Cross-border movement, migration, and HIV:

opportunities and challenges

USAID SOTA meetingWashington DC

Oct. 8, 2002

Stephen MillsFamily Health International

Asia Regional OfficeBangkok, Thailand

Topics

• Evidence for linkage between HIV and population movement worldwide, with an emphasis on Asia

• What’s in a word: defining movement and its linkage with HIV

• Example of linkage between HIV and migration: Nepal and India

• Lessons learned from previous interventions• Plans for the future

Evidence on linkage between HIV transmission and HIV

• Most epidemiologic evidence on mobility and HIV is from Africa

• Evidence strongly supports major role of mobility in seeding and sustaining epidemics– Early stage of Uganda epidemic thought to be due to 3

types of mobility• Trucker/FSW (highway spread)• Migrant workers (urban-rural spread)• Military (ethnic and urban-rural spread)

• Research consistently shows that mobile populations are 3+ times more likely to be infected with HIV than non-mobile groups

Highlights of findings from Africa

• Men and women who had changed residence were 3 times more likely to be HIV-infected (Uganda, South Africa)

• Migration disrupts family life and creates market for prostitution in destination sites (South Africa)

• HIV spread occurs between men and sex workers during seasonal migration and then to rural partners when they return (Senegal)

• Male migrants AND their wives both more likely to be infected from outside the relationship (South Africa)

Mobility and HIV in Asia: Potential routes of transmission

• International and national labor migration is high in Asia, often between low and higher prevalence countries– Laos Thailand– Nepal India– Because of the size of many Asian countries,

significant migration occurs within countries• Rural India Urban India• Rural China Urban China• Others?

Population movement/migration: Many definitions

• Mobility is complex and has various components, all important in understanding linkage with HIV

– time in transit – an hour, day, months?

– frequency of movement – daily, monthly?

– reason for mobility/migration – poverty, wealth, trafficking?

– one-way vs. circular mobility

Migration and HIV transmission

• Research and surveillance in Asia linking mobility and HIV transmission has been limited

• ANE-funded research/surveillance has begun to fill these gaps

HIV and mobility research/surveillancein Asia funded by ANE

• HIV/STI prevalence and risk behaviors among sex workers and truckers in Nepal (1999)

• Lao-Thai-Cambodian Border Area behavioral surveillance (2000)

• Lao National Surveillance System (2000-1)• HIV/STI/behavioral surveillance linked to

interventions– Nepali migrants in India (2002)– To-be-selected groups along Thai/Burma/Cambodian

borders (2002)

HIV/STI prevalence survey among female sex workers in rural Terai, Nepal

• Study sampled FSW along highway routes in Central/Eastern Terai

Sex work in India among Nepali sex workers

83

17

4

0

10

20

30

40

50

60

70

80

90

100

Did not work in India Worked in India Worked in Mumbai

Percent

4.8 % UP

8.2 % Bihar4.1% West Bengal

3.9% Mumbai

• 17%of Nepali sex workers in the Terai reported having worked in India

• Another 3.6 % in other states or unknown destination

HIV and STI prevalence among female sex workers in the Eastern/Central Terai

3.9

9.3 9 9

18.8

25.621.2

47.3

0

5

10

15

20

25

30

35

40

45

50

Percent

HIV prevalence among sex workers by practice of sex work in India

1.27.4

50

0

10

20

30

40

50

60

70

80

90

100

Never worked inIndia (n=340)

Worked in India/notMumbai (N=54)

Worked in Mumbai(n=16)

Percent

Logistic regression model of determinants of HIV infection among rural FSW in Nepal

Factor OR 95% CI

Age 20+ 0.68 (0.17,2.7)

Sex work in India None 1.0 Yes, not Mumbai 6.9 (1.6,29.1)

Mumbai 51.8 (13.8,245.6)

Syphilis 3.8 (1.1,12.9)

HIV linked with trafficking?HIV prevalence among sex workers by reported

coercion to engage in sex work in India

33.3

10.2

1.20

10

20

30

40

50

60

70

80

90

100

Coerced (n=21) Went on their own(N=49)

Didn't work in India(n=340)

Percent

Significant findings

• Although only 4% of the FSW population in the sample area, women who report having worked in Mumbai account for 50% of the HIV prevalence

• Sex workers who worked in India account for 75% of the HIV prevalence

• Almost 9 in 10 sex workers (87.5%) who said that they were coerced to go to India worked in Mumbai

