needs assessment can empower them. Some illegal migrants who have worked with Tenganita are now trying to get their employers to help make their status in the country legal.
Income-generation activities in home communities can help people earn money without having to migrate. Many women from Agomanya town in Ghana used to migrate to a neighbouring country where they worked as sex workers. When women started coming home with AIDS, health workers in a local clinic realised that the women needed other ways to make money. They helped get support for the women to set up a small food-processing business.
Looking at home communities
The article on South Africa (page 6) shows the need to work with the sexual partners of migrants in their home communities to give them access to sexual health information and services. Partners can be at increased risk of HIV because of their own sexual behaviour as well as that of their migrant partners.
Illustrations by Petra Röhr-Rouendaal
With thanks to Joe Decosas, Box 947 Kaneshie, Accra, Ghana and Michael Tan, Executive Director, Health Action Information Network (HAIN), 9 Cabanatuan Road, Philam Homes, Quezon City, Philippines.
Women on the move and at home
Women who migrate to cities to work often have little education and limited job opportunities. Many join the informal sector as domestic workers, market traders or sex workers. They do not have access to health and social security benefits and can be exposed to sexual exploitation.
Women who stay at home may be at risk of HIV infection from migrant husbands or boyfriends, or from relationships with other men while their partners are away.
Three-quarters of the world's refugees are women and children. Women and girl refugees may be separated from their partners and families. They are often exposed to sexual violence. For example, in one area of Rwanda, two out of three women said that they had been raped during the civil war of 1996.
Women refugees may be pressured to exchange sex for food, water, or other basic needs for themselves and their children.
Some women and girls are traded for sex work, marriage and forced labour. In Japan, for instance, organised crime syndicates called Yakuza force young women from other parts of the region into sex work.
Educating the community
Training community leaders as peer educators is a very good way to reach large numbers of people with information about HIV.
'I am a volunteer because I feel loyal to the people of my village. I take my flip charts and posters to all social events – weddings, naming ceremonies, even funerals! I don't miss an opportunity to teach people about preventing AIDS.'
Fatima Hamidine, a 60-year-old peer educator and the leading woman elder in her village of Founkoye.
About one million people, mostly men, leave Niger every year to look for work in countries on the coast of West Africa. These migrants are particularly vulnerable to sexually transmitted infections (STIs), including HIV. Around 70 per cent of Niger's reported AIDS cases are in migrant workers or their families, and about 90 per cent of confirmed AIDS cases are in Tahoua and Tillabéry Districts where most of the migrants come from.
CARE International's SIDA en Exode (AIDS and Migration) Project targets migrants travelling along the 2,500 kilometre route that connects Tahoua District with Abidjan in Côte d'Ivoire.
The project has trained community leaders, including male migrants, their wives, bus drivers, sex workers and Muslim religious leaders, as volunteer peer educators. The peer educators promote HIV prevention and distribute condoms to people along the migration route, and refer people who think that they might have STIs to health clinics.
'In the beginning, people in Founkoye had not heard of AIDS and they were sceptical about using condoms. Now, they know that AIDS is a real and deadly disease, and they come to me for information on how to protect themselves.'
Abdou Sahabi, a 38-year-old peer educator from Founkoye.
Abdou Sahabi is a peer educator who migrates annually to Abidjan. On the three-day journey he uses educational materials to tell other migrant workers about HIV and how to prevent it. He uses the project's educational materials to conduct training sessions, both formally at truck stops along the route and informally through one-on-one peer sessions and small group discussions. In Abidjan, he gives AIDS awareness talks and sells condoms.
Training community leaders as peer educators is a good way to help them develop activities that work for them and their communities.
Migrant leaders Peer educators who worked at bus depots on the border between Niger and Burkina Faso formed The Association of Bus Transporters in the Fight Against AIDS. The group has regular monthly meetings, video shows and talks on HIV. It also forwards statistics from its work to the National AIDS Program and CARE. Recently, members of the Association travelled with CARE to another part of Niger to see activities and share experiences with peer educators there.
Youth leaders. Young people can have a lot of influence on their friends' behaviour. They can also be very creative. When one of the project's youth peer educators went to Abidjan, he contacted official organisations there and arranged to work as a peer educator carrying out AIDS awareness activities with migrants and their partners and selling condoms.
Religious leaders Religious leaders can reach hundreds of people every week and can have a lot of influence on day-to-day decisions and behaviour. Islamic religious leaders or marabouts based in Tahoua tell their communities that HIV exists in Niger and that everyone is responsible for how they behave.
Since 1993, nearly 500 peer educators have been trained. Between them they have reached nearly 120,000 migrants through HIV/AIDS education sessions. One important reason for the project's success has been the innovative educational tools used by the peer educators. These include colourful, funny posters and flip charts that promote safer sex, audio-cassettes and videos (in the local Hausa language), photo books, and wooden models of a penis that are used to demonstrate the proper use of condoms.
Joan Schubert, Assistant Country Director, CARE Niger, BP 10155, Niamey, Niger and Karen Robbins, CARE International, 151 Ellis Street, Atlanta GA 30303, USA.
Tracking the trucks
A national programme in India is helping to improve truck drivers' sexual health by bringing many local projects together.
Truck drivers are an important part of India's migrant labour force, but around 20 per cent of truck drivers and their crews (truckers) are infected with sexually transmitted infections (STIs) including HIV. Reasons for this high infection rate include unsafe sexual practices and lack of information on sexual health. A number of local or regional activities have aimed to reduce the spread of STIs among truckers, but these have had limited effect because truckers move all over the country.
In response to this problem the National AIDS Control Organisation (NACO) set up a national programme to improve awareness, diagnosis and treatment of sexually transmitted infections among truckers. The programme involves 38 regional NGOs working in sexual health. Its main aims are to encourage networking between these NGOs and collaboration between projects in different cities and states.
The programme covers 1,800 kilometres of the highways across the country (5 per cent of the total highways of India), and includes more than 150 truck stops. The NGOs have clinics or a trained doctor and outreach worker at nearly all the truck stops. The clinics diagnose and treat truckers, give information to encourage low-risk sexual behaviour and promote condom use. Each NGO builds on the work done by clinics at earlier stops. Information is shared so that the programme can measure the health of truckers along the whole stretch of the highways it covers. So far the programme has reached 1.7 million truckers and treated 25,000 cases of STIs.
The Top Gear Clinic
The Top Gear Clinic is run from a rented room in the transport section of Azadpur market on the outskirts of Delhi. Run by a Delhi-based NGO, Naz, the clinic provides free and confidential counselling and medical care. It also doubles up as a drop-in centre where the truckers can relax and meet people. Previously, there had been no lodging places or hotels for the truckers to rest – most of them used their trucks. Now they use the clinic area as a place to spend time together, watch television and relax. The outreach team and a Naz worker draw the truckers into group discussions on sexual and reproductive health issues. This relaxed atmosphere helps the truckers talk to the clinic staff, making it easier to diagnose and treat STIs.
The Naz team has gradually built a relationship of trust and friendship with the truckers through the outreach work, and the truckers now feel free to talk to the outreach team about their problems. These include their poor living conditions, unpredictable and very heavy work schedules and their loneliness. They use opium and alcohol as well as sex to escape this daily grind. Sexual intercourse is mostly done 'unthinkingly and rapidly' under the influence of drugs.
Naz has produced a poster in Hindi advertising the drop-in centre, and individual medical cards that show each truckers' blood group in case of an emergency. The poster uses the truckers' term for STIs, garmi ki bimari or a 'disease of heat'. The outreach team also uses this local term and promotes the use of condoms by linking them to safe behaviour practices that can help protect the truckers from STIs. Top Gear distributes free condoms and sells superior quality (unbranded) condoms at low cost, especially for men who have sex with men.
The Naz initiative is one of many initiatives that are linked through the programme organised by NACO. One challenge facing the programme is how to develop initiatives to target sex workers and truckers together.
M Rajyasri Rao, Research Associate, Health Action Information Network (HAIN), Delhi c/o HAIN, 9 Cabanatuan Road, Philam Homes, Quezon City, Philippines.
Seeing the whole picture
A study in South Africa shows the importance of working not just with migrants but also with their wives and girlfriends at home.
There are more than 2.5 million official – and many more unofficial – male migrants in southern Africa. Take millions of young men, remove them from their rural homes, house them in all male hostels, give them easy access to sex workers and alcohol, and soon you will have a major epidemic of HIV and other sexually transmitted infections (STIs). Send those men back to visit their wives and girlfriends in their rural homes every once in a while, and the epidemic will take hold in rural areas as well. This is the common belief, but is it the real story?
