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Addressing migrants’ HIV/AIDS vulnerabilities in India

May 20, 2014

Both for Nepalese and Bangladeshi migrants the conditions during and after migration increases their overall vulnerability towards diseases especially HIV, writes Tahseen Alam, Regional Advocacy Manager, EMPHASIS.

Life is brutal here’, was one of my first few thoughts as I reached a village in Accham district in Far-West Nepal. January, in Accham, was bitterly cold, the sun came out for barely five to six hours each day before darkness enveloped the hills again. We were there to document the lives of the Nepalese citizens who made their way to various destinations in India to find a better life for themselves and their families; and were trying to explore the motivations which encouraged families to migrate to India where they more often than not lived in quite difficult circumstances. The reasons were not hard to identify-poverty; lack of employment, and a dream of making it big in India!

“I want to give good education to my children, build a pucca house, buy some land and start my own business from the savings. I have to spend less and save more. I have to give more time to my work so that I can earn more”-Migrant from Nepal (EMPHASIS project)

Almost every family we met had a member living in India. In fact, studies suggest that one in three Nepalese households has a member living abroad.  One study (Wagle et al. 2011) reports that for more than 80% of households in the far western region of Nepal, migration was a major source of income. An estimated 700,000 to 1.7 million Nepalese migrants are living and working in India, mostly as unskilled permanent or seasonal laborers and domestic workers.

Migration between India and Nepal is made possible by the Indo-Nepal Friendship Treaty of 1950 which allows for free movement of people between the two countries and guarantees the same rights to the nationals of one country in the other as citizens, except for the right to vote. In spite of the treaty, the reality is quite different for the majority of labour migrants who come from across the border.

Although the treaty allows them access to India, lack of a valid identity cards in India, makes it extremely difficult for them to access services at destination, avail of employment contracts, open bank accounts or even obtain a mobile sim card. Additionally, they are often exposed to violence and harassment, at the transit and at the work-place and in their places of residence at destination; exploitation and abuse is also something they experience on a routine basis-for instance, receiving less wages than their Indian counterparts, being harassed by the police and locals. Women migrants are in an even more vulnerable position as most structures, policy and systems are balanced against them. Women migrants in India are primarily engaged in domestic work which is completely unregulated and hence women migrants are often at the mercy of their employers with little or no safety nets and legal recourse to fall back upon.

The situation is even more difficult for Bangladeshi migrants to India. Unlike Nepal, there is no treaty between India and Bangladesh which makes the situation for Bangladeshi migrants in India extremely vulnerable. Studies suggest that there are about 3 million Bangladeshi migrants in India. Their irregular status makes them vulnerable to violence and abuse across the mobility continuum right from the time they begin their journey to India. Often cheated by brokers and agents, women end up as victims of trafficking. They are also exposed to violence and harassment by border authorities. At destination, they live and work under severe constraints often unable to reveal their true identity for fear of violence, threats and deportation.

Both for Nepalese and Bangladeshi migrants the conditions during and after migration increases their overall vulnerability towards diseases especially HIV. Epidemiological data from India, Nepal and Bangladesh indicate that migrants, particularly the most vulnerable age group of 15-29 (HIV in Asia and the Pacific UNAIDS Report 2013) years have high vulnerability towards HIV, STIs or Tuberculosis (TB) because of vulnerability conditions they are exposed to at source, during transit and mostly at destinations.

Enhancing Mobile Populations Access to HIV and AIDS Services, Information and Support (EMPHASIS) is a 5-year project (2009-2014) by CARE International and funded by the Big Lottery Fund, U.K., implemented in India, Nepal and Bangladesh to address vulnerabilities faced by mobile population across the continuum of mobility. For EMPHASIS, the opportunity to address HIV/AIDS vulnerabilities of mobile populations opened up pathways to address a range of other vulnerabilities including safe remittances, access to services including health services, social security, labour rights, education for children, etc.

The EMPHASIS intervention is the only one of its kind that works along the continuum of mobility, that is, at origin, transit and destination. The project focuses on promoting access to services, capacity-building of stakeholders, government, and NGO partners; and research and advocacy to add to the knowledge base on migration and HIV and to highlight migrants’ vulnerabilities and learnings from the project to influence policy-makers at the national, regional and global levels.

