(Based on an interview with Gilles Cesari Regional Director, International Union Against Tuberculosis and Lung Disease (The Union)
Every year nearly 9 million people continue to suffer from TB. Among them, 3 million people are not diagnosed or misdiagnosed or not started on treatment and care-- and many of these are migrants. It is estimated that there are approximately 200-250 million migrants (documented, undocumented, refugees, asylum seekers, etc) in the world. Unfortunately, migrant workers are more vulnerable to develop active TB disease or get infected by HIV because of their poor living/working conditions, low wages, poor nutrition, overcrowded living quarters, no or little access to healthcare (especially undocumented migrants).
Moreover, in many countries, especially in Asia and the Gulf States which have counterproductive and absurd ‘protective’ health policies, migrants face the risk of being deported if diagnosed with active TB disease or HIV infection and so tend to remain underground. Then again, as they are on the move, there can be interruption of treatment which results in drug resistance in both diseases. All these factors not only increase their risk of getting infected by TB and/or HIV, or progressing to active TB disease, but also increase the risk of delayed diagnosis and treatment in migrant populations, resulting in poor treatment outcomes. And yet, little has been done to effectively diagnose and treat TB and HIV in this population
Status of TB and HIV in migrants
As of now there is little data in terms of access to healthcare, prevalence, treatment adherence and outcomes on the issue of TB and HIV in migrants. But the data from some studies done in New York, in refugee camps in Africa, and in London, show a higher prevalence of TB in migrant communities. Again, as there are many diverse groups among migrants: refugees, internally displaced populations, asylum seekers, documented migrant workers, undocumented migrants, more evidence is needed.
Both documented and undocumented migrants are more vulnerable to TB and HIV. Even though legal, internal migration within a country (from rural to urban or rural to rural areas) is also fraught with some of the challenges described above. In Yunnan province of China, where both TB and HIV are very prevalent, thousands of Chinese people migrate from rural villages to Kunming, the largest city of Yunnan. They are mainly employed as construction workers and face most of the challenges any migrant would face, leading to poor access to healthcare and treatment.
Human rights abuses targeting documented migrants living with HIV and/or affected by TB are a matter of great concern too. Even today many countries continue to ban entry, stay and residence for migrants who are living with HIV, and/or had TB disease (and have been cured) or even have latent TB infection. These outdated laws are in total contravention of scientific evidence that people living with HIV (PLHIV) who receive appropriate treatment and care are not infectious, and that TB is curable and most smear+ patients are not infectious after a few weeks of treatment. Such policies deter migrants (documented and undocumented alike) from seeking diagnosis, treatment and care, forcing them to remain hidden, thus contributing to more infections rather than controlling them.
TB and HIV control in migrant population
The issue of continuum of care is essential for management of internal migrants within a country. A good referral system should be put in place so that a patient can easily continue his/her TB (or HIV) treatment from one city to another. This is also true for migration from one country to another. But unfortunately this is rarely happening as of now, although a good practice example was shared during the 44th Union World Conference on Lung Health held in Paris: the 2012 Southern African Development Community Declaration on TB in the mining sector and how it can address TB among migrant miners in Southern Africa.
Removing discriminatory laws (related to access to health, HIV restrictive policies, labour laws) is of key importance. Laws like deportation or losing one’s job due to one’s HIV or TB status, do not work as they threaten migrants and prevent them from seeking care and treatment. Then again accessibility and affordability of treatment is important for any patient, but more so for migrants. At a workshop in the above mentioned conference there was cited an example of great collaboration between government-employer-patient, where the employer of an MDR-TB survivor has supported the employee in the best possible way, and where 3 governments, across 3 countries in Latin America, have been involved in treating this patient.
The working group on TB and Migration at the International Union Against Tuberculosis and Lung Disease (The Union) is working on the issue of TB and HIV control and care in migrant communities—how to reach this population, how to offer them diagnosis and treatment services despite challenging law environments, and how to ensure continuation of treatment. It will also focus on getting more data and evidence in the area of health of migrants. The Union also hopes to produce a best practice booklet on working with migrants in the context of health, and TB in particular.
We need to make sure that migrants, irrespective of their legal status, have access to quality diagnosis, treatment and care. Otherwise we will continue to fail globally, in our fight against TB and HIV. TB anywhere is TB everywhere. Closing the frontiers to PLHIV, or people with latent TB infection, or people with old TB scars is not an option in the case of international migration. It only creates a false sense of protection, and increases stigma and discrimination of migrants, PLHIV and people affected by TB. Let us hope that with the strong push for universal health coverage, migrants will have better access to healthcare in general, and improved chances of diagnosis, treatment and care for TB and HIV in particular.
December 2013
(The author is the Managing Editor of Citizen News Service - CNS and is supported by Lilly MDR TB Partnership to provide conference coverage from 44th Union World Conference on Lung Health. She is a J2J Fellow of National Press Foundation (NPF) USA and received her editing training in Singapore. She has earlier worked with State Planning Institute, UP and taught physics at India's prestigious Loreto Convent. She also co-authored and edited publications on childhood TB, childhood pneumonia, Hepatitis C Virus and HIV, violence against women and girls, and MDR-TB. Email: shobha@citizen-news.org, website: www.citizen-news.org)