A study based in Hlabisa District in northern KwaZulu/Natal in South Africa has been looking at migrants and their rural partners. HIV prevalence in migrant men and their partners is much higher than in non-migrant couples. Migrant couples also have much higher rates of HIV discordance. (This means that one partner is HIV positive and the other is HIV negative.) However, early findings show that in at least half of the HIV-discordant couples in the study it is the woman living in Hlabisa who is HIV positive and her migrant partner who is HIV negative. The project is looking at why this is so.
The Hlabisa project is studying men from Hlabisa who work as gold miners in Carletonville and Richards Bay. Carletonville is far from Hlabisa, and men working there are only able to return home about four times a year. Richards Bay is much nearer, and men who work there come home at the end of every month. The project is also studying partners of these migrants, and a group of non-migrant couples living in Hlabisa. All study participants are screened for HIV and STIs, counselled, and given health education. All STIs are treated.
What can be done?
Clearly, migrants and their partners need good management of STIs, health education and access to health services as they are a highly vulnerable group. But there is also a need for interventions that change the ways in which people live and work to make migrants and their sexual partners less vulnerable to STIs. In South Africa, this includes looking at how couples can avoid living away from each other for long periods of time.
One possibility is to develop sustainable rural development programmes that offer local employment. Another approach would be to encourage mining companies to provide family-friendly housing – at present only about 2 per cent of miners live with their families. But one thing is clear: interventions aimed at migrants must be aimed at their partners as well.
Mark Lurie, Principal Investigator, Migration Research Project, South African Medical Research Council and The Africa Centre for Population Studies and Reproductive Health, Box 198, Mtubatuba 3935, South Africa.
HIV and refugees
HIV interventions for refugees help stop the spread of HIV.
CARE's HIV prevention project with Rwandan refugees in Benaco refugee camp, Tanzania, is recognised as a successful model for early HIV prevention and care in emergency settings. Successful activities included:
involving political and religious leaders
coordinating activities with other organisations in the camp
setting up a network of AIDS community educators and condom distribution points
providing nursing care for people with AIDS in their camp 'homes'
holding mass education activities
encouraging people who were raped to get medical care and counselling.
Reaching young people
Many young refugees are sexually active but community educators often find it hard to talk to them about HIV prevention. CARE found that providing special activities helped. These included weekly sporting events, which were especially popular with young men, income-generating activities for young women, and Adolescent Health Days where young people visited the health clinics.
With thanks to Barbara Monahan, Reproductive Health for Refugees Initiative, CARE International, 1625 K Street, NW, Washington, DC 20006, USA.
In 1993, the Ministry of Health in Mozambique began an HIV intervention to reach the refugees and internally-displaced people returning to their homes after the war. This involved about four million people, a quarter of Mozambique's population. Many of them had been living in neighbouring countries, such as Malawi, that had high levels of HIV, and they were returning to a very poor country whose health system had been devastated. People were worried that in this situation there was a high risk of the spread of STIs including HIV.
The project, which was supported by the European Union, identified 15 high-risk districts, which expected large numbers of refugees. Activities in these areas included:
Using traditional drama to educate people about STIs including how they are transmitted, how to recognise them, how to avoid them, and where to get treatment. The theatre groups performed at transit settlements and areas with temporary housing.
Supplying health centres in the districts with drugs, medical and laboratory equipment, condoms and educational materials to help them provide care for returning refugees.
Training health workers to provide correct treatment and counselling for patients with STIs including HIV.
The project was successful and in 1994 it expanded to cover other districts. By the end of the year, four times as many people were attending STI clinics than in 1993. Condom distribution doubled, which prepared the ground for a condom social marketing programme. Partner referral and treatment had also increased four times.
Dr Brigitte de Hulsters, European Commission Technical Advisor to the National Programme on STD/HIV/AIDS and Dr Avertino Barreto, Deputy National Director of Health and Head of the National Programme on STD/HIV/AIDS, Ministry of Health, CP 264 Maputo, Mozambique.
Working with refugees
Treat refugees with patience and understanding. They have many urgent needs, and may not see HIV prevention as a priority.
Involve the refugee community in planning and implementation.
Consider the sexual health needs of the host country.
Include the military in HIV prevention activities wherever possible.
Collect information that will help you plan your programme.
Ensure a safe blood supply by testing blood for HIV and other blood-borne diseases.
Adopt universal precautions to support HIV prevention.
Ensure a good supply of condoms and training in how to use them.
Provide STI and tuberculosis diagnosis and treatment.
