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CROSS-BORDER MOBILITY AND HIV VULNERABILITY: EMPHASIS EXPERIENCE

CARE Bangladesh and The Daily Star have recently organised a roundtable on "Cross-Border Mobility and HIV Vulnerability: EMPHASIS Experience". We publish a summary of the discussion — Editor
Md. Abu Taher, Team Leader-, Enhancing Mobile Population's Access to HIV and AIDS Services, Information and Support (EMPHASIS Project, CARE-Bangladesh) EMPHASIS is an operations research project on cross border mobility and HIV in South Asia. CARE was also the pioneer in working with sex workers, MSM/ Transgender, injecting drug users, internal migrants and people living with HIV (PLH1V) since 1995. Still we have been continuing IDU intervention since 1998.
The first HIV-positive case diagnosed in Bangladesh, in 1989, was a returnee migrant. National surveillance data of 2011 revealed that HIV prevalence among sex workers in land port areas (Hili) is higher than average prevalence rate among sex workers in general. According to IOM data of 2012, 60% of the reported HIV-positives are migrants. We have to take this issue seriously because there are case studies in our neighbouring countries for example in Ganjam district in India where HIV-positive cases was in single digit in 1999-2000 but within ten years the number increased in thousands.
According to 2001 India census, there were approximately 3 million Bangladeshi migrants working in India. Reasons of this huge number of cross border migration are lack of employment at source (Bangladesh), comparatively high wages at destination (India), low migration cost, porous border and geographic proximity.
These migrant workers remain in isolation and poor working condition that led to engage in risky sexual behaviour. They lack spousal communication and consistent condom use. They often pursue sexual relationships with commercial sex workers without condom. There are also incidents of women and girls trafficking across border who are also vulnerable to HIV and AIDS.
The EMPHASIS project has been started in 2009. Our goal was to reduce the vulnerability to HIV and AIDS of population mobile between Bangladesh and Nepal to India. And our objective was to demonstrate effective good practice models and for HIV prevention care and support; to enhance capacity of government other service providers; to develop evidence based advocacy.
Our project implementation area covers source, transit and destination areas. At the source area we work in Jessore and Satkhira in Bangladesh and Achham and Kanchanpur in Nepal. Transit areas include jessore/ Satkhira border and West Bengal in case of Bangladeshi migrants. And the destination areas where we work under this project are Delhi, Mumbai and Kolkata.
In Bangladesh, 82,008 target populations has been reached with health education as of January 2014. We have established two Voluntary Counselling and Testing (VCT) centres in Jessore and Satkhira government hospitals. As of April, 2014, 2184 individuals were diagnosed in these two centres. We got 38 HIV-positive and that is more than 1.5% of total number of tested clients.
We have to continue awareness, BCC and counselling activities targeting migrants and their family members using existing GoB health infrastructure as well as to establish and continue HIV testing and counselling services at GoB health facilities in the district with high concentration of migrant populations. Another immediate action would be integration of prevention and referral services including adequate supplies of STI drugs and condoms to all.
In the long term we need to ensure migrant rights and entitlements at all levels and universal access to health services. Bilateral dialogues should be held to address the cross border mobility issue.
Leo Kenny, Country Representative, UNAIDS
It is really critical in Bangladesh that we do not silo the issue of HIV and migration. It needs to be looked at globally, regionally and locally. Recently, 52 countries have met in Bangladesh to discuss on migration in post 2015. This is a long term issue and it is a global issue. It is about equity, human rights and equality.
The work EMPHASIS is doing is not sustainable and it should not be so. This is the job of state to be providing care, support, and treatment to migrants. There are a lot of Bangladeshis in India and they are called Bangle Speaking Population (BSP). It is so stigmatized that they even do not call them Bangladeshis. It is the role of UN to help countries in the region to have inter-country dialogue to ensure safe migration because it is very good for everybody as a choice. Shakirul Islam, Chairman, Ovibashi Kormi Unnayan Program ( OKUP) Every year officially 4 lakh people migrate from Bangladesh to overseas. Various research show that migrants are vulnerable to HIV. Migrant workers are cross sectional populations. Many of them are practising MSM behaviour and many women workers are forced into sex work in the overseas. Most of the migrants do not have knowledge about AIDS. We should have very intensive and effective education for potential migrants. There is no referral system for migrants who are often deported for being HIV-positive when they go to renew their visas. These deported migrants often hide their status. So there should be referral system for these HIV-positive migrants. Ms. Mukti, Executive Director, Mukto Akash Bangladesh
We are working with PLHIV. We are providing supports to 500 PLHIV. When we refer a patient to clinics for surgery, doctors deny providing health service to a HIV-positive. So PLHIV needs special care and under this project we are trying to fill this gap.
