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HIV and Migrant Workers in the GMS

Program and Policy Issues

Aurorita M. Mendoza
ICAAP 11 Bangkok, 21 November 2013
Disclaimer: The views expressed in this paper/presentation do not necessarily reflect the views or policies of the Asian Development Bank (ADB), or its Board of Governors, or the governments they represent. ADB does not guarantee the accuracy of the data included in this paper and accepts no responsibility for any consequence of their use. Terminology used may not necessarily be consistent with ADB official terms.

Background on the study

Setting the Context

Study Highlights and Moving Forward

1. Monitoring and surveillance system 2. Strategic approach 3. Community-level HIV programs 4. Enabling environment

Purpose of the study

Know more about:
The HIV epi profile of migrant workers Contexts of HIV risks of migrant workers Tailoring the HIV response for migrants to these contexts Improving the enabling environment

Methods and Data Sources

1. Literature review: available epi data, HIV country reports, HIV and migration literature 2. Site visits of migrant services in Lao PDR and Thailand 3. Focus groups: migrant workers, migrant workers living with HIV, sex/service workers 4. Key informants: government officials, health workers serving migrant workers, NGOs serving migrant workers, UN migration and HIV agencies

Migration issues that impact on HIV programs and policies

1. Rapid, inequitable, and variable economic development Unequal capacities to address HIV among local populations

2. Unreliable data on migration volume and migrant profile Insufficient bases for estimating who and how many migrant workers are at higher HIV risk 3. Migration patterns of concern: High proportion of irregular migrants difficult to track and to reach Increasing female migrants in low-level and low-skilled occupations high-risk HIV contexts GMS countries evolving into source, transit, and destination point need to have harmonized HIV services and policies

GMS Migration Patterns

HIV Prevalence in GMS Countries

HIV Prevalence (%) Among Selected Populations, 2010 FSWs MSM IDUs 14 3.4 Phnom Penh 0.98 24 (2007) N/A

Countries & Province Cambodia

Adult (A) 0.6



Myanmar Thailand

0.5 1.3

4.4 Vientiane 7.8 1.8 venue-based 3 3

Viet Nam Yunnan, China

0.5 0.9 (2008)

7.8 20 Bangkok & 2 cities 16.7 (2009) 6.3 national

21.9 21.9

13.4 N/A

Study Highlight 1
Except for Thailand, there is no monitoring or surveillance system of migrant workers, thus there is limited knowledge of the HIV prevalence, vulnerabilities and risk behaviors of migrant workers.

What do we know (1)?

HIV prevalence among migrant workers from three source countries to Thailand is higher than the national HIV prevalence in their respective countries.

Source: Government of Thailand, Ministry of Public Health, 2012

What do we know (2)?

HIV prevalence among some population sub-groups among migrant workers is higher than their Thai counterparts. Pregnant women Female sex workers
6 5

4 3 2 1 0 Thai Migrants Thai Migrants Thai Migrants Trat Ranong Tak Source: IOM, Thailand Ministry of Public Health, UNAIDS, CSEARHAP, 2010. 2004 2005 2006

What do we know? (3)

HIV prevalence of male migrant workers in specific Thai locations is higher than Thai men.

Border with Cambodia (Trat): 8 times higher among non-Thai fishermen than Thai fishermen between 2004-2006
Border with Myanmar (Prachuap Khiri Khan, Tak, and Ranong): 2-4 times higher among non-Thai male workers than Thai military conscripts between 2004-2006

Source: IOM, Thailand Ministry of Public Health, UNAIDS, CSEARHAP, 2010

Filling in the Data Gaps

Rapid situation assessment of high migration locations

Mapping: origins, geographic, risk behaviors, social networks, health services

Surveillance system: biological and behavioral

Study Highlight 2
A risk-zone/hot spot HIV strategy is needed, as not all migrant workers equally at risk. Settings that have a combination of heavy mobility, large concentrations of migrant and mobile populations, and an associated sex and entertainment industry are HIV high-risk zones.

High-risk zones

Cross-border areas

Fishing and sea ports

Heavy mobility Large concentrations of mobile and migrant populations Associated sex and entertainment industry

Transport corridors

Commercial sex settings

HIV Prevalence in Border Areas: Overlap of commercial sex and injecting drug use
Lao PDR Viet Nam (North), Dien Bien: 42.9% (2009): Vietnamese male IDUs 20% (2009): Vietnamese FSWs PRC -- Viet Nam: 23% (2009): Vietnamese IDUs in Lang Son 46% (2005): Vietnamese IDUs in Lang Son 17% (2005): Chinese IDUs in Lang Son 18.3% (2005): Chinese IDUs in Ning Ming Cambodia Viet Nam: 24.3% (2002): Vietnamese street-based FSWs in Dong Thap 2.5% (2002): Border traders in An Giang 1.3% (2002): Vietnamese karaoke-based FSWs in Kien Giang Yunnan, PRC Myanmar: 1.9% (2007-10): Dai migrant women workers

Fishermen: Wide mobility trajectory and accepted norm of sexual risks and multiple relationships

Source: Jian H, 2005; Htoo K.M., 2009

Truck drivers: Inconsistent condom use between different sex partners

Condom Use Rates among Truck Drivers from Lao PDR, Thailand, and Viet Nam, 2005

Source: United Nations Economic and Social Commission for Asia and the Pacific, 2007.

Addressing risk factors

HIV risk awareness and perception

Health practices and risk behaviors in countries of origin

Study Highlight 3
Community-level HIV programs and services for migrant workers are highimpact interventions in high-risk/hot spot zones but are few, usually projectbased, and reach only a few.

Male and Female Migrant Workers Good knowledge of VCT, but poor action

Source: IPSR, 2011.

HIV Interventions in Sex Work Settings

HIV services should reach ALL sex workers, whether migrant workers or not. Peer outreach to indirect sex workers as a priority

Structural interventions at places where sex is solicited or where sex occurs.

Community health services as strategic focal point

A minimum prevention package?

Changing health worker practices?

Engagement of migrant workers?

Study highlight 4
A stronger, more migrant-sensitive enabling environment is needed to increase access of most-at-risk migrant workers to HIV services.

National Strategic HIV Plans

Need sharper, more direct focus on migrant and mobile populations: strategic information, resource support

HIV Policies

Only one country provides ART services for migrant workers Need harmonized ART policies to prevent ART disruption Adult sex work illegal in 4 GMS countries MOUs should prohibit mandatory HIV testing Operationalization of MOU for Joint Action to Reduce Vulnerability Associated with Population Movement: mapping migration patterns, HIV services, advocacy

Regional Policy Frameworks

First steps taken Reducing vulnerabilities of female migrant workers High-level political will needed Migration issue beyond health sector: multi-sector dialogue; coherent policies needed Sub-regional collaboration for policy and program actions