Provide care for people with AIDS in their temporary 'homes'.
AIDS action Issue 44 7 Page 8
Photographs and drawings
Thank you for the latest copy of AIDS Action/Child Health Dialogue (Issue 42). I find the newsletter to be a valuable tool in teaching nursing students and of interest to the members of our AIDS Programme. However, I am writing with a concern about one of the photographs published in Issue 42. It is on page 3 and shows an old woman and a young child preparing vegetables. I know these people very well as they were one of the first families to benefit from our orphan care project when it was in its infancy.
Gogo NyaShaba became the sole carer for 9 grandchildren in 1991, when she was 69 years old and when Magopa, the child in the picture was only 4 months old. I am glad to say that she is still very much alive as are all 9 orphans. She is now 77 years old and still has children under 10 years old to care for. My concern is that to use photographs which are so old in an article that does not even mention Malawi shows poor use of materials. Surely Healthlink must be able to produce up to date photographs which complement the written information? How do you know that NyaShaba is still alive? Or for that matter, Magopa? How do you think any of their family might feel if they saw that photo, as the magazine is read by some of our community volunteers? Perhaps asking those who write articles to produce photographs from their own projects would help.
Carol Finlay, Nurse Teacher, CCAP Hospital, Ekwendeni, Malawi
Healthlink regrets the upset caused by the use of Gogo NyaShaba's photograph. The photograph was used in good faith to illustrate a realistic 'caring' situation. Healthlink Worldwide always confirms with the photographer or agency that consent has been given for pictures used, and that confidentiality is not broken. As a general principle, we ask authors for photographs to illustrate their article. However, this is not always possible in which case we use photo agencies and other development agencies. If an article is about a specific country we usually try to identify a photograph from that country. However, this article, although by a Zimbabwean, was not about a specific country and we felt that this was a suitable photograph with which to illustrate it. We cannot know if somebody is still alive or has died since the photograph was taken, but try to use recent photos to avoid any distress to people who knew the individual involved. We would be interested to know what other readers feel about our use of photos and drawings.
AIDS and the military is a booklet from UNAIDS Best Practice collection, which gives a summary of the issues, challenges and solutions.
Single copies available free from UNAIDS Information Centres. To find the one nearest you, write to the UNAIDS Information Centre, CH-1211 Geneva, Switzerland. E-mail [email protected]
Guidelines for HIV interventions in emergency settings are suitable for government, NGO and United Nations agencies that are implementing HIV care and prevention programmes in emergency situations.
Available free from UNAIDS, CH-1211 Geneva 27, Switzerland.
Migrants: HIV testing and counselling provides guidelines to counsellors working in emergency settings. It offers basic information and suggestions on how to refer people for longer-term support.
Available free from International Organization for Migration, Medical Services, BP 71, 1211, Geneva 19, Switzerland. E-mail [email protected]
Refugees and AIDS is a booklet from UNAIDS Best Practice collection, which gives a summary of the issues, challenges and solutions.
Single copies available free from UNAIDS Information Centres. To find the one nearest you, write to the UNAIDS Information Centre, CH-1211 Geneva, Switzerland.
Reproductive health in refugee situations: an inter-agency field manual offers guidance to field staff in introducing and implementing reproductive health services in refugee situations.
Available from UNHCR, CH-1211 Geneva 2, Switzerland.
Commissioning editor Siân Long
Editor Christine Kalume
Copy editor Celia Till
Design and production Ingrid Emsden
Editorial advisory group Calle Almedal, Dr Sandra Anderson, Kathy Attawell, Dr Rachel Baggaley, Dr Nina Castilio-Caradang, Nancy Fee, Susie Foster, Peter Gordon, Dr Sam Kalibala, Dr Elly Katabira, Dr Ute Küpper, Philippa Lawson, Dr Simon Mphuka, Dr Arletty Pinel, Dr Eric van Praag
Aids Action Publishing partners HAIN (the Philippines) KANKO (Kenya) SANASO Secretariat (Zimbabwe) ENDA (Senegal) ABIA (Brazil) Colectivo Sol (Mexico) Consultants based at University Eduardo Mondlane (Mozambique)
AHRTAG's AIDS programme is supported by CAFOD, Christian Aid, DfkF/JFS, HIVOS, ICCO, Misereor, Norwegian Red Cross, Oxfam, Save the Children Fund.
The International Newsletter on AIDS Prevention and Care
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