Access to HIV Prevention and Treatment for Internal Migrants

Scope of the Issue

Internal migrants – as opposed to international migrants – are those individuals who change residence from one civil division to another within their country of origin. Reasons for migration are varied, but typically stem from social, political, or financial causes, or natural disaster. Internal migration has increased in many countries throughout the world in recent years.[30]

Already marginalized and subject to stigma as a result of their migration status, migrants with HIV/AIDS are often doubly stigmatized and subject to neglect and exploitation. Gaps in internal migrants’ access to HIV/AIDS services—either as a result of official restrictions or logistical, cultural and linguistic barriers—have significant consequences: individuals are less able to access care and are increasingly vulnerable to infection and death, states are less able to realize the goals of universal access to treatment and reduction of the AIDS epidemic, and the public health community may face the emergence of drug-resistant strains resulting from interruptions in treatment.[31] Barriers to access to HIV/AIDS-related services faced by internal migrants when they move from their place of origin include internal migration restrictions, and logistical, linguistic and cultural barriers to HIV/AIDS prevention and treatment. To successfully achieve global goals for reducing the burden of HIV and providing universal access to prevention and care, states must recognize the rights of internal migrants and their own obligations to eliminate barriers to care. 

International Law

International law provides for the basic right to the highest attainable standard of health, and requires states parties to take steps individually and through international cooperation to progressively realize this right via the prevention, treatment, and control of epidemic diseases and the creation of conditions to assure medical service and attention to all.[32] International law also establishes the basic principles of non-discrimination and equality.[33] Taken together, these rights imply a right to access a core minimum set of health care services, including ART, without discrimination, including on the basis of social origin.

According to the UN Committee on Economic, Social and Cultural Rights, the Convention on Economic, Social and Cultural Rights’ monitoring body, states must guarantee certain core obligations as part of the right to health, including ensuring non-discriminatory access to health facilities, particularly for vulnerable or marginalized groups.While the Committee, in its General Comment 14, notes the progressive nature of the right to health, it also points to the fact that states must immediately take steps to realize the right to health, and must immediately guarantee the exercise of the right without discrimination of any kind.The right to health is thus centrally linked to the right to non-discrimination. Discrimination against internal migrants – who are in fact citizens of the state in question – is banned as explained by the Committee’s Comments, which state that the Covenant prohibits discrimination based on “social origin.” Thus, the Committee findings make clear that the Covenant prohibits discrimination against internal migrants in receiving health care, and are an immediate call on all states parties to eliminate discrimination.[34]

Case Studies

The People’s Republic of China

While urban residents holding permits in China have long been entitled to state-sponsored social welfare benefits, individuals without hukou (a form of registration with local authorities that is often time-consuming, expensive, or difficult for internal migrants to obtain) are unable to access basic public services such as education and health care, and therefore are forced to pay all costs.[35] The vast majority of internal migrants are uninsured, and rarely visit doctors or hospitals.[36] Furthermore, lack of health care coverage for sick migrants has, in the past, been compounded by additional, harsh consequences: For example, internal migrant workers have been returned to their home province under armed guard after being found to be HIV-positive.[37]

HIV-positive internal migrants’ access to treatment remains extremely limited, confounded in part by the effects of the hukou system. In 2003, the Chinese government announced a national HIV/AIDS treatment program – free to rural residents and poor urban residents. However, universal HIV/AIDS treatment is far from a reality among the general population.[38] Indeed, even when free treatment is ostensibly offered, delays in diagnosis and referral can create significant costs for the patient prior to the availability of free treatment, thus particularly disadvantaging migrants, who are not entitled to free basic health care.

The Russian Federation

Vestiges of an internal registration system also plague access to health care for internal migrants in Russia. While officially simplified and relaxed by the federal government, in practice, registration in cities including Moscow may be cumbersome and expensive, and lack of registration status may have serious official or unofficial consequences for internal migrants. Instances of unregistered migrants unable to legally marry, vote, send their children to school, and receive public assistance, have all been reported.[39] Indeed, individuals who are legally in the country but lack local registration have also reportedly faced harsh consequences, such as detention or deportation.[40] 

While the Russian government is constitutionally required to provide free medical care to all citizens and most HIV treatment is officially provided free of charge to citizens, in practice the implementation of this right is limited and major challenges exist in access to free health care.[41] Internal migrants especially face barriers, as registration is a precondition for entitlement to many free health services. Human Rights Watch research has documented that a migrant without registration is often denied both short-term (for purposes of Prevention of Mother to Child Transmission) and long-term antiretroviral treatment[42] and will typically be directed to his or her city of origin to receive the treatment.

Republic of India

HIV prevention in India is seriously hindered by the low awareness of the disease among internal migrants, particularly from rural areas,[43] as a result of mobile nature of this population, language, and cultural barriers. Significant HIV/AIDS treatment gaps exist for all groups throughout the country, but migrants also face particular challenges in accessing health care.[44] Health care is administered on a state-by-state basis in India, and in some states significant uncertainty exists among government officials as to whether state authorities are responsible for social welfare services to temporarily resident workers and their families.[45]  Furthermore, internal migrants are often unable to use the government-issued “ration cards” outside their local home authority in order to access social services, and migrants may face significant logistical challenges and delays in procuring a new ration card.[46]  Absent a ration card, it can be difficult to access even programs designed to provide health care to the poor, as some such services specifically target ration card holders.[47] Indeed, some local authorities reportedly refuse to provide ART to individuals without ration cards.[48]

Recommendations

First of all, in countries that place formal or informal eligibility restrictions on access to health care, such restrictions based on social origin within different regions of the country need to be immediately eliminated. As noted above, the Economic, Social and Cultural Rights Committee directs that states have an immediate obligation to eliminate discrimination in health care provision, including discrimination based on “social origin.” The obligation to ensure HIV/AIDS prevention and treatment to all individuals without discrimination is all the more acute, as HIV/AIDS services are included as essential drugs in the core minimum of health care services nations have an obligation to provide.[49]

Second, states should reduce barriers to ART uptake for internal migrants. User fees constitute the main barrier to ART adherence, and free care at point of service leads to improved uptake of HIV-related services, especially among the poorest users.[50] Internal migrants are often subject to greater fees and indirect costs than non-migrants, and the resulting lack of access to treatment serves to push internal migrants toward self-medication or illegal clinics.[51]

Creating programs tailored specifically to internal migrants’ needs is essential to ensure uptake even of free HIV prevention and treatment services. To remove barriers in access to HIV/AIDS services when free care is officially available, states and international agencies and donors need to formulate programs to specifically address internal migrants’ needs. Cross-regional linkages need to be developed to facilitate the transition from one regional health authority’s care to the next, where health care is not administered at a national level. Additional programs could include providing translators who could translate to the languages internal migrants to the region frequently speak, providing mobile outreach services or transport from areas where internal migrants live to health centers, educating health care providers as to migrants’ particular needs and rights, or holding patient education sessions geared toward migrants.

Finally, national governments need to remove restrictions on movement that prevent or delay internal migrants from establishing residence in urban areas. The harsh consequences and rights violations of restrictions on internal migration in some countries can include detention or deportation. Fear of such consequences may lead internal migrants to avoid HIV-related services even when they are available.

Additional Resources

Katherine Wiltenburg Todrys and Joseph J. Amon, “Within but Without: Human Rights and Access to HIV Prevention and Treatment for Internal Migrants,” 2009 (forthcoming).