Feature HIV/AIDS

Mass economic migration: the greatest threat to HIV control in India

BMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f474 (Published 29 January 2013) Cite this as: BMJ 2013;346:f474
  1. Kounteya Sinha, health editor, Times of India, New Delhi
  1. ksinha78{at}gmail.com

A third of Indians are socioeconomic migrants, and unprotected sex far from home and spouses is driving India’s HIV epidemic, reports Kounteya Sinha. Can targeted interventions reverse the trend?

Latika Samaddar’s husband, Ratan, (all names have been changed) pulls a rickshaw in New Delhi railway station while she stays in the village Malda in West Bengal, looking after their two daughters aged 8 and 6. Ratan takes a break and comes home every four months and stays for three weeks. Usually healthy, Latika has lately had a nagging flu. A blood test, prescribed by a doctor who suspected malaria, came as a shock—Latika was infected with HIV.

The doctor asked her whether she had ever had a blood transfusion or was involved in unsafe sex with multiple partners. Latika, a devout housewife, told the doctor that she was completely dedicated to her husband. Latika, however, said that her husband never used a condom. After much questioning, Ratan told the doctor that he had visited sex workers in Delhi. He was diagnosed as having HIV a month before but had decided to keep quiet.

Unlucky women

It seems that mass migration is the greatest threat to India’s HIV control programme. What’s most worrying is that unlucky women such as Latika are becoming victims. The latest HIV/AIDS estimates released last month by India’s health minister, Ghulam Nabi Azad, showed that, of all HIV infections, 39% (816 000) are among women, most of whom are housewives.

More than 200 million Indians do not live at the place of their birth. The 2001 census reported that 30.1% of the population in 2001 was considered to have migrated (314 million of the total 1028 million people)—up from 27.4% in 1991.

The latest figures from the National AIDS Control Organisation (NACO), a division of the Ministry of Health and Family Welfare, show that, besides high risk populations such as sex workers, the highest burden of HIV infection is among migrants, with a prevalence of 3.6%, 10 times the prevalence among the general population. And with migration rates increasing, India’s health ministry fears that the HIV prevalence will only get worse. “While migration plays a pivotal role in India’s socioeconomic and political fabric, there is increasing evidence and growing recognition of the part played by migration in the spread of HIV infection,” said a NACO official.

According to NACO, the risk of HIV infection for migrants seems to arise from a multitude of factors—risky sexual behaviour, lack of social and economic security, and involvement in peer driven risk taking activities such as drinking alcohol.

Poorly educated

A NACO note says that a recent study by the United Nations Development Programme (through the Population Council) study found that the risk of HIV infection among migrants was reported to be 1.68 times higher than in non-migrants. Most migrants are also poorly educated, with most reporting fewer than five years of formal education. This contributes to limited knowledge of HIV transmission.

India has for a long time thought that migrants are at risk only at destination sites, away from home and their spouse. However, recent evidence shows that migrants who return continue to fuel the epidemic because infected migrants tend to return home when they are sick. Subash Ghosh, in charge of planning the migration strategy for NACO, says a study found that returning migrants were 3.86 times more likely to be HIV positive than working married migrant men. This is why the wives and husbands of informal workers and migrants who stay at home are at risk of HIV, vulnerable to infections from their spouse.

Ghosh said, “Migration is fuelling India’s HIV epidemic,” and a note prepared by Ghosh states: “Out of the total estimated migrants, 8.64 million are temporary, short duration migrants. These are of special significance as part of National Aids Control Programme III—because of their frequent movements between source [home] and destination. Keeping this in mind, NACO at present has 196 targeted interventions covering 3 lakh [300 000] high risk male migrants.”

NACO has now produced a new migration policy that will focus on covering the corridors of migration, which would include source, transit, and destination. A NACO internal note says, “Currently, the interventions are based on either the place of residence or of work. This has proved to be ineffective in driving consistent condom behavior—primarily because of the large time gap between the actual intervention and the time of sexual encounter.”

Railway stations

NACO has therefore identified 108 railway stations—which are both source and destination of migrants travelling in search of work. These are now the focus of the country’s anti-HIV fight.

Studies have shown that two to four times as many informal workers have non-regular sexual partners or visit sex workers compared with formal workers, with only 25% using condoms compared with 42% in the general population. About 5% of male migrants and 13% of female migrants reported sexually transmitted infections, nearly double the national average.

“NACO has now drafted a new migrant intervention policy. The primary focus is on informal labourers forming part of high volume migration, high and low prevalent districts to high volume destination, with high prevalence of HIV. The second priority sector are those migrating from high or low prevalence districts, but those moving to high prevalence destinations,” Ghosh said.

Ministry data show 314 different types of migrants in India, and not all are at the same risk of acquiring HIV. “It is important to focus on informal laborers, more than blue collared workers or formal workers as clearly their vulnerabilities are many fold and their knowledge levels, practices (sexual behavior, health seeking) amongst the poorest. Rural interventions are 3-5 times more expensive than urban. It is important to interrupt the urban-rural transmission, particularly from urban high risk groups (which have the highest prevalence) to rural migrants,” a NACO note said.

According to the ministry’s strategy, the migrant interventions will focus on filtering to reach those migrants most at risk and vulnerable migrants—that is, male migrants, female migrants, and spouses of male migrants who either travel with them to the destination or stay at home.

Ghosh said that 68 main railway stations in districts throughout 11 states had been identified from where migrants usually board long distance trains. NACO has identified 122 districts with high outward migration in 11 states that are priorities for starting community level interventions. Another 75 important transit locations have been identified across these 122 districts from where these migrants usually board long distance trains or buses to reach their destinations.

Studies on the relation between migration and HIV infection conducted recently by NACO in three popular migration corridors—Ganjam-Surat, Darbhanga-Delhi, and Azamgarh-Mumbai—revealed shocking findings. HIV sentinel surveillance among pregnant women at antenatal clinics in the big states of Gujarat, Orissa, Bihar, Delhi, and Mumbai shows that those whose spouse is a migrant worker have a significantly higher prevalence of HIV infection.

Also, HIV sentinel surveillance study conducted by the ministry in 2011 among migrant men at 20 important destination points throughout the country showed that 56% of migrants had had sex with female sex workers and 38% had had non-commercial sex with a female partner in the past six months.

Similarly, a Behavioural Sentinel Surveillance study conducted in Maharashtra state in 2009 indicates that about 18.6% of migrants had symptoms of a sexually transmitted infection, and 45% of these did not seek any treatment. Three quarters (76%) of migrants did not perceive any risk of HIV, and only 13% of total migrants had ever been tested for HIV.

“The major barriers to access health services at place of work (destination) are language, cultural norms and available timings for migrants to access services,” a ministry official signed off.

Notes

Cite this as: BMJ 2013;346:f474

Footnotes

  • Competing interests: I have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare.

  • Provenance and peer review: Commissioned; not externally peer reviewed.

  • Patient consent: Patient consent not required (patient anonymised, dead, or hypothetical).