|HIV vulnerability and migration in the Americas|
By Shira Goldenberg
Population migration is extensive and continues to accelerate in the Americas. For instance, at least nine percent of Mexico’s population is living in the United States. Migration, defined as the “movement of people through space and time”, can be intra-national (e.g. rural-urban migration) or inter-national (e.g., Southern nation-Northern nation migration). It can also be voluntary or forced. Migrant populations include seasonal workers, economic migrants, trafficked or smuggled persons, deportees, refugees, and internally displaced persons (IDPs). Poverty and limited income opportunities, social and political conflicts, discrimination and stigma, as well as climate change and natural disasters are examples of factors that encourage migration. In contrast, communities of migrants established abroad, access to information regarding the availability of jobs in economically developed areas, and desire for family reunification attract migrants to their respective destinations.
Migration brings significant impacts on public health, including vulnerability to HIV/AIDS and sexually transmitted infections (STIs). Mechanisms that may explain the relationship between migration and HIV vulnerability include social factors, such as the tendency for migrants (especially men) to seek new, concurrent, casual, and/or same-sex partners to ease the isolating experience of migration, as well as exposure to new (often more liberal) social norms for sexual behavior and substance use. Equally important are structural factors, including the tendency for undocumented or deported individuals to engage in risky behaviors. Such tendency is primarily due to: economic necessity or increased psychosocial vulnerability, immigration policies that result in large, and often highly, marginalized populations of undocumented or deported persons, large-scale human rights violations (e.g. by immigration authorities), gender-based violence, and limited access to health, social, legal and other services.
In areas of high transit — such as borders, ports, and tourist areas — the confluence of activities including sex tourism, drug and sex trafficking, and human smuggling, as well as the presence of vulnerable populations such as migrant women, indigenous populations, female sex workers (FSWs) and their clients, drug users, and others, together constitute a “risk environment” for the acquisition and transmission of HIV and STIs. In addition to the risks faced by migrants and others living or working in border areas, migrants may sometimes form a “bridge” for the transmission of HIV and STIs from high prevalence populations (e.g. FSWs) to low prevalence populations, including wives. This phenomenon has been widely implicated in the rapid spread of HIV in Sub-Saharan Africa, in particular along major transit routes. It has also contributed to the increasing proportion of HIV/AIDS cases attributable to contact with spouses among women in rural Mexican states where a large proportion of men are U.S. migrants who engage in extramarital sex while away from home.
While research and programs addressing migration and HIV in Africa and Asia are long established, evidence suggesting the impact of migration in the HIV/AIDS and STI epidemics in the Americas has grown over the past decade. Along the Mexico-U.S. border, these links may help explain the emerging HIV epidemic in Tijuana as demonstrated by recent research carried out by a bi-national team along the Tijuana-San Diego border. This region is the world’s busiest international land crossing, and a location where deportations from the United States have increased by 48% since 2002. Researchers found that deported male injection drug users had over 4 times the odds of HIV infection, compared with their non-deported counterparts. In a following qualitative study, deportation was described as common among Mexican-born men who purchase sexual favors in Tijuana. Participants also linked the social isolation and economic dislocation that followed deportation to susceptibility to HIV through unprotected sex with FSWs and substance use. More research is necessary to elucidate the role of these potential causal factors, their interaction with other structural factors (including homelessness and criminality), and their impacts on HIV.
To address migration induced HIV vulnerability, it is necessary to implement tailored and targeted interventions for itinerant and vulnerable populations in areas of high transit. New technologies and approaches, such as mobile or roadside clinics and rapid HIV/ STI testing, provide opportunities to prevent HIV and STIs among mobile populations. For example, in a South African mining community, an intervention involving mobile units offering STI screening, treatment, and condom promotion for miners and FSWs witnessed significant reductions in STD prevalence within both groups. Among FSWs, the prevalence of common curable STIs dropped by as much as 85% in nine months. Annual screening revealed a 43% lower rate of Gonorrhea and Chlamydia infection and 78% fewer genital ulcers among miners and proximity to the intervention site was found to reduce a miner's risk of acquiring an STI. These reductions in STIs were estimated to have averted 40 HIV infections among the women and 195 HIV infections among the group of miners.
Although less information on the impact of migration on HIV and STIs is available for Central America, similar trends have been reported and available data suggest an urgent need for research and delivery of appropriate service. In response, community-based organizations and bi-national/regional teams of investigators from Mexico, Central America (e.g. Guatemala), and the U.S. are currently conducting research in this under-represented region. In Central America, high levels of mobility within the region, different national approaches and policies, increased fluidity in cross-border movements, and under-resourcing require integrated approaches across the region. As a result, various regional projects have included the Global Fund-supported Mesoamerican Project in integral care for mobile populations: reducing vulnerability of mobile populations in Central America to HIV/AIDS; and the USAID-led Program for Strengthening the Central American Response to HIV/AIDS (PASCA), among others. These projects represent an important response to the gap in resources and knowledge on migration, mobility, and HIV and STIs in Central America.
This summer, Shira is working at PAHO with Dr. Omar Sued, Regional Advisor HIV/STI Care & Treatment, on a literature review of HIV, migration, and mobility in Central America.
Regional Office of the World Health Organization
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