The complex relationship between migration and the spread of infectious disease is well exemplified in the case of HIV and AIDS. While South and South-West Asia has a low HIV prevalence (less than 1 per cent), it is the subregion with the second highest number of people infected with HIV after sub-Saharan Africa (UNDP and ILO 2010). Table 5 shows that India, the Islamic Republic of Iran, Pakistan and Nepal have the highest number of adults living with HIV and AIDS, respectively. However, data collection methods vary greatly between the countries in the subregion and this must be taken into account when making comparisons of HIV prevalence in the region (UNDP and ILO 2010).
A consistent finding across Asia is the strong influence that the type of migration has on risk of HIV infection. In most countries the highest rates of infection are recorded among highly mobile groups, such as truck drivers, fishermen and itinerant workers (Chantavanich and others 2000). In Nepal, seasonal labour migrants to India accounted for 46 per cent of the estimated HIV cases reported in 2005 (UNAIDS 2008).
However, as cautioned in the report, HIV/AIDS and Mobility in South Asia (UNDP and ILO 2010), discussions of HIV and migration must take into account the fact that migrant workers are often subject to mandatory or routine HIV testing, both before their departure and while abroad, and this significantly biases any comparison of HIV prevalence between migrants and the general population who in general are not routinely tested. Despite this reporting bias, the fact that significant numbers of people living with HIV become infected while working abroad clearly demonstrates that there is a gap in current measures to tackle HIV.
An Integrated Biological and Behavioural Surveillance Survey (IBBSS) conducted in 2008 of 360 male migrant workers from the Western and Mid- to Far-Western development regions of Nepal4 found that they were almost four times more likely to use a female sex worker when they were in India than in Nepal (New ERA and STD/AIDS Counselling and Training Services 2008). While reported awareness of HIV was high among the male migrants, between 20 and 33 per cent had engaged in unprotected sex with a female sex worker while in India. Of further concern is the fact that spouses and female partners of migrant workers account for approximately 20 per cent of adult HIV infection in Nepal (UNAIDS 2008).
India has the highest number of people living with HIV in the region and is also the largest country of origin for migrant workers in Asia (UNAIDS 2009). However, returning migrant workers are not routinely tested for HIV and as such, no data are available for this group. Studies have, however, indicated a higher incidence of the disease among people returning from overseas (www.keralamonitor.com 2009).
There is a complex linkage between migration, the commercial sex industry and infectious disease, as explained in the Monitoring the AIDS Pandemic’s (MAP) 2004 Report on Aids in Asia which makes three crucial points on this relationship:
- “In Asia more people engage in commercial sex than in any other behaviour that carries high risk of HIV infection. Indeed most new infections in the continent are still contracted during paid sex” (MAP Network 2004, p. 4).
- “The women at highest risk are those who migrate specifically to sell sex in large cities where demand is high” (MAP Network 2004, p. 72).
- “Sex workers also move around, since their earnings tend to be better when they are new to an area and drop as they become familiar and no longer satisfy clients’ preference for variety and novelty” (MAP Network, 2004 p. 72).
In addition, Hugo (2010) has pointed out that the commercial sex industry is concentrated in locations where there are large numbers of circular migrants such as cities, border crossing points, construction and mining sites, plantations, tourist destinations and transport corridors. This highlights the important nexus between migration, HIV and the commercial sex industry. Sex workers are often placed in powerless situations in which they cannot use condoms and therefore often have higher prevalence of HIV infection than the general population.
The fact that many migrants are unaware of AIDS and continue to remain so even after testing HIV positive, indicates a lack of support services and treatment for STIs, including HIV, throughout the migration cycle. The development, implementation and enforcement of a comprehensive migration policy at the national and regional level represent a vital first step toward effective protection of South and South-West Asian migrant workers.
As suggested in a report from the Commission on AIDS in Asia, “the future of Asia’s epidemics depends to a considerable extent on what happens to men’s incomes and their mobility outside family settings. Men who have disposable income, and who travel or migrate-to-work opportunities, provide most of the demand for commercial sex. If countries in Asia continue to experience rapid economic growth and men’s incomes continue to rise, the demand for commercial sex in the region is also likely to rise” (Commission on AIDS in Asia 2008, p. 58).
However the report also states that generalizations can be misleading because a significant number of migrants move with their partners, and are less likely to engage in HIV-related risk-taking behaviour. In addition, research from China has shown that conservative social norms survive longer among migrants than is commonly thought, such as the view that paying for sex is seen as unacceptable (Hesketh and others 2006). It is therefore not the case that all migrants are necessarily at higher risk of HIV infection (Commission on AIDS in Asia 2008).
4 Nepal is divided in to five development regions, namely Far-Western, Mid-Western, Western, Central and Eastern.