Access to HIV care and treatment for migrants between Lesotho and South Africa: a mixed methods study

Access to HIV care and treatment for migrants between Lesotho and South Africa: a mixed methods... Background: HIV treatment and care for migrants is affected by their mobility and interaction with HIV treatment programs and health care systems in different countries. To assess healthcare needs, preferences and accessibility barriers of HIV-infected migrant populations in high HIV burden, borderland districts of Lesotho. Methods: We selected 15 health facilities accessed by high patient volumes in three districts of Maseru, Leribe and Mafeteng. We used a mixed methods approach by administering a survey questionnaire to consenting HIV infected individuals on anti-retroviral therapy (ART) and utilizing a purposive sampling procedure to recruit health care providers for qualitative in-depth interviews across facilities. Results: Out of 524 HIV-infected migrants enrolled in the study, 315 (60.1%) were from urban and 209 (39.9%) from rural sites. Of these, 344 (65.6%) were women, 375 (71.6%) were aged between 26 and 45 years and 240 (45.8%) were domestic workers. A total of 486 (92.7%) preferred to collect their medications primarily in Lesotho compared to South Africa. From 506 who responded to the question on preferred dispensing intervals, 63.1% (n =319) preferred 5– 6 month ARV refills, 30.2% (n =153) chose 3–4 month refills and only 6.7% (n = 34) opted for the standard-of-care 1– 2 month refills. A total of 126 (24.4%) defaulted on their treatment and the primary reason for defaulting was failure to get to Lesotho to collect medication (59.5%, 75/126). Treatment default rates were higher in urban than rural areas (28.3% versus 18.4%, p = 0.011). Service providers indicated a lack of transfer letters as the major drawback in facilitating care and treatment for migrants, followed by discrimination based on nationality or language. Service providers indicated that most patients preferred all treatment services to be rendered in Lesotho, as they perceive the treatment provided in South Africa to be different often less strong or with more serious side effects. Conclusion: Existing healthcare systems in both South Africa and Lesotho experience challenges in providing proper care and treatment for HIV infected migrants. A need for a differentiated model of ART delivery to HIV infected migrants that allows for multi-month scripting and dispensing is warranted. Keywords: HIV care and treatment, Migrants, ART, Lesotho, South Africa, Multi month scripting and dispensing * Correspondence: alfred.musekiwa@gmail.com EQUIP – Innovation for Health, 1006 Lenchen Avenue North, Centurion, South Africa Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Faturiyele et al. BMC Public Health (2018) 18:668 Page 2 of 10 Background populations with customized and targeted interventions, in- Globally, it is estimated that there were 36.7 [30.8–42.9] cluding mobile populations, migrants, and undocumented million people living with HIV (PLHIV) in 2016, with two foreigners. In particular, the proposed interventions include thirds from Sub-Saharan Africa [1]. South Africa has the strengthening cross-border collaborations with neighbouring highest number of PLHIV estimated at 7.1 [6.4–7.8] mil- countries and other stakeholders [10]. Furthermore, the lion, although its prevalence of 18.9% [16.6–21.0%] is South African Constitution provides the right of access to lower than Swaziland and Lesotho, which bear the highest health care to all South African residents including migrants HIV prevalence estimates in the world at 27.2% [24.9– and, in particular, the National Department of Health issued 29.1%] and 25.0% [22.7–26.5%], respectively. Lesotho had a memo in September 2007 to clarify that refugees and asy- 330,000 [300000–360,000] PLHIV in 2016 [2]. lum seekers should be given equal access to ART as citizens The United Nations Joint Programme on HIV and AIDS [11]. However, irrespective of this progressive legislation (UNAIDS) introduced the 90–90-90 targets to reduce the affording migrants and non-nationals the right to access of burden of HIV/AIDS globally. This translates to the follow- health-care, there is lack of effective response to migration ing targets to be reached by 2020: 90% of all PLHIV will and health, especially in Johannesburg, which is home to a know their HIV status; 90% of all people diagnosed with diverse of migrants from Southern Africa [12], including HIV infection