Bangkok AIDS Conference
Mandatory Testing - Violating the Rights of Migrant Workers
by CARAM Asia firstname.lastname@example.org
July 26, 2004
Many may not have noticed the poster that was exhibited yesterday on mandatory testing and migration. Of course, the sessions on access to ARVs are fascinating. But a conference with the name ACCESS FOR ALL is not only about access to treatment. It is also about access to human rights. And human rights are ignored in the case of mandatory testing of migrant workers. In CARAM research done in Bangladesh with migrants leaving for Malaysia, it was found that 83% of prospective migrants were tested for HIV. 65.8% of them knew that they were tested for HIV. Only 6.2% received pre-test counselling. On arrival in Malaysia, 86% underwent a medical check. Apparently because Malaysian authorities have little confidence in their colleagues in Bangladesh. 61% of the migrants were aware that they were tested for HIV. And only 7.8% received counselling. This illustrates vividly how the test is considered by the authorities. It is used to pick out the 'rotten apples' that may cost them, and not as a tool to improve the health of migrants.
Mandatory testing of migrants is demanded for 60 countries. Current practice is a medical check including a test in the home country. Upon arrival there is random testing. After that there is a medical check including an HIV test each year upon renewal of the work permit. No test, no permit. In times where everybody is discussing the choices that we have to make, we cannot say that this leaves migrants much choice. It implies testing or becoming an undocumented worker.
And what are the consequences of testing? It is not access to treatment. That would be a fair deal. Because when you test positive for HIV after a clean bill of health at arrival, it implies that you were infected during your period working in the host country. You were infected because you were put at risk by not giving you access to proper preventive material in a language that you understand and with understanding of cultural sensitivities. You were infected because you were denied access the right to come with your family. In your loneliness you have done things that you would not have done were you with your partner and if you were fully informed about the risks.
You were infected because when you had an STI you were denied access to anonymous good quality care, because you are supposed to go to the company doctor and you run the risk of being deported. And you cannot afford to be deported as your family made big expenses for you to migrate. The consequences of testing are that you are sent back home to your country, and denied access to the right to earn your money while you are healthy. Testing positive for HIV is not a reason for your employer to fire you.
The consequences of mandatory testing is that we see one-sided testing results in some of the countries that export a lot of labour. 32% of people living with HIV/AIDS in the Philippines are overseas Filipino workers (April 2004). In Bangladesh 41% of people living with HIV/AIDS are returned migrants (2002). In Pakistan 80% of people living with HIV/AIDS are prospective migrants or returnees from the Gulf (December 1999). Migrants are at risk. They are denied programmes that will better protect them. Even at this 15th International AIDS Conference it is embarrassing to notice how often they do not have access to our attention.
Medicine and migrant populations: where are we headed?
Travel for survival has a long tradition in the HIV/AIDS epidemic. In the early days, people with HIV/AIDS who could afford to, went to see an experienced doctor, or travelled far to get experimental wonder drugs promising a cure. In the era of antiretroviral drugs, we mainly now think about people from countries without access to treatment travelling to rich countries in order to procure life-saving medication.
For reasons supposedly linked to public health and healthcare budget concerns, the US has barred HIV-infected people from entering the country. It is not alone; the US is one of the 13 countries imposing a blanket proscription against people with HIV crossing their border. Others include China, South Korea, Iraq, Saudi Arabia and Brunei.
Today, politicians in many rich countries fear that the lure of antiretroviral therapies could attract HIV-infected immigrants in large numbers, overburdening public health programmes. Based on such apprehensions, several countries have introduced new movement restrictions directed at migrant populations living with HIV, such as Canada in 2002 and New Zealand in 2004, or made existing measures more stringent, as Australia did in 2002.
However, the picture of medical migration is a broader one. Medical migration happens all over the world in all sorts of situations: people from Britain travel to France for surgery because of lower prices and shorter waiting lists; high drug prices in the US create an incentive to travel to Canada; in Norway, the government is sending depressed patients, including people with HIV/AIDS, to spend some weeks in sunny Spain; India and Mexico both experience hoards of visitors leaving with their cases full of cheap generic and branded medication; terminally ill people from many countries travel to Switzerland for assisted suicide; and, until not long ago, Irish women had to take a trip to Britain if they wanted an abortion.
Medical migration is clearly a large garden with many different flowers, of which the above is only a small sample. Stakeholders are not only patients, but also public institutions, states and private bodies such as insurance companies. The variety and tradition of the phenomenon coincides with the multiple ways states either encourage forms of medical migration, tolerate a policy of laisser faire, or try to remove people who could become a burden out of their territory.
