Playing the politics of exclusion means everyone loses

By Sharon Ekambaram

Elbow tests and “amakwerekwere” — these are some of the new markers of difference in South Africa, but playing the politics of exclusion in public health gives new meaning to the slogan “an injury to one is an injury to all”.

Although estimates vary, as many as 3.3 million migrants from neighbouring countries may be living in South Africa. Some seek asylum, fleeing war or political persecution. Others, sometimes called “survival migrants” come to escape poverty and hunger working on South Africa’s farms and mines, and in its cities.

Between patients and pills
Once here, migrants lack the social support of friends and family in a new, often hostile country in which HIV is more often than not a bigger problem than it is at home. Their new lives are a complex brand of vulnerability to the virus that may include poor living conditions, sexual exploitation and risky behaviour like alcohol abuse.

Despite risk factors like these, research by Médecins Sans Frontières / Doctors Without Borders (MSF), Wits’ African Centre for Migration and Society and the Open Society for Southern Africa show that migrants are often unable to access the HIV and tuberculosis (TB) care and treatment they are legally entitled to in South Africa due to associated costs, fear of arrest and deportation, and some health workers’ discriminatory attitudes.

Meanwhile, frequent trips home, varying treatment regimens between countries as well as detention and deportation may disrupt access to treatment for those on HIV or TB medication. These interruptions can cause drug resistance, treatment failure and the associated risk of disease and death.

The South African department of health extended free HIV care and treatment to all people regardless of immigration status in a 2007 directive. The country also extends TB treatment free of charge to all patients.

People living with HIV are at an increased risk of developing active TB and it remains the leading killer of people living with HIV globally — and the leading natural cause of death in South Africa. Antiretrovirals can reduce an HIV-positive person’s risk of developing active TB by 65%, according to a 2012 study published in the medical journal PLoS Medicine.

ARVs can also reduce the risk of transmitting HIV to others. The 2011 HPTN-052 study indicated that HIV patients who are able to effectively treat the virus are about 96% less likely to pass the virus onto others.

This strengthens the logic of treating HIV patients early and effectively as treatment may currently be our best hope in curbing the HIV epidemic. Similarly, TB patients on effective treatment usually become non-infectious within the first two months of treatment in the absence of any drug resistance, according to a 2010 study published in the Clinical Infectious Diseases medical journal. Less infectious patients, means fewer new TB cases.

Treatment without borders
In November 2010, MSF began providing mobile HIV and TB services in Limpopo on six Musina farms and found that Zimbabwean migrant farm workers travelled between Zimbabwe and South Africa an average of up to five times a year.

MSF also found that a quarter of the 770 farm workers tested were HIV-positive but only half of those in need of treatment were receiving ARVs, which then could only be accessed at the Musina district hospital up to 50km away.

In order to improve HIV care and treatment in this highly mobile population, MSF piloted measures like migrant-specific treatment counselling, patient-held medical records or “health passports” and mapping HIV services in patients’ home areas before they travelled home. MSF also issued migrants with an additional short course of treatment to help prevent drug resistance if patients were forced to interrupt treatment.

Between November 2010 and February 2012, about 70% of patients who returned to Zimbabwe were able to continue treatment. While 12% of those who returned home defaulted on treatment after their MSF-issued, three-month supply ran out, the majority of these patients were able to use the MSF-prescribed short-course of treatment to help reduce the risk of drug resistance.

A year later, 90% of patients were still in care and roughly as many had managed to suppress their HIV viral loads enough to reduce the risk of transmitting HIV to their partners.

Less than two years after MSF began offering mobile clinic services in Musina, the number of HIV patients diagnosed and assessed for treatment has grown by about 40%. As of early 2012, the project had started about 410 patients on ARVs.

What must be done
Providing HIV and TB care and treatment for everyone — including migrants — is not only morally right given historical migration patterns and the region’s high HIV and TB burdens, but also the smart thing to do from a public health perspective.

To achieve this, access to free HIV and TB care for migrants must be ensured at every health facility in South Africa. Xenophobic attitudes of health staff are unacceptable and disciplinary actions must be taken when they occur.

Finally while the Southern African Development Community should work towards the regional harmonisation of treatment regimens and drug formulations, national health departments should adapt services to mobile populations by introducing simple measures such as those piloted in Musina.

Failure to include migrants in HIV care and treatment, and denying them access to HIV programmes tailored to their needs would not only be short-sighted but an ultimately dangerous decision that is really an injury to all when we know treatment really is prevention.

Sharon Ekambaram is the MSF South Africa head of programmes.

MSF has been providing medical and humanitarian assistance to refugees and survival migrants since 2007 in South Africa in Musina and Joburg’s inner-city slums.