will receive antiretroviral therapy (ART), and Lesotho where most citizens migrate to seek jobs which are 90% of all people on ART will achieve viral suppression [3]. not easily available in their country. In this study, we assessed The UNAIDS Report 2017 show that, in Lesotho, 72% of healthcare needs, preferences and accessibility barriers of all PLHIV knew their status and 74% of these were on ART HIV-infected migrant populations in high HIV burden, bor- [4]. The results of the recent Lesotho Population-based derland districts of Lesotho. Furthermore, we assessed ser- HIV Impact Assessments (PHIA) survey reveal that 68% of vice providers’ knowledge around healthcare services PLHIV aged 15–59 years were virally suppressed [5]. While provision to migrant HIV patient populations. The findings it seems that Lesotho is on track in achieving the 90–90-90 of this study are needed to inform the design of targeted in- targets, innovative interventions are still needed especially terventions that can help Lesotho reach its 90–90-90 targets. as we are fast approaching the target year of 2020. To meet the UNAIDS 90–90-90 targets, marginalized Methods subpopulations such as migrants need to be reached. Study design, population and setting HIV-infected migrants interact with HIV treatment pro- We used a cross-sectional survey design to assess needs, grams and healthcare systems in different countries and preferences and barriers to HIV care and treatment among this negatively impacts the success of the HIV treatment HIV-infected migrants from 15 facilities in Lesotho. In this cascade [6]. HIV treatment requires strict adherence to study, we defined a migrant as a Lesotho national who is prevent drug resistance and treatment failure; however, currently living or has been living in South Africa for at migrants often default in their treatment [7], due to fac- least three consecutive weeks in the past six months. tors such as legal and administrative issues limiting access Lesotho is a small landlocked country surrounded by to treatment for foreign nationals, language and cultural South Africa. It covers an area of 30,355 km with an esti- barriers, failure to afford transport costs to collect medica- mated population slightly above 2.2 million in 2017. The tions, discrimination from healthcare providers in foreign gross domestic product per capita for Lesotho was countries, and the lack of protocols that allow continuity US$2808.20 in 2016 and its economy relies on remittances of HIV care across borders of neighbouring countries [8]. from migrant labourers who mainly work in neighbouring The Policy Framework for Population Mobility and Com- South Africa. It is divided into 10 districts of which municable Diseases in the Southern African Development Maseru is the country’s capital city and about 27.3% of the Community (SADC), from which South Africa and Lesotho population is urban as of 2015. are member states, acknowledges gaps in plans and strategies We focused on three borderland districts of Lesotho for controlling communicable diseases in the region, includ- where migration flows are thought to be the highest, tar- ing HIV/AIDS. The particular gaps and barriers include geting high patients’ volume health facilities in Maseru, higher fees for migrants, lack of information on where the Leribe and Mafeteng. The geographic distribution of the services are provided, health care providers not willing to selected sites in the three districts are indicated by red provide long-time treatment such as ART, differing treat- dots on the map (Fig. 1). The facilities ranged from ment protocols between countries, reluctance of health care clinics, health care centres, to hospitals. providers in dealing with undocumented migrants, and under-resourced health care systems in either source or des- tination country leading to lack of sufficient drugs [9]. Goal 3 Survey sampling size and sampling allocation of South Africa’s National Strategic Plan (NSP) for HIV, TB Facilities were selected among high-volume ART sites, and STIs 2017–2022 is to reach all key and vulnerable using a non-probabilistic quota sampling methodology Faturiyele et al. BMC Public Health (2018) 18:668 Page 3 of 10 Fig. 1 Map of Lesotho showing 15 health facilities included in HIV-infected migrant survey, 2016 with proportional allocation across groups, based on dis- physicians, nurses, pharmacists, or counsellors). In order to trict and urban versus rural catchment area. prevent skewed results, only one cadre per type