Example: Nepali male laborer migration to India• An estimated 600,000 to 1.3 million males

migrate to various sites in India for seasonal labor each year

• Migration not evenly distributed– High cross-border movement– Additionally, Far West region of Nepal

provides extremely high percentage of male population (Example: 60% of males in Bahjang district migrate to India)

• Migration is not random: Networks between source districts and destination areas produce migratory “corridors”

Nepali male migration to India

Majority of mobility is at the border area between adjacent areas

Nepali male migration to India

However, significant migration occurs from areas farther within Nepal to areas farther within India

Achham, Nepal study of HIV among males in a highly migrating rural community

Background

• Highly migrating community: Estimates of over 50% of males migrating to India for work

• Migration behavior (frequency, locations), risk behaviors, relationship to HIV prevalence all unknown

• Qualitative reports of increased AIDS cases

• Surveillance system did not include area

Year 2000 results from Nepal HIV sentinel surveillance sites among STI clinic attenders

• Biratnagar

0.3%

• Kathmandu 0%

• Nepalgunj 6.6%• Pokhara 2.5%

•Mahendranagar

3.7%

• Birgunj 1.3%

Far West/Western Region HIV epidemic dynamics “missed”by current HIV surveillance sites

        

                                    

Map Showing Study Site

        

                                    

 

HIV Prevalence among males in Achham: overall and by migration category

2.3

0.7

3.73.0

0

2

4

6

8

10

Overall Non-Migrants Internal Migrants international migrants

Percent

Source: FHI/New ERA Survey

Behavioral differences: Males reporting ever having sex with female sex workers

25.3

15.7

5.6

0

5

10

15

20

25

30

International Migrants Internal Migrants Non-Migrants

Source: FHI/New ERA Survey, 2002

HIV Differentials among international migrants:Last migration destination

8.8

5.4

3.12.6

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10

Mum

bai O

nly

Mah

arashtra

Hariyan

a

Oris

sa, W

B, A

dj

Source: FHI/New ERA Survey, 2002

Summary and implications• 64% of current HIV prevalence burden can be attributed to

international migration in this rural community; additional 21% to internal migration (Total 85%)

• In this case, cross-border areas are NOT the priority• Migration destination is key: Migrants whose destinations are

high HIV prevalence areas are far more likely to be infected (Mumbai)

• Implications- HIV prevention for Nepal belongs partially in India- Dual interventions necessary at source and destination

- Prevention emphasis may be at destination- Care emphasis may be at source

Border Area HIV/AIDS Project (BAHAP)

• Pilot project designed to reduce risk behaviors at key cross-border “hot” spots between Thailand, Laos, Vietnam, and Cambodia

• Implemented from 1997-2000 in collaboration with FHI and CARE, local NGOS, and governments

• Evaluation included qualitative interviews with stakeholders and target groups

Chiang Rai

Huay Xai

Trat

KohKong

SvayRieng

Mukdahan

LaoBao

TayNinh

Thailand

Laos

Vietnam

Cambodia

Savannakhet(Route 9) Sepon

BAHAP Border Area Model

Lessons learned• Management very difficult

• Government buy-in hard won because migrants not prioritized

• Collaborations between sites difficult to organize and maintain

• Dynamics of mobility combined with epidemiology need to be factored into the selecting sites and tailoring interventions

• Border areas are not all ‘high risk’ environments

• Mobile population’s source and destinations require specific approaches

• More rigorous evaluation needed, including trends in HIV/STI/behaviors

Looking towards the future • Scaled-up interventions among mobile

populations in key sites in Asia with surveillance-based evidence of HIV/STI and risk behavior decline

• Rigorous evaluation and documentation of best practice elements of interventions with mobile populations

• Proposed population groups and sites include:• Nepali migrants in 3 sites in India: Delhi, Mumbai,

Bangalore• Lao, Burmese, Cambodian mobile groups in

Thailand (to be decided)

Challenges in surveillance and prevention with mobile populations Geographic – migrant populations tend to be

rural-based; services and surveillance are urban-based

Practical and political challenges of source and destination interventions– Migrants are often not present at origin communities for

most of the year– Destination governments may not see migrants as

priority Surveillance issues

– Typical surveillance sites (ANC, STI, FSW) DO NOT capture HIV prevalence levels nor trends among migrants and mobile populations

Major take-home messages

• Mobility/migration/population movement complex

• Research highly important in determining what types of mobility lead to what type of HIV spread

• More research needed on dual source/destination interventions

• Management of cross-border/regional interventions challenging