From 1891, when the US Public Health Service first took on its task at Ellis Island, tuberculosis was diagnosed by stethoscope. Less than two decades later, the characteristic X-ray and a positive acid fast bacilli slide were required to prohibit entry to newcomers. PHS doctors didn't have a lot of time, but they did have a number of techniques to detect would-be immigrants with germs or bad genes . The two conditions that especially worried the PHS were trachoma (an infectious eye disease) and favus (a superficial fungal infection affecting the scalp).
Technology has improved since. Thanks to antibiotics, many infectious diseases can be cured for little money. However, diagnostic tools have also become more sophisticated. HIV testing is cheap, highly reliable and offers very good predictability. The predictive value of the HIV test is unusually powerful: a person testing positive for HIV has a 95% likelihood, in the absence of treatment, of developing an AIDS-related condition within a decade. As a means of identifying populations whose movements one wants to control, HIV testing is almost as simple as the PHS's stethoscope. A continuous study by the German AIDS Federation showed that 104 out of the 169 countries they looked at had some form of institutional residency or entry restrictions applicable to people with HIV/AIDS.
The real danger is that HIV testing of migrants could become a precedent, and lead to widespread genetic testing and screening of migrants. In the next few years, especially in light of our expanding knowledge of the human genome, predictive medical science will progress dramatically. We need to think now about how we will ensure its potential should not be used to discriminate against people or patients.
Medical migration is clearly a large garden with many different flowers.
A continuous study by the German AIDS Federation showed that 104 out of the 169 countries they looked at had some form of institutional residency or entry restrictions applicable to people with HIV/AIDS.
In the next few years, especially in light of our expanding knowledge of the human genome, predictive medical science will progress dramatically. We need to think now about how we will ensure its potential should not be used to discriminate against people or patients.
HDN Key Correspondents Team
Tuesday, 9 April, 2002
Burmese migrants face HIV test by Thailand Government
by Larry Jagan, BBC's Burma analyst in Rangoon
Burma and Thailand have agreed on a plan to repatriate more than 500,000 Burmese illegal immigrants currently resident in Thailand.As part of the deal, Thai Foreign Minister Surakiart Sathirathai told the BBC, the Burmese workers will be screened for HIV. Those testing positive will be separated from the other workers being repatriated.
The agreement was reached in a bilateral meeting between the two countries in Rangoon, when both countries were attending a tripartite summit with India.
This is part of the Thai Government's efforts under Prime Minister Thaksin Shinawatra to improve relations with Burma.Thailand has been anxious to get Rangoon to agree to take back more than 500,000 illegal Burmese believed to be living in Thailand.To achieve this, the Thai Government has bent over backwards to accommodate Rangoon.
Now the policy of renewed engagement is producing results, Mr Surakiart said. The two countries have now ironed out most of the obstacles which had prevented the repatriation scheme from starting.
The Burmese Government asked Thailand to screen all returning refugees for HIV/AIDS and Thailand agreed.
This is likely to anger many human rights groups, who have already accused the Thai Government of violating the workers' human rights by insisting on a medical examination before they are registered or re-registered.
Mr Surakiart said those workers who were diagnosed as HIV positive would be separated from the other illegal immigrants and would be treated as part of a special repatriation scheme.
The modalities of the illegal workers' return are still being worked out and should be completed when the joint task force meets again in the next few weeks. Mr Surakiart confidently predicted the return of the refugees later this month. However, other Thai Government officials admit this is an optimistic estimate and that even if the repatriation scheme starts this month, it will take months rather than weeks before any appreciable number of workers return to Burma.
New Zealand confirms compulsory HIV-testing for migrants aidsnet website
New Zealand has been discussing compulsory HIV testing for migrants since a number of years. A set of measures were passed in November 1999 by a former New Zealand cabinet. However, shortly afterwards a new government was elected, which decided not to implement these measures.
Press reports from the last 12 months have now been confirmed by the Immigration Services at the Department of Labour in Wellington.
From early 2005, New Zealand will be undertaking HIV screening for migrants. This decision has been made as part of a comprehensive review of New Zealands health screening requirements. Some changes relating specifically to tuberculosis screening have already been implemented. The full set of changes, including screening for HIV, and a wider and updated set of tests for other expensive-to-treat conditions, will be implemented in early 2005, for people seeking to be in New Zealand for longer than 12 months.