was selected at each facility: this approach ensured sufficient representa- Data collection and analysis tiveness within the sample of service providers. Service pro- HIV-infected individuals who self-identified as migrants were viders as such identified were interviewed in either English asked to complete the actual survey, which included ques- or Sesotho by a trained English or Sesotho speaker, accord- tions on needs, preferences, and experienced barriers to ing to their preferences. accessing healthcare services, as well as socio-demographic Data were analysed using STATA version 15 and indicators such as occupation, age and gender. Survey ques- NVIVO for quantitative and qualitative data, respectively. tionnaires were administered within the premises of the 15 Descriptive statistics were used to summarize the data, selected facilities in the districts of Maseru, Leribe and Mafe- utilizing frequency distribution tables, bar and pie charts teng, by either nurses, pharmacy personnel, or counsellors, to visualize the data. Association between categorical vari- depending on the processes in place at each facility. Data col- ables was tested using the Chi-square test or Fisher’sexact lection was undertaken during two consecutive weeks over test, where expected frequency was less than 5. P-value of the Easter holidays, at which time most HIV infected mi- less than 0.05 was considered statistically significant. For grants return home to Lesotho to collect their antiretroviral the qualitative component, interviews were recorded digit- (ARV) medications. As for the qualitative component, pur- ally, and the interviewer captured written notes during the posive sampling was used to recruit health care providers for interview. The interviewer used an interview guide and in-depth interviews across facilities. Two service providers at were trained to pursue new themes that came up during each facility were identified among those with highest inter- the discussion, in order to explore areas of interest to the action with HIV-positive patients on ART (e.g. clinicians, respondent and the interviewer. Faturiyele et al. BMC Public Health (2018) 18:668 Page 4 of 10 Results could not afford transport costs, 29.4% (n = 37) did not A total of 2784 HIV-infected patients on ART were surveyed know where to get ARV’s, 23.8% (n =30) were afraid be- at 15 selected facilities over a period of two weeks (Table 1). cause they were not legally registered, 19.8% (n =25) had Of the total respondents, 524 (18.8%) self-reported as be- other reasons, 15.1% (n = 19) said that their ARV regimen ing migrants. Most of the 524 HIV-infected migrants were was not available at the facility they visited, 14.3% (n =18) from Maseru (n = 217, 41.4%), followed by Leribe (n = 183, were being charged for the ARVs, and 11.1% (n = 14) were 34.9%) and Mafeteng (n = 124, 23.7%) districts of Lesotho. refused service (Fig. 2). Themajoritywerefromurbanareas(n = 315, 60.1%), Out of the 524 HIV infected migrants, the barriers to women (n = 344, 65.7%), aged 26–45 years (n = 375, 71.6%), getting ART while in South Africa included the follow- and domestic workers (n = 240, 45.8%). Rural areas had sig- ing: 35.7% (n = 187) did not afford transport costs; 23.7% nificantly higher percentage of women (69.4% versus 63.2%, (n = 124) did not know where to get ARV’s, 19.3% (n = p = 0.047) and more domestic workers (58.9% versus 37.1%, 101) were afraid because of not being legally registered p < 0.001) than urban areas. There was no significant differ- in South Africa; 15.8% (n = 83) felt discriminated as a ence in ages between rural and urban areas (p =0.585) foreigner, 8.6% (n = 45) were refused health service; 8.4% (Table 2). (n = 44) were afraid that the ARV’s would be confiscated Out of the 517 HIV-infected migrants for which at the border; 6.1% (n = 32) had their ARV’s regimen not defaulting status was known, 126 (24.4%) had defaulted available at facility; and 5.9% (n = 31) had to pay for on their treatment. We describe the demographic health services (Table 4). characteristics by default status (Table 3). Out of the 524 migrants, 93% (n = 486) preferred to col- Default rates were significantly higher in urban areas lect their medications primarily in Lesotho. From 506 mi- compared to rural areas (28.3% versus 18.4%, p =0.011). This grants who responded to the question regarding preferred is also reflected in the differences between districts (p < frequency of collecting ARV’s, 6.7% (n = 34) opted for the 0.001) due to the different number of urban and rural standard-of-care 1–2 month ARV refills whereas 30.2% facilities in the different districts. There was no significant (n = 153) and 63.1% (n =319) indicated a preference for difference in default rates between different genders (p = 3–4 month and 5–6 month refills, respectively (Fig. 3). 