“We acknowledge that San Francisco, California, where the 23rd International AIDS Conference was to take place, sits on the land of the Ohlone people and other indigenous groups. Now that the conference went virtual due to the COVID-19 pandemic, consider where you are and on whose ancestral lands you live,” Renée Masching of the Canadian Aboriginal AIDS Network asked.
While Canada has universal health care, providing it is the responsibility of each province. Historical displacement and overlapping tribal and provincial boundaries make it difficult for many First Nations people to access health care. People living with HIV (PLWH) may migrate to urban areas for care, but treatment is often not culturally sensitive. We need indigenous control of local health services, Masching emphasized: “Indigenous people have the solutions for our own health and are willing to share our knowledge in respectful relationships.”
Indigenous people are still displaced today, Francisco Javier Olivares Antezana of Corresponsales Clave in Chile noted. The Mapuche, for example, continue to fight for protection of their territory in the Andes mountains. Ancestral lands also span national borders, so indigenous people move between countries to be with family, attend ceremonies, etc. As non-citizens of the other country, they are often ineligible for public health care there.
Health care access is the determining factor for seroconversion risk, Nicholas Medland, M.B.B.S., Ph.D., of the Kirby Institute in Australia said. In his country, universal health care does not cover the more than 2 million holders of temporary visas, such as students or migrant workers. They are required to purchase private health insurance, which does not pay for preventive services, such as pre-exposure prophylaxis (PrEP). Immigrants are also afraid to get tested for HIV, because of the impact a documented seroconversion may have on their visa status.
“Leaving HIV unchecked in any part of the community will reduce the overall population benefit,” Medland noted, calling for a rethinking of the meaning of the word, “resident.”
People forced to leave their homes often face an even bleaker situation. In 2019, the United Nations High Commission for Refugees counted 26 million refugees and 4.2 million asylum seekers worldwide. In Botswana, refugees must live in camps that are overcrowded and have limited sanitation and no HIV treatment, explained Cindy Kelemi of BONELA, a legal and advocacy organization.
“We shouldn’t look at refugees as beneficiaries, but we should look at them as change agents,” Kelemi demanded. At the Dukwi refugee camp, no HIV care at all was available until 2018. Camp residents organized—with BONELA’s help—and the government has since allowed the Red Cross to provide HIV testing and treatment at the camp.
Overcrowding and lack of sanitation also plague the Bidi Bidi refugee camp in Uganda and increase the risk of spreading SARS-CoV-2, the virus that causes COVID-19, noted Carmen Logie, Ph.D., of the University of Toronto, Canada. Partly due to the lack of accessible information, the specter of the novel respiratory virus has induced fear and panic across the camp, with some people considering a return to their countries of origin to escape the pandemic.
The United Kingdom’s “hostile environment” policy is intended to produce precisely that result, or—better yet, in the government’s view—keep people from coming to the country in the first place, Kat Smithson of the National AIDS Trust explained. While HIV care itself is free for all, immigrants are charged for any other health care. They are also afraid of being deported should they test positive for HIV. Thus the National Health Service becomes an instrument for creating this environment, Smithson pointed out.
The environment can be even more hostile to women, who make up about half of migrants globally, reported Catherine Hankins, M.D., of the Amsterdam Institute for Global Health and Development in the Netherlands. During transit, they may be forced into sex in order to secure transportation or official permission to continue their journeys. On arrival, they may be coerced into sex work by people exploiting their precarious situation in the new country, resulting in a high risk of seroconversion.
The situation is exacerbated by COVID-19: Crowded living conditions, disappearing informal-sector jobs, and movement restrictions make migrants’ precarious situation worse. In the U.S., the pandemic’s economic impact is felt especially acutely by Latinx households with at least one non-U.S.-citizen member, reported Michael Karpman, M.P.P., of the Urban Institute in the United States. Such households experienced the highest level of economic hardship among all ethnic and racial groups, as well as compared to Latinx all-U.S.-citizen households, their study showed. These economic effects must be addressed if we are to conquer the pandemic, Karpman concluded.
That sentiment was echoed by Winnie Byanyima, executive director of UNAIDS, who noted: “COVID-19 reminds us that pandemics cannot be tackled by health systems alone.” We must address inequalities with multisectoral, decentralized approaches that put people before profits, Byanyima demanded.