While HIV-positive people may not, prima facie, meet the definition of acceptable standard of health, waivers of this requirement will be available for family members of New Zealand citizens and residents, and for refugees. HIV screening will also be carried out for people proposed for the Refugee Quota programme. A maximum of 20 HIV positive people will be accepted as Quota refugees in any one year.
From "voluntary counselling and testing" to routine testing
Why we should oppose a return by stealth to the days of mandatory HIV testing.
While every effort should be made to increase the practicality of Voluntary Counselling and Testing,
the principle of voluntariness remains central to sound public health practice.
It is time to raise the alarm about HIV testing. In addition to fighting HIV and AIDS, we now must return to an issue that many of us thought had been settled years ago: voluntary versus mandatory testing.
No-one who believes in enhancing treatment access can question the need to scale up HIV testing. The expression routine testing has been often used at the XV International AIDS Conference to describe this. On the surface, it may seem perfectly reasonable to choose the word routine to describe a procedure that is to be done systematically in a health setting.
However, given the past history of the responses to HIV/AIDS, there is an ominous subtext taking form. Early in the AIDS epidemic, members of affected communities and human rights activists argued that the HIV test must be voluntarily, because consent was central to encouraging testing and creating a climate of confidence and mutual trust between the person tested and service providers. Most public health professionals eventually recognized this.
The mounting pressure towards making HIV testing mandatory was curbed at that time. HIV testing with pre- and post-test counselling, often referred to as VCT (voluntary testing and counselling), became a central part of the global response to HIV/AIDS.
The experience of the last 20 years has clearly established that VCT remains the approach of choice to enhancing HIV/AIDS prevention, care and treatment, and today no one would dare claim mandatory testing in the health-care setting is an acceptable option. But with increasing frequency in recent months other terms have begun to creep into the dialogue gradually overshadowing VCT most notably routine testing.
Why does this matter? Because the vagueness of this term hides the underlying intent and a range of practices, some of which with greatly damaging potential.
Much of the momentum behind the shift in terminology can be attributed to the urgency of scaling up access to antiretroviral (ARV) treatment throughout the world in particular where coverage of VCT remains low. Since many of the people who could benefit from ARVs do not currently know their HIV status, an enormous testing campaign must accompany any scale-up efforts. However, the rhetoric of routine testing, obscures a central issue whether HIV tests are being routinely offered or routinely imposed, and whether in either case the individual has a true informed choice to opt in or opt out of being tested.
Opt in testing commonly refers to a situation in which patients are offered an HIV test by the service provider and make an informed decision to be tested. Opt out testing refers to a situation in which patients are systematically given an HIV test unless they take the initiative to decline.
If the world of HIV is to move forward we cannot afford vagueness in such critical concepts surrounding the key entry point to ART scaling-up. While every effort should be made to increase the practicality of VCT, the principle of voluntariness remains central to sound public health practice.
HDN Key Correspondents Team
TESTING ONLY WORKS
WHEN THERE IS TREATMENT
New Campaign for Testing
In a panel discussion during the Journalist to Journalist pre- AIDS Conference seminar, American Trevor Neilson, Executive Director of the GLOBAL BUSINESS COALITION, announced a new campaign for the HIV testing of the workforce. He hedged on replying to a question on his personal opinion on "routine testing" (i.e. a form of mandatory testing).
He shared the discussion with Brian Brink, Senior Vice President of ANGLO AMERICAN (South Africa's premiere mining corporation), who explained that when Anglo first offered (voluntary) testing to their workers, few employees got tested. But later, when TREATMENT was eventually provided to all of their immediate employees, they got tested in great numbers.
The irony is obvious, between the presentation from the Global Business Coalition's new testing campaign, and the result of policies which never mention treatment:
Testing without access to treatment is irrelevant
or worse . . . leading to discrimination.
Anglo will expand their treatment access wider to employee families
through grants from U.S. PEPFAR funding.
El Salvador repeals mandatory HIV testing regulations aidsnet website
The General Direction of Migration and Alienage has repealed existing
regulations requiring HIV testing for temporary and permanent residency
permit applicants, the Assistant of the General Director informed by e-mail July 31, 2004.
Under the old regulations, anyone age 15 and older applying for temporary
and permanent residency had to undergo HIV testing.
According the continuous survey of the German AIDS Federation, El Salvador
becomes the second country to lift discriminatory measures against PWHAs
(India has done so in 2002).
see also U.S. Immigration and Travel Policy
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