0.567), ages (p = 0.081), and occupation (p =0.322). Quotes under various themes from the in depth inter- We also asked the 126 migrants who defaulted regarding views with healthcare service providers are summarised their reasons for defaulting on ART while in South Africa: below and they confirm and support the quantitative 59.5% (n = 75) could not get to Lesotho, 51.6% (n = 65) findings. Table 1 Sample distribution for HIV-infected migrants enrolled in the study, by site, Lesotho, 2016 District Location Health Facility Patients on ART N Surveyed N (%) Migrants N (%) Leribe Rural Matlameng H/C 315 30 (9.5) 7 (23.3) Leribe Rural Pontmain H/C 1337 119 (8.9) 50 (42.0) Leribe Rural Seshote H/C 1136 70 (6.2) 11 (15.7) Leribe Urban Maputsoe Filter Clinic 2074 347 (16.7) 100 (28.8) Leribe Urban Maputsoe SDA H/C 1539 260 (16.9) 15 (5.8) Mafeteng Rural Matelile H/C 667 99 (14.8) 10 (10.1) Mafeteng Rural Ts’akholo H/C 591 235 (39.8) 24 (10.2) Mafeteng Urban Mafeteng Hospital 3277 424 (12.9) 90 (21.2) Maseru Rural Nazareth H/C 1960 441 (22.5) 26 (5.9) Maseru Rural Scott Hospital 1239 136 (11.0) 16 (11.8) Maseru Urban Domiciliary H/C 1550 28 (1.8) 28 (100) Maseru Rural Paki H/C 1185 61 (5.1) 52 (85.2) Maseru Urban RLDF H/C 1247 243 (19.5) 34 (14.0) Maseru Rural St Joseph Hospital 1399 13 (0.9) 13 (100) Maseru Urban Thamae H/C 2178 278 (12.8) 48 (17.3) TOTAL 21,694 2784 (12.8) 524 (18.8) H/C – Health Care; At Domiciliary H/C and St Joseph Hospital, surveys were administered only to self-reported migrants; At Paki H/C the same held true, except for the last three days of data collection Faturiyele et al. BMC Public Health (2018) 18:668 Page 5 of 10 Table 2 Socio-demographics of HIV-infected Lesotho migrants Table 3 Socio-demographics of HIV-infected Lesotho migrants by location by defaulting status Characteristic All N Urban N Rural N P-value* Characteristic All N Defaulted Not defaulted P-value** (col %) (col %) (col %) N (row %) N (row%) Patients 524 315 209 All patients* 517 126 391 Sex 0.047 Location 0.011 Men 150 (28.6) 101 (32.0) 49 (23.4) Rural 206 38 (18.4) 168 (81.6) Women 344 (65.7) 199 (63.2) 145 (69.4) Urban 311 88 (28.3) 223 (71.7) Unknown 30 (5.7) 15 (4.8) 15 (7.2) District < 0.001 Age (years) 0.585 Leribe 181 34 (18.8) 147 (81.2) 18–25 38 (7.3) 20 (6.3) 18 (8.6) Mafeteng 123 49 (39.8) 74 (60.2) 26–35 173 (33.0) 105 (33.3) 68 (32.5) Maseru 213 43 (20.2) 170 (79.8) 36–45 202 (38.6) 121 (38.4) 81 (38.8) Sex 0.567 46–55 71 (13.5) 42 (13.3) 29 (13.9) Men 148 35 (23.6) 113 (76.4) 55+ 17 (3.2) 13 (4.1) 4 (1.9) Women 341 89 (26.1) 252 (73.9) Unknown 23 (4.4) 14 (4.4) 9 (4.3) Unknown 28 2 (7.1) 26 (92.9) Occupation < 0.001 Age (years) 0.081 Domestic worker 240 (45.8) 117 (37.1) 123 (58.9) 18–25 37 3 (8.1) 34 (91.9) Construction worker 87 (16.6) 60 (19.0) 27 (12.9) 26–35 172 45 (26.2) 127 (73.8) Textile worker 52 (9.9) 43 (13.7) 9 (4.3) 36–45 200 53 (26.5) 147 (73.5) Farmer 24 (4.6) 19 (6.0) 5 (2.4) 46–55 70 19 (27.1) 51 (72.9) Miner 23 (4.4) 9 (2.9) 14 (6.7) 55+ 17 2 (11.8) 15 (88.2) Health-care professional 2 (0.4) 2 (0.6) 0 (0.0) Unknown 21 4 (19.0) 17 (81.0) Student 6 (1.1) 3 (1.0) 3 (1.4) Occupation 0.322 Other occupation 49 (9.4) 32 (10.2) 17 (8.1) Domestic worker 238 67 (28.1) 171 (71.9) Unknown 41 (7.8) 30 (9.5) 11 (5.3) Construction worker 85 21 (24.7) 64 (75.3) *P-value excludes unknown Textile worker 52 15 (28.8) 37 (71.2) Farmer 23 5 (21.7) 18 (78.3) Miner 23 4 (17.4) 19 (82.6) 1. Cultural and nationality-based discrimination Health-care professional 2 2 (100.0) 0 (0.0) Student 6 1 (16.7) 5 (83.3) “They say they even face discrimination in some of Other occupation 49 9 (18.4) 40 (81.6) the health facilities just because they are foreigners Unknown 39 2 (5.1) 37 (94.9) and some travel very far in order to access services *7 had no default status, ** P-value excludes unknown while others do not know where to go at all for example those that work at farms.” “There are several challenges: most ladies that work as Pharmacy Technician, St. Joseph hospital, Maseru housekeepers fear possible discriminatory attitudes of their employers because they know that they will be “Some [migrant workers] say that they live very far expelled as soon as they are found to be HIV positive.” from the health centres, some believe that the HIV treatment from South Africa is not the same as the Pharmacy Technician, St. Joseph hospital, Maseru one provided in Lesotho (the side effects are extreme), some say that people from Lesotho are not allowed “They have issues accessing health care services to access the services.” because most of them do not have permanent jobs and they can be fired any time. They have been Nurse, St. Joseph hospital, Maseru discriminated against so disclosing their statuses have become a problem.” 