Issue Contents    People on the move Vulnerability Mobility and HIV Peer educators Educating the community Tracking the trucks Home communities Seeking the whole picture Refugees HIV and refugees Returning home Letter Resources

In this issue   Mobility and HIV Page 2 Educating the community Page 4 Trucking the truck Page 5 Seeing the view whole Page 6 HIV and refugees Page 7

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

Practical responses 
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 services 
 

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 communication between migrant communities and health service providers is also important. TAMPEP (Transnational AIDS/STD Prevention Among Migrant Prostitutes in Europe Project) trains 'cultural mediators' from the migrant community who act as a bridge between migrants and health workers.

 

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.

 

Increasing income 
 

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. 

Peer educators 
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. 

Lessons learned 
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.

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.

Returning home

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'.

Page 1  2  3  4  5  6  7  8  |  Contents

Healthlink Worldwide Grayston Centre, 28 Charles Square, London N1 6HT United Kingdom

Telephone:  Fax:  E-mail:  Web site:

+44 (0) 207 250 6950 +44 (0) 207 324 4740   www.healthlink.org.uk