Binoy Krishna Mallick, Executive Director, Rights Jessore
In the project areas of EMPHASIS there has been significant improvement of people's consciousness about HIV. So we have to continue this type of initiative in the border areas.
Migration is a continuous process and a large share of migration happens through land boundary. Both India and Bangladesh should recognize this reality and come to an agreement to issue work permit to migrant workers.
Dr. Tariqul Islam, Deputy Director, Addin Welfare Centre
We have been working with undocumented migrants. There is a serious gap in awareness about HIV among migrants. Only projects are not adequate .We need strong government intervention to continue mass campaign and awareness building activities among migrants. Dr. SZ Atiq, Principal, Satkhira Medical College The establishment of VCT centres in Satkhira and Jessore, initiated by Care Bangladesh and Rights Jessore, is a matter of pride for our health ministry. Since April 2012, 895 patients have come to the VCT centre for voluntary testing in Satkhira. Among them, 16 were HIV-positive. In order to sustain this project, I would urge the government and other stakeholders to continue with this programme.
Mahtabul Hakim, Programme Coordinator, UN Women
The issue of cross border migration is of particular importance because earlier on we would hear of migration cases from India but recently more and more cases of emigration to Nepal have emerged. As a result, cross-border migration should be a crucial issue which needs our special attention.
1 congratulate CARE on the work they've done so far but I think that if work in this area gets over with the completion of this project then we have cause to worry. The government needs to concentrate on how these works can be brought under its health system.
Tarik Hassan Shahriar, The Daily Sun In the case of cross border migration, both formal and informal migration is part of it. Health is a very significant issue for migrant workers. We have a database for our local workers who travel abroad for work but we don't have any database for returning migrant workers. If we could create a database for returning migrant workers, it would be easy for those working in this area to screen the workers for providing them HIV testing and counselling services. Secondly, stigma discrimination is prevalent in our society and it is a significant barrier in rendering proper medical services to HIV-positive patients. If we could reduce this stigma and gradually eliminate it, we will find out that the number of HIV-positive patients will be much higher.
DrTajudeen Oyewale, Head of HIV, UNICEF
Firstly we need to have a cross border partnership that looks into the health of migrants from source country and also in the destination country. We need cross ministerial walk on that and also the involvement of the foreign affairs ministry.
We really need the leadership of the honourable secretary to consider having an integrated centre for HIV and AIDS management in Bangladesh. We don't need many; probably just three to four will be fine. For example, we can have a centre in Dhaka at the BSMMU; they can offer every kind of service related to HIV, irrespective of type, treatment, testing and care. Same thing could be replicated in Khulna and probably in Sylhet and Chittagong as well
1 will want to use a community based approach because all of us are migrants. We all move from one place to another so you cannot really say that this is one place where you will find migrants but you can say that this is the source community where most migrants that do cross border migration really emerge from, like the work that the EMPHASIS project has done in Satkhira and Jessore.
In the context of HIV, we really need to bring a lot of family planning into the work that we do because if you think about a male migrant who has gone out, when he comes back the risk lies with his spouse and with other female partners in the community.
Lastly, in migrant communities, we need to think about the children of migrants, their partnets and their spouses. That's where my earlier proposal of integrated centres comes into place. When you have a centre that can do VCT, Prevention of Mother-to -Child Transmission (PMTCT) and monitoring all year around and offer treatments Theresa Blanchet, Director, Drishti Research Centre
Every time 1 hear the numbers of people living with HIV and AIDS in Bangladesh, 1 think that we are catching only the tip of the iceberg. In our studies, we found that women in Mumbai who found that they were HIV-positive did not return. We heard of cases of women who were staying illegally in Dubai and caught HIV and AIDS committing suicides instead of returning. I don't know where the statistics are for these people. That points out to the huge stigma that this illness bears.
The issue of migrant workers and especially female workers, they have really been ignored by everybody except to be beaten up and victimised. Back in 2003-2004, we were in Mumbai when Arab men from Dubai came to recruit bar dancers and it became known that the rate of
HIV was very high. Suddenly there was great interest in recruiting girls from Bangladesh as the low prevalence in Bangladesh made it very attractive for them to be hired by those men.
We also need to continue with research. Lot
of good ideas and intentions were voiced around in this discussion but unless it's really grounded in the reality of these migrant workers, you won't go very far.
Syed Saiful Haque, Chairman, WARBE Dev Foundation
As cross border migration and HIV vulnerability is an international issue, we need support from our own government as well as international governments.
We know that there is a parliamentary caucus on HIV and AIDS in Bangladesh. We now need a grassroots based social structure where all stakeholders can talk and exchange ideas. If we need the focus on this issue to sustain, we can't just depend on a project. Thus, if all those organisations who work on migration can work in a coordinated manner, there would be a real differ-
ence.
