Henrique Barros Vienna, July 2010

1. Overcoming the barriers in establishing access to healthcare services for migrants and mobile populations: best practices Henrique Barros Vienna, July 2010 Ministério da Saúde

2. Barriers to health care - Language; - Cultural specificities; - Religious beliefs; - Lack of appropriate services; - Fear, stigma, discrimination;

3. Knowledge gaps - HIV epidemiologic profiles in migrants and mobile populations; - why migrants, particularly undocumented migrants, consistently appear to be at increased risk of treatment failure.

4. Portugal

5. Barriers in access to the National Health Service

6. Economic concerns Work-related obstacles Transportation and safety issues Social context Cost of transports Cost of medical treatment Avoiding loss of income Power dynamics Sick leave Working hours, overtime and days off Access to the official documents Fear of harassment and arrest by the police Forced to pay bribes Gender issues (violence) Factors that restrict migrants’ access to health care

7. Promoting HIV testing A community-based survey of sexual attitudes and lifestyles among 746 Africans in London found that 34% had ever tested for HIV. HIV testing resides almost exclusively within the domain of the professional sector. More innovative approaches to testing that encourage overlap with the popular and folk sectors may improve acceptability and help reduce stigma. Example - community-based voluntary counselling and testing, like that successfully implemented in Kenya (The Voluntary HIV Counselling and Testing Efficacy Study Group, 2000), with lay people trained as counsellors and rapid HIV tests performed in community settings.

8. Access to health care insurance and work permit Arrest by the police If needed, introduce a separate identification system for migrants on ART, so they do not need access to their health care insurance cards (or work permits) for ART Advise the patients to keep extra pills on them at all times, in case they are arrested and kept from their medicines Migrants – ARV therapy

9. Cost of treatment Discrimination Provide all parts of ART for free Support transportation costs Provide tools and guidelines for the delivery of ART to migrants Train health care staff on issues of cultural sensitivity and the relationship between migration and health Migrants – ARV therapy

10. Language and communication Social support Use high-quality professional translators Use peer educators who speak the patients’ own language, and can relate to the patient’s background and situation in the host country Use visual information Provide written information in the patients’ own language Provide peer support groups Eliminate social support as an inclusion criterion for ART (if present) Provide extra support and attention to adherence during follow-ups Migrants – ARV therapy

11. Limited sick leave/ability to attend follow-up appointments Give follow-up appointments after migrants’ working hours, so migrants do not have to miss work to attend them Show more flexibility and tolerance for migrants who miss regular appointments Provide ART at different type of clinics or community centres, and thereby reduce the distance to health care centres, thus making regular appointments less time consuming Provide ART where the migrants work and live (combine with directly observed therapy for tuberculosis if possible) Migrants – ARV therapy

12. Taking medicine at work Careful integration of ART into the patient’s daily life Provide education and information on adherence in the patient’s own language Create a good relationship and good cooperation between the patient and health care provider Keep medicines in discrete packages so they cannot be recognized by colleagues as HIV medication Migrants – ARV therapy