Health facilities must be responsive to the needs of mobile
individuals and of migrants if they are to retain people in care, Bwalya
Chiti of Zambart told the 22nd International AIDS
Conference (AIDS 2018) in Amsterdam yesterday. Lifelong engagement with care is
required for good individual and public health outcomes, but the rigidity of
many health services in African countries is a barrier.
“It is crucial to integrate the dimension of mobility and
migrations into our responses to the HIV epidemics,” Joseph Larmarange of the Centre
Population et Développement (CEPED) said at the same session. If health is seen
as a human right, this must apply to mobile and migrant populations too.
Larmarange is one of the social scientists who have been
working in the settings of ‘universal test and treat’ studies in African
countries, in order to understand the social context and social impact of these
interventions. Mobility and migration has emerged as a key theme – the reality
of many people’s lives is that people often need to travel in order to create or
find work. Examples include women selling vegetables 100km from their home,
street vendors in peri-urban settings, construction workers travelling to urban
areas, cross-border traders and people working in domestic service in a
neighbouring country.
Movement within countries and between different parts of
Africa is much more common than migration to Europe. Rural-urban migration is
not the only practice: circulation between rural areas, towns and the rural
perimeters of cities is common.
The forms of livelihood that people are able to look for are
highly gendered, with women tending to travel shorter distances and for shorter
periods of time. While male migrant workers are frequently described as having
sexual risk behaviour that impacts on their partners back home, an analysis
from the SEARCH study in Kenya and Uganda found that concurrent sexual relationships
were more strongly associated with mobility in women than in men.
In KwaZulu Natal, the ANRS 12249 Antiretroviral Treatment as
Prevention trial offered HIV treatment regardless of CD4 count. Repeated
household surveys showed that individuals with HIV who had recently arrived in
the area and people who subsequently left were less likely to be retained in
care or to be taking HIV treatment. So it appears that the movement of people
in and out of communities slowed down efforts to increase treatment coverage
and population viral suppression. This is one factor that may explain this
study’s failure to show a reduction in HIV incidence at population level.
In countries where welfare and social protection systems
usually do not exist, people’s reasons for mobility are primarily to raise
money for household basic needs such as food, shelter, children’s schooling and
other social obligations. People are forced to make difficult choices between accessing medical care and
sustaining their livelihoods. Frequently, people prioritise providing
for their households and their dependents over their own health – they delay,
miss or stop taking treatment.
Bwalya Chiti pointed out that the clinic system usually
requires people living with HIV to collect their medication on a routine basis
from the same location. They usually need to attend once a month, within normal
working hours, and a visit can take a full day.
However, mobility creates discontinuities: an individual may
be too busy to attend the clinic or may never be home during clinic opening
hours. He or she may move temporarily to an area that does not have a clinic
that dispenses antiretrovirals. In a new area, the individual may lack
knowledge of the health facilities and how the health system works there. There
may be bureaucratic barriers to obtaining medication from a facility in the new area, without registering as a new patient.
When individuals miss appointments, they are often
reprimanded by staff. This discourages people from remaining engaged with
care and contributes to further movement of patients between services. People
may seek care elsewhere to avoid being made to feel guilty by healthcare
workers.
Chiti argued people living with HIV need to be involved in
decisions about service design. There should be a collaborative process to
develop more flexible services. Clinic
hours should be adjusted to allow people to attend in the evening or at the
weekend.
Staff should be trained to be more sensitive to patients’ needs
concerning mobility. They should ask patients about travel plans and provide
medication refills that will
cover the whole period the patient is away. Patients
should be given cards with full details of their medication, be educated on
which drugs they are taking and be given details of alternative facilities, in
case they run out of drugs.
Better
means of information sharing for healthcare providers, both within a country
and across borders, need to be developed. Audience members suggested that one
possibility may be for patients to carry their own health record on their
phone. At a more basic level, clinics need to be willing to take simple steps,
such as to phone a person’s usual clinic to check details of their
prescription.
Joseph Larmarange
commented that whereas the solutions in relation to short-term mobility seem
fairly clear, it was less obvious how to adapt services for migrants who cross
borders.
During discussion, Ria Reis of
the University of Amsterdam noted that these issues are not unique to HIV, but
are seen in relation to all chronic health conditions. She suggested forming
alliances with people working on non-communicable diseases, including community
representatives, providers and academics.