Bangladesh's policy is to export manpower and collect remittance from there but their health issues are ignored. CARE is taking a great initiative but we need to address how we can integrate migrants and health in Sustainable and Development Goal (SDG) or post-MDG, and health and migration policies as well.
Hassan Imam, Programme Coordinator, Migration Programme, BRAC
The presentation emphasised on the need for counselling and coordination between the two sectors of migration and health. If we come to the issue of counselling, the recommendations here clearly suggest that both documented and undocumented migrant workers need counselling.
There is a gap in coordination between the migration sector and the health sector. We need to do much more work to establish this coordination between the two sectors for the welfare of migrant workers.
Dr. Samir Kumar Howlader, National Programme Officer, IOM
Migration and cross-border mobility have always remained aside and still there is a gap in policies, collaboration and coordination between the ministry that deals with migration and the ministry of health. There is a health policy but migration is not integrated there or the policy and strategies related to migration does not account for the health issues of migration.
Mainstreaming of HIV is very important, and the Ministry of Expatriates' Welfare and Overseas Employment should consider this health issue as a mainstream agenda in migration management. Dr. Jahangir Hossain, Programme Director-Health, Care Bangladesh EMPHASIS is a learning platform to understand the vulnerability of migrant workers and test appropriate approaches, interventions and solutions. This is one of the important events with the participation of important policy makers and practitioners where we are sharing our experiences that we have learned through implementing EMPHASIS regional project of CARE International. The EMPHASIS project was primarily targeting undocumented migrant populations. One project or organisation can't deal with an issue of such magnitude. We need to develop a government response to address this issue.
Through EMPHASIS we tried to reach the Cross Border Mobile Population at source using existing health infrastructure structure & system like the community clinics, Community Support Groups, FWC, health complexes and district hospitals. We found out that this approach yielded good results and the HIV prevention knowledge and service uptake level have been increased. This is a tested approach and this can be integrated into existing health systems in the other part of the country.
There is a treaty between India and Nepal that if anyone from India is working in Nepal, they have access to services. If someone from Bangladesh works in non-Bengali speaking cities in India, they are always vulnerable often hide their identity as Bangladeshi. Civil Society Organisations working on HIV in India and Bangladesh share information but at the government level it almost absent. The governments need to patronise these civil society organisations for further collaborations.
I hope in the future Government and Development Partners will allocate more resources for addressing the vulnerability of migrant workers and their family members at sources, transit and destinations. We are happy that NASP has already allocated some resources on this issue through the World Bank, however, which is too small than the requirement. Hope, MOHFW will allocate more resources in the next operation plan and take leadership to coordinate with other ministries and stakeholders for effective implementation of migration program. M G Mustafa Khan, Director, BMET, Ministry of Overseas Employment & Expatriates' Welfare We need a strong coordination among the ministry of health, the ministry of home affairs and ministry of foreign affairs on cross border migration and HIV issue. I also agree that awareness programmes should be organised in local health centres every month if not every week. I also believe that media has an important role to play in creating awareness.
Professor A.K.M Nurun Nabi, Vice Chancellor, Begum Rokeya University Migration is a social and economic indicator of change. It is inevitable and universal. It is a new phenomenon to look at migration from health perspective. So we have to discuss over it in great length to understand the full gamut of this linkage.
1 think, the initiation of our HIV programme was on a wrong footing. HIV has become a matter of stigma and fear to general people. Our approach to HIV is guilty of this misrepresentation. HIV should be treated like any other diseases.
HIV issue should be assumed in our development paradigm; as such HIV is seriously hindering development efforts of several African countries. I would urge you all to join hand in upcoming ICAAP 12 to make the issue of migration and HIV as an international develop agenda.
Dr. Hussain Sarwar Khan, Line Director, National AIDS/ STD Programme- NASP Migrants are one of the vulnerable communities around the world. We identified the issue in our programmes but could not make any intervention. Now we are preparing a project to do that intervention. In this project we are emphasising on labour migrants and cross border migrants. We have already built up some government infrastructures to provide HIV and STD services. Previously it was NGOs who led the HIV programmes, now the government is going to shoulder the responsibility.
M. M. Neazuddin, Secretary Health, Ministry of Health & Family Welfare Though Bangladesh is a low prevalent country we have to do many more things to keep it low . The information of 38 HIV-positive case diagnosed in VC!’ centre at district Govt. Hospitals of Jessore and Satkhira supported CARE-Bangladesh is really alarming and we have to be really cautious about the issue of cross border migration and their vulnerability of getting infected. We have to immediately take some initiatives for the cross border migrants.
1 am fully agreed with the urge of holding bilateral and multilateral discussion over the issue of cross border migration and HIV vulnera-