Impact of Immigration on HIV and Tuberculosis Epidemiology on the Mediterranean Area Workshop 2, Madrid- Spain June

1. 1  Impact of Immigration on HIV and Tuberculosis Epidemiology on the Mediterranean Area Workshop 2, Madrid- Spain June 25- 27, 2008 Dr Aziza Bennani NAP

2. Context National Strategic Plan to fight aids 2007- 2011 Strategic objective: ensure universal access to quality services of prevention, care and support in HIV-aids’ field Specific area of intervention to mobile populations particularly illegal migrants 2

3. Evaluation of mobility and HIV situation in Morocco Survey conducted by the MoH with UNAIDS support Period: February- March 2007 Team: Pr Mehdi Lahlou: Economist, team leader Mme Claire Escoffier: Sociologist Dr Najia Hajji: Public health specialist

4. Evaluation of mobility and HIV situation in Morocco Methodology and survey protocol Priority sites Migrant : profile and needs Site-based partners Access to Care Two field surveys Survey on migrants (and associations) – care request Survey on care structures – care provision

5. Main objectives of the 2 surveys Collecting data and information: Available demographic data, broken up according to gender and age Information on migrants socio-economic status and characteristics, including information on schooling rates, employment rates in formal and informal sectors Ethnographic observations and analysis  Presence of sex workers and available Information 

6. Main objectives of the 2 surveys Care services coverage and other legal and social services : Available health facilities and access of the population to such facilities Most frequent pathologies, follow-up difficulties and other issues Health staff knowledge and attitudes and other issues   Reports on STIs, HIV and aids, with data broken up according to: gender and nationality (when available) situation analysis and other unpublished documents, local press, etc

7. Selected sites Eastern region, Oujda Crossing site Northern region, Tangiers Crossing site, which has become stay site Rabat/Salé, waiting/stay site Casablanca, referral facility Southern region, Laayoune Retention/crossing site

8. Targets 45 migrants Local associations and international support NGOs/assistance to migrants : MSF, MdM, Caritas, ALCS, OPALS, Alter Forum, ABCDS, AMDH UN agencies : HCR , WHO, UNDP, UNICEF, UNIFEM, UNCA, IOM, UNFPA

9. A mainly qualitative survey Reflecting more the situation of migrants rather than quantitatively applicable to all migrants Each case is at the same time unique and representative of all migrants There are accumulated reports and information, and therefore trends indications: at least 4 significant qualitative surveys were conducted on this topic since 2000 2006: more than 500 migrants

10. Composition of interviewed sample 45 persons, i.e. 26 men & 19 women 13 migrants from CDR 13 from Nigeria 4 from the Congo Republic 4 from Cameroun 3 from Côte d’Ivoire, 3 from Mali 2 from Sierra Leone one Guinean, one from Senegal and one from Liberia Age of men, 21 to 42 years of women, 16 to 45 years Out of the 45 persons encountered, 15 had refugee status They come from countries in conflict : Côte d’Ivoire, Liberia, Sierra Leone, CDR or Congo Republic

11. Significant continuity elements The border between Algeria and Morocco remains the main gateway to Morocco Migrants cling at all times to the hope of crossing to Europe Migrants live in national communities ; they are close to Moroccans of the same socio-economic level The Moroccan population is relatively indifferent The attitude of Public authorities is in ups and downs alternating apparent carelessness and severe harshness

12. New migration parameters Morocco has become more of a country of stay than a transit country Migrants who are both older and younger (many children are born in Morocco) A more feminized migration and notably more visible Human beings trafficking has slowed down considerably but let women exposed to exploit: as an almost direct consequence of this: begging has become widespread with a higher prostitution prevalence

13. New migration parameters Longer stay (4 to 5 years, on average) A tendency to regroup in some neighborhoods, particularly in Oujda, Tangiers and Rabat, with decreased domestic mobility Subsistence means more and more precarious Hardly bearable living conditions Increasing vulnerability Stronger social and psychological fragilization

14. New migration parameters Wider presence of Moroccan associations Stronger presence / involvement of international NGOs A more significant HCR role: the number of recognized refugees increased from 219 persons on December 20th 2005 to 476 on December 31st, 2006

15. Findings Migrants are rather young and apparently in good health but many had some diseases related to their living conditions (diet, clothing, housing) Yet they do not go to hospitals for fear of being denounced as “irregular migrants” they’re not receiving treatment not being understood (for linguistic reasons) lacking the means to pay for treatment and/or medicines

16. Findings Condom use as a HIV prevention means seemed to be known to the persons interviewed but it was far from being used on a regular basis

17. Findings Associations play a major intermediation role between care structures and migrants Not all of them have sufficient means neither do they enjoy the same level of trust on the part of migrants

18. Findings Moroccan associations, especially those in Oujda, showed strong human commitment which allowed them to win migrants’ trust , but they do not have significant means ALCS is mainly active – regarding migrant populations in Tangiers and Rabat. It has only few resources in Oujda and has just started working in Laayoune, having not decided yet what to do regarding migrants in this city/region

19. Findings Absence of Moroccan charity associations Many other foreign associations came and …left Migrants themselves created many associations but these associations are created by separate communities absence of resources and association members are confronted to legal and social precariousness

20. Survey on care provided to mobile populations

21. Findings Little documented information The majority of migrants encountered are young, in good health and bear the harsh travel conditions without complaining Before arriving to Morocco all migrants had to various degrees suffered from everyday pathologies such as: ARDs gastroenteritis or skin problems No «tropical» pathology was recorded except for bouts of malaria

22. Findings Care Provision System Public sector PHC Services hospitals Emergency Units maternity hospitals Partner associations ALCS, OPALS, MSF, MDM limited Access to care despite the work of NGOs which is not the responsibility of health facilities

23. Findings Modes of access to hospitals/ public health facilities: Through associations (MSF and Caritas mainly) Transfers from prisons/ detention-waiting centers Emergency situations: street violence, accidents, serious traumas, complicated delivery Directly at PHC services (particularly in Rabat)

24. Perceptions of mobile populations by health workers General good perception, care provided on equal footing No stigma or rejection Ambivalent feelings sometimes, racist attitudes and aids stigma but not migrants specific «charity on religious grounds» wish to help migrants but fear of authorities reactions

25. Infectious pathologies : Tuberculosis Precariousness and mobility = risk factors for transmission of diseases No public sector intervention in camps no reliable information 1200 new cases/year for the Moroccan population and 10 for mobile populations (Tangiers)

26. Infectious pathologies : Malaria Insufficient data Rare confirmed cases

27. Infectious pathologies : STIs Frequent infections based on migrant cases Do not necessarily consult for STIs Doctors report on cases without giving accurate figures ALCS Rabat : in 2005, 36 migrants treated for STIs and in 2006, 67 cases

28. Infectious pathologies : AIDS Increase in infected persons Increasingly severe forms Case management network : Rabat and Casa pole, CR (Tangiers), INH Collaboration with OPALS, ALCS, MSF,MDM

29. PLWA case management actions Profile of 38 People Living With Aids Distribution /Phase: 11 at stage C, 12 at stage B 15 at stage A Distribution /Sex: 20 women and 18 men outcome: - 26 adequately monitored of which 20 are under ARV 3 deliveries / vaginal delivery with undetectable viral load and 2 non-infected infants - 2 Lost to follow up - 2 Refusals of case management - 2 Repatriated with the help of ‘Médecins Sans Frontières’ - 6 deceased

30. AIDS case management Problem of monitoring lost to follow up patients? Relevance of triple therapy? First case of therapeutic failure (1%) Difficulties to schedule for ARV use

31. AIDS Prevention Young and literate population, relatively better informed Many partners: OPALS, ALCS, MSF,MDM Varying access to condoms Risk behavior: not much information

32. Prevention of Mother to Child Transmission Program Total and free case management yet problems to pay for delivery and test costs.. Follow-up problems

33. Difficulties encountered Precarious living conditions Difficulties to communicate with health workers Migrants administrative status: identity, residency Scheduling difficulties for health facilities : lack of information : number of migrants, pathologies Hospitals fiscal balance

34. Strategy for mobile population Workshop for elaborating a national strategy to fight STIs/HIV-aids for mobile population and migrants was held on Novembre, 27- 28th - 2007 Recommendations: 4 areas of intervention: Advocacy, coordination and partnership Reinforcement of prevention activities Improvement of access to care Enlargement of medical aids case management and psychological support for migrants living with HIV 34

35. Advocacy Dissemination of the situation analysis of mobility and HIV Actualization of the ministerial document concerning migrnats Inter-ministerial document to ensure acces to care and support Protection of vulnerable migrants Respect of the 02/03 law and international commitments Integration of migrants specific interventionsiwithin the RSP Multisectoral approach: current and potentiels partners Budget and identification of means sources Fund mobilization 35

36. Prevention Access of migrants to prevention in the PHC serices IEC Activities in Reproductive Health field and STIs:aids Peer education approach Elaboration of specific skills and tools adapted to migrants (langage, culture…) Promotion of HIV Volontary Counselling and Testing Mobile units if needed Promotion of outreach programs and condom provision Integration of HIV prevention within non thematic NGOs’ programs Global approach for migrants Social and basic needs 36

37. Access to care Creation of provincial units Access to PHC services Access to hospitals’ care Guarantie of reference and coordination between differents levels of care Updating the ministerial document concerning migrants access to care Elaborating inter-ministerial document to ensure access to care and follow up Sensitization of Health care profesionals to migrants’ health problems Setting up a mobile unit to promote health for migrants Providing all IEC and care needed 37

38. HIV Testing and case management of PLWHA Enlargement of geographical cover by VCT Fixed and mobile units Constitution of national working committee Establish ways of case management and access to ARVs Institutionnalization of the case management of migrants living with HIV Décentralized access to care and case management for migrants living with HIV Set up a ntework between all the regional centers and pole centers to ensure patientscare and follow up Collaboration frame between frontalian countries and transit countries Training of NGOs staff and educators in the field Psychological support Network between national NGOs and other countries (transfrontalians and transit)

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