At the end of the five-years, EMPHASIS project has made significant contributions to the migration discourse in the South Asia region and more importantly, it has piloted a model of an effective cross-border migrant intervention which has highlighted the importance of working along the continuum of mobility; and of having an effective intervention at transit point to target a significantly large number of migrants, promoted safe remittance sending for migrants which has reduced incidents of violence and harassment at the border, and successfully established the cross-border ART referral mechanism-a first in the region!

Some more learnings from the project are highlighted below:

Key Learnings that emerged from the project (EMPHASIS Project, Learning Series):

a) Establishing an information network that reaches out to migrants across the mobility continuum leads to better outcomes than interventions that only operate at source or destination.

37 service centres (Community Resource Centres, Drop In Centres and Helpdesks) established at strategic locations in the three countries provided meeting and recreational spaces and were instrumental in fostering community mobilisation. A network of 700+ outreach workers, peer educators and volunteers reached out to inform and empower over 300,000 migrants and their families with context-specific and multi-lingual Social and Behavioural Change Communication (SBCC) materials. A referral network embedded within the outreach strategy linked migrants and their families to existing public, private and non-government service providers. Mobilising existing service providers strengthened accountability and ownership.

A project end-line study to measure change in knowledge and attitude of stakeholders showed an increase of over 100% over the baseline and that the project fostered behaviour change through its use of mass and folk media, campaigns and SBCC.

b) Ensuring HIV services across borders requires different strategies for open versus closed borders.

An ART (Antiretroviral) cross-border referral mechanism was operationalized between Nepal and India for migrants with HIV. Prior to EMPHASIS, migrants had no choice but to travel back to their homes in Nepal to access treatment which many migrants were not able to do and were therefore, forces to miss their ART medication. (b) Access was increased to Voluntary Counselling and Testing (VCT) services in both Bangladesh and Nepal. Training was made available to service providers on syndromic management of sexually transmitted infections (STIs), infection prevention, universal precautions, counselling and testing protocols and rationale use of anti-retroviral therapies. Referral mechanisms were strengthened. Health camps and mobile clinics were made available for migrant populations that were unable or unwilling to access health services. Special attention was given to the health and wellbeing of HIV+ migrants and stigma and discrimination were addressed through inclusion strategies.

c) Promoting safe mobility, security and dignity requires robust research and power analysis focused on specific corridors.

The project was able to reduce the number of cases of violence and harassment at the Indo-Nepal border. Formats were developed to monitor and address harassment, violence and rights abuses, and the findings were widely shared. Stakeholders (nongovernment and community-based organisations; hoteliers and food stall owners; transport unions, bus drivers and rickshaw pullers; and border security and police officers) were enlisted as allies; and accountability mechanisms were activated.

The project was also able to promote safe remittances and a culture of saving and ensure women had greater control over remittances. Banks and money transfer services in India and Nepal were lobbied to develop migrant-responsive banking procedures; trust was built in the use of official money channels amongst migrant populations; and the media was engaged to build wider public awareness and to bring about accountable responses from duty bearers.

d) It is possible to bring about these changes in ways that empower women.

Ensuring women have access to information about migration and HIV and to referral and support services is key to reducing their vulnerability to HIV and STIs. Second, inter-spousal communication is key to reducing women’s vulnerability to HIV and leads to more equitable family relationships.

In all 55 community-led women’s groups evolved in Bangladesh, India and Nepal and provided creative spaces for women to express themselves as agents of change. Additionally linkages were established with existing organisations to address violence against women and barriers to decision making related to migration and sexual and reproductive health. The women’s groups played a significant role in addressing stigma and discrimination, as well as their own issues.

e) Regional cooperation and acceptance of cross border mobility is essential to ensuring inclusion and the protection of rights, dignity and the service needs of mobile populations.

Issues-based research and policy briefs informed policy dialogues across multiple levels (national, regional and local), alliance building, networking and campaigning. Sensitisation meetings were facilitated with policy makers, civil society organisations, service providers and security forces on rights and concerns. The media and other enablers were engaged to add weight to lobbying efforts.

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