Discussion and dialogue around people on the move have occurred at the United Nations (UN) since at least 1951 when the Convention Relating to the Status of Refugees was adopted, and the forerunner of the International Organization for Migration (IOM), the Intergovernmental Committee for European Migration (ICEM), was established to help resettle people displaced by World War II. Fifty years later, the link between migration, population mobility, and HIV surfaced in the 2001 UN General Assembly Declaration of Commitment on HIV/AIDS. In 2016, the IOM became a related organization of the UN. UNAIDS and IOM first entered into a Cooperation Framework in 1999, which was later revised in 2002 and in 2011. In 2017, IOM and UNAIDS renewed a General Cooperation Agreement to enhance dialogue and cooperation to combine and coordinate their efforts.
The 2018 NGO Report to PCB is intended to help renew and focus the dialogue around people on the move so that the 2030 target of ending AIDS as a public health threat can be achieved. It is the NGO Delegation’s contribution to support Member States to ensure that mobile populations are covered for services across their origin, transit, and destination countries.
This report builds on last year’s 2017 NGO Report, which clearly showed that mobile populations are over-represented among people living with HIV who are undiagnosed, not on antiretroviral therapy (ART), not virally suppressed––even in countries that have achieved or exceeded the 90–90–90 targets.2 Those insights were instrumental in deciding on people on the move as the theme for the 2018 NGO Report.
For the purposes of this report, and given the lack of international consensus about key terms like “mobile” or “migrant” populations, people on the move or human mobility is used as a comprehensive term that includes international migration, refugees, people experiencing internal or forced displacement, people moving because of climate change impacts, or labor migrants. This mirrors the definition developed by the International Organization for Migration (IOM), which uses migration and migrant to refer to people moving across an international border and within states, regardless of legal status, willingness, cause, or length of stay.
This report explores certain key global trends: increasing diversity and complexity of human mobility, the increased prominence of women on the move, the shift in our health paradigm towards a more positive appreciation of development and people on the move, the growing acknowledgment that mobility is not only or even predominantly about crossing international borders but also about internal or in-country population movements, and the resurgence of attacks on human rights and international migration. These trends are having significant impacts on the health and HIV vulnerability of people on the move.
It is difficult to ensure continuity of care during the current spike in population mobility. Increased population mobility is confounding traditional approaches to healthcare financing, which are still based largely on stable residence, citizenship, occupational category, or family relationships. Mobility can increase exposure and vulnerability to HIV, tuberculosis (TB), and viral hepatitis. In addition, the various legal and regulatory challenges encountered in moving can aggravate health conditions and increase treatment costs, with higher morbidity and mortality as possible outcomes. The UNAIDS/PCB (43)/18.20 Page 5/52 fact that there is a lack of international consensus about the definitions of key terms like migration and mobility only adds to the complexity of these issues.
The Delegation collected community experiences and self-reports illustrating key challenges related to mobility and HIV mainly via interviews with people on the move and stakeholders, as well as via survey responses. Interviews were conducted across all the regions represented on the Delegation: Africa, Asia-Pacific, Europe, Latin America and the Caribbean, and North America. The majority of survey participants were employed, with access to health care and with good knowledge of available services for HIV, TB, and, to a lesser extent, viral hepatitis. About half self-identified within a key population group. They came from 28 different countries of origin, predominantly Colombia, India, Jamaica, Kenya, Nigeria, the Philippines, Poland, the United States of America (USA), Venezuela and Zambia. Brief quotes from people on the move and from stakeholders appear throughout the report to highlight the issues being discussed.
Interviewed people on the move pointed to various factors that may increase vulnerability to HIV and coinfections. They included language and cultural barriers, fear of requesting/accessing services and being reported to authorities, lack of access to targeted services for people on the move, lack of understanding about the health-care system, poor living conditions, risky behaviors and sexual practices, and lack of access to prevention services.
Stakeholders interviewed were engaged in various activities, including direct HIV services, policy making, legal support, advocacy and campaigning, research, capacity building, and language classes. The majority stated that they involved people on the move as peers in delivering their activities, including leadership and management, frontline services, volunteering, and research.
In general, stakeholders noted similar needs and challenges as those identified by people on the move, including the absence of basic protections, difficulties acquiring documented status/legalization, lack of knowledge about HIV and coinfections, lack of awareness about and access to culturally and linguistically competent health-care and other services, difficulties obtaining employment, stigma, and discrimination, isolation, poverty, lack of housing, mental health challenges, fear of violence, fear of criminalization/detention and deportation, and trauma. The report indicates several avenues of good practice which, if implemented and scaled up, could give us a better chance of achieving the 2030 targets. These good practices include:
- The meaningful involvement of people on the move;
- Legal and/or regulatory reforms;
- Capacity building for people on the move and related service providers;
- Development of national health systems and Universal Health Coverage (UHC) that are sensitive to and inclusive of people on the move;
- Ensuring continuity of care;
- Addressing stigma and discrimination;
- Protecting against economic exploitation and
- Effective responses to the needs of undocumented migrants.
The report illustrates these good practices through 12 case studies from Brazil, Canada, China, Germany, India, Kyrgyzstan, the Philippines, the Russian Federation, Thailand, the USA, and Viet Nam.
The report notes the lack of data and evidence about links between population mobility and HIV in general and the needs of specific sub-populations on the move. Without enhancing such an integrated population mobility and HIV evidence base, it is unlikely that lawmakers or healthcare planning will become more sensitive and inclusive for people on the move.
The report recognizes that there are a significant number of people on the move who belong to key populations in the AIDS response because they are also gay men or other men who have sex with men, sex workers, transwomen, and transmen, or people who inject drugs. However, other people may have a claim to be considered as key populations, including people imprisoned and kept in closed settings such as detention centres or camps, people with “illegal” or undocumented status, or because a specific country may have so designated them internally based on the national epidemiological and social context.
- The relatively recent increase, acceleration, and diversity of human mobility is aggravating the HIV vulnerability of people on the move;
- Mobile populations face significant obstacles in accessing HIV and coinfection services;
- Mobile populations, many of whom belong to key populations, are in danger of being left behind in the AIDS response and
- There is a range of innovative and scalable good practices for advancing HIV and related services among mobile communities.
Finally, the report presents recommendations based on the following conclusions: