By Prabodh Devkota Senior Regional Project Director CARE International HIV Services for cross border migrants in the context of Nepal, India and Bangladesh By Prabodh Devkota Senior Regional Project Director CARE International

Cross border mobility contexts in South Asia (Nepal, India and Bangladesh) Nepal and India share open border India and Bangladesh do not share open border Mobility with in South Asia remains as a historical fact Enhancing Mobile Population’s Access to HIV Services, Information and Support (EMPHASIS) works in Nepal, India, Bangladesh with research partners in the UK EMPHASIS experience offers learning from two different cross border contexts of South Asia

EMPHASIS Project Sites Source: Nepal Achham and Kanchanpur Bangladesh Jessore and Satkhira Transit Nepal Gaddachauki, Nepal Banbasa and Gaurifanta, India Bangladesh Border area of Sarsha, Sub-district of Jessore Border area of Debhata, Satkhira Sadar & Kalaroa Sub-district, Satkhira Destination Mumbai: Thane, Bandra, Jogeshwari, Mulund, Malad, Borivalli, Andheri, Goregaon, Kalwa, Wadala, Mankhurd, Koper Kairne, Santacruz Delhi : Naraina, Ramesh Nager, Kirti Nager, Madipur, Kapashera, Gurgaon, Jhilmil, Kashmiri Gate, Nand Nagri Kolkata Bongaon, Barasat, Machhalandpur, Cossipore, Rajabazar, Gardenreach, Madhyamgram

EMPHASIS Women Empowerment Collaboration Safe Mobility Social Mobilization Health System Strengthening Remittance Referral & Peer Education Capacity Building Research/Policy advocacy Cross border referral linkage

Living Conditions of migrants

HIV and Migration: Bangladesh According to the NASP Report of 2006, approximately 67 percent of identified HIV-positive cases in the country were returnee migrant workers and their spouses. NASP on the World AIDS Day 2010 stated that 40 per cent of total new HIV cases reported were from external migrant workers and 34 per cent of total cases were female, of which 24 per cent were wives of HIV-positive men. In 2011, out of the 445 new HIV infections, 138 (31%) are the external migrant workers and 21.1% are the housewives.

EMPHASIS collaborated with Gov Bangladesh to set up two VCT Centers Total number of tested cases at VCT Centers

Status of HIV Test result All the cases have migration history Male (6) Female (11) Male (408) Female (244) EMPHASIS is still in the process of analyzing the context and technicalities of these data in coordination with government and other stakeholders

The process to receive ART in India requires the following documents: Address proof (Ration card/electricity bill) OR Recommendation letter/undertaking from NGO or Recommendation from employer and Employee ID card  Key Issues faced by PLHIV in the continuum of Mobility Lack of Information Lack of identity proof Long queue (some time 300-400 persons) for getting ART (Mumbai/Delhi) Inadequate time given by ART counsellor though efforts are made to make it easy Access to medicine other than ART Accessing services from different points within a hospital Travel cost-Poor financial status women and widows are on the hardest hit Language barrier

Opportunities India operates under the principles of universal access to treatment services

EMPHASIS Efforts in Destination Accessing services through regular referral system in India Male Female Total NMP 85 29 114 BSP 14 27 41 99 56 155 Accessing services through cross-border referral: A Historic Achievement Male Female Total NMP 28 4 32 BSP 3 5 8 31 9 40 People with HIV in EMPHASIS India Male Female Total NMP 113 33 146 BSP 17 32 49 130 65 195

ART TRANSFER FROM NEPAL TO INDIA Transfer Letter should mention the following: Letter on hospital letter head with email & phone number of hospital ART number Current course of medicine Date when started ART Current status of CD4 count Name of preferred ART centre (asked in Mumbai)

Chain of Partners: EMPHASIS Facilitation for Cross Border Referral RS forwarded an email to country team Nepal to act on the issue On the same day more details sent from Mumbai: Name, VDC, Village and ART site Reflection: Linked to ART at destination with in 4 working days Direct communication among partners (Destination to Source) Close collaboration with ART at both sides Hard work regardless of weekend Nov 24th Saturday Project Coordinator GaRDeF in Achham received information including a request letter from patient for ART transfer Nov 23, 2012 Friday ARC Project Coordinator sent an email to Country Team India with a copy to RS Nov 26th ART Transfer letter sent from source to destination Nov 22, 2012 Lali Guras DIC, Mumbai Nepali Migrant ART # ; who was travelling every six months to Nepal for CD4 testing and access ART Nov 29th Linked to ART site in Mumbai

Strategic significance of having a cross border program EMPHASIS services were provided to 13828 migrants at destination in 15 months who were from 67 districts of Nepal at source. This proves the fact that for a cross border program it is important to have programs both at source and destination.

Key Learning Unless Migration is underscored as a key priority within National AIDS Response, reaching migrants will be more challenging Program at source and destination are strategic to reach the mobile population Governments, civil society and people’s network can make universal access possible A comprehensive migration program can make a difference

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