Interventions aimed at curbing the burden of HIV among people migrating from Bangladesh to India in search of work risk having only temporary impact if such efforts are not institutionalized as part of cross-border policy, experts say.
The inter-agency South Asia regional programme called Enhancing Migrant Populations' Access to HIV and AIDS Services, Information and Support (EMPHASIS) has reported success in reaching Bangladeshi migrants with HIV prevention services, and boosting HIV awareness among service providers.
“We have used the EMPHASIS model to address migration as a cyclical phenomenon,” Mohammad Abu Taher, a team leader at CARE-Bangladesh, the lead partner of EMPHASIS, told IRIN. “Nuanced interventions at source, in transit, and at destination have allowed us to access Bangladeshi migrants with HIV services.”
But others warn that such interventions are not addressing the problem comprehensively. “While excellent in the short term, this type of work is simply not sustainable; we cannot have INGOs [international NGOs] doing the work of governments,” Leo Kenny, the Joint United Nations Programme on HIV/AIDS (UNAIDS) country coordinator for Bangladesh, told IRIN.
“The imperative first step is an inter-governmental dialogue to start figuring this out at a policy level.”
Labour migrants are responsible for more than 10 percent of Gross National Income in Bangladesh, but on returning home they and their spouses also contributed more than half of the new HIV infections in Bangladesh in 2011, according to government data.
Observers say the issue of effective cross-border interventions should include migrants in HIV responses, making services accessible, and negotiating sensitive political issues such as how the illegal status of irregular migrants can negatively affect their access to life-saving services.
Migrant HIV risk
While migration alone is not an HIV risk factor, it can expose people to higher HIV risk.
Bangladeshi migrants are leaving a low HIV-prevalence region (less than 0.1 percent general adult HIV prevalence) and moving to parts of India where prevalence is estimated to be three times higher, which researchers say may increase workers’ risk of infection.
“We are not seeing migrants treated as a key affected population, but they are vulnerable, so we should be,” said Taher, noting language barriers limiting migrants’ service access – and disease awareness – in India.
UNAIDS declared in 2012 that while new HIV infections have been decreasing globally, the HIV epidemic has continued to expand among what it calls “key affected populations” (KAP), such as men who have sex with men and sex workers, and urged interventions targeting these populations.
Not identifying migrants as critical to the fight against HIV infection could be a harmful oversight.
“Migrants experience a different kind of stigma from other key affected populations, so in a lot of ways the traditional intervention systems and perspectives have overlooked them,” said Fiona Samuels, a research fellow at the London-based Overseas Development Institute (ODI).
“Other [KAP] experience marginalization because their behaviours are perceived as deviant or immoral. For migrants, it's legal status and nationality and racism,” she told IRIN from London, adding that stigma could hamper migrant healthcare access worldwide.
Pia Oberoi, a migration advisor at the Office of the United Nations High Commissioner for Human Rights (OHCHR), says part of the problem is lack of legislation that spells out the healthcare rights of a country’s migrants, as well as those migrants’ “own fear that they may be reported and detained or expelled by the authorities” when seeking healthcare.
“Most migrants in an irregular situation are not criminals… they are more likely to be working in a hospital than unfairly using its facilities,” she told IRIN from Geneva, adding that OHCHR is developing principles and guidelines on migration and health.
“The key to working with populations that are operating illegally – whether we agree with that illegal status or not – is to make sure our interventions are not putting them in more trouble or danger,” Samuels, the ODI researcher, told IRIN.
“Ethically and logistically it’s complicated, because in some ways you are going behind the backs of the government,” she said, explaining that aiding people who are illegally on a country’s soil can be perceived as abetting their illegal passage and stay.
An estimated 3.2 million Bangladeshis have migrated to India, forming the “single largest ‘bilateral stock’ of international migrants in the South”, according a 2013 UN report, which Dhaka disputed in local media.
Workers in India’s informal sectors (93 percent of its labour market, according to ODI) lacked any social benefits.
“Our partner organizations in India noticed people would rarely come forward and say they are from Bangladesh, so we changed our phrasing in outreach programmes from ‘Bangladeshi’ to ‘Bengali-speaking people,’” Taher said. After the change, EMPHASIS saw an immediate increase in the number of Bangladeshis accessing their HIV programmes.
While such interventions were “tremendous”, they were only temporary. “Ultimately, they are doing the work that governments and UN agencies should be doing,” said UNAIDS’ Kenny.
“It is inexcusable that UN partners have not been able to come together to elevate this programme beyond a service-delivery intervention and into a meaningful cross-border policy-level solution. Migration is no longer an issue that we and governments can comfortably deal with from within the borders of individual countries.”
The International Organization for Migration put the number of migrants worldwide at 232 million in 2013.
It has called for broader inclusion of migrant health issues on the post-2015 development agenda, maintaining that migrant health not only affects individual lives, but also socio-economic outcomes in home countries and the places where they work.