2. Experienced barriers: Discrimination based on HIV status Nurse, LDF health centre, Maseru Faturiyele et al. BMC Public Health (2018) 18:668 Page 6 of 10 Fig. 2 Reasons for defaulting ART amongst HIV infected Lesotho migrants 3. Experienced barriers: Transport costs access healthcare services abroad and most of the times they do not have such documents.” “They [migrant workers] mainly complain about transport costs as they come here for refills. They say Professional Counsellor, Maputsoe filter clinic, Leribe they cannot afford to take days off because it reduces their wages.” “Sometimes when they [migrant workers] get to the health centres, they are normally required to present Professional Counsellor, Maputsoe filter clinic, Leribe some legal documents which allow them to stay in the foreign country and it may happen that some of them “It is mainly transport costs and they are always might not have it, while others are required to present required to present legal documents like passport their bukana [health booklets] which they may have with work permits.” left behind.” Pharmacy Technician, Domiciliary health centre, Nurse, Matelile health centre, Mafeteng Maseru 4. Experienced barriers: Legal requirements and referring abroad “Furthermore, they [migrant workers] are required [to produce] the legal documents and to provide reasons why they are in the foreign countries if they want to Table 4 Barriers to getting ART in SA among Lesotho migrations Barrier N % Cannot afford transport costs 187 35.7 Do not know where to get ARVs 124 23.7 No barrier 174 33.2 Afraid if not legally registered in South Africa 101 19.3 Feel discriminated as foreigner 83 15.8 Refused health services 45 8.6 Afraid medications confiscated at the border 44 8.4 ARVs regimen not available at facility 32 6.1 Fig. 3 Preferred months of ARV’s refills amongst HIV infected Lesotho migrants Have to pay for health services 31 5.9 Faturiyele et al. BMC Public Health (2018) 18:668 Page 7 of 10 “Some [migrant workers] say that they are being Nurse, Thamae health centre, Maseru refused to access their ARV treatment if they do not present referral letters.” 8. Other proposed interventions for improving migrants’ treatment adherence Counsellor, Matelile health centre, Mafeteng “We should increase treatment supply so that they 5. Preferences on ARVs collection site: Perceived do not come often to the health facilities. Also there treatment differences should be a well written document focusing on ART patients flow. There should also be a binding legal “I normally hear them [migrant workers] complaining document between the two countries to curb racism.” about the severe side effects that are incurred by using ARVs from South Africa. They say that they Adherence Counsellor, LDF health centre, Maseru disfigure their bodies, causing them to have Kyphosis.” “I suggest that we provide them with treatment to last them six months because they incur so much Counsellor, Matelile health centre, Mafeteng transport costs having to come for re fills every month.” “They [migrant workers] prefer Lesotho since there are not as many barriers as in South Africa. Also they Pharmacy Technician, St. Joseph hospital, Maseru believe the medication from Lesotho is much stronger than the one supplied in South Africa.” Discussion Nurse, Paki health centre, Maseru The objective of this study was to assess healthcare needs, preferences and accessibility barriers of HIV-infected mi- 6. Current processes for tracking patients who are grant populations in high HIV burden, borderland dis- migrants tricts of Lesotho. We surveyed 524 HIV-infected migrants from 15 facilities in the districts of Maseru, Leribe, and “We use the appointment book to assess whether they Mafeteng. Most of the migrants were from urban areas are adhering to their appointments because they usually (60.1%), were women (65.6%), aged 26–45 years (71.6%), do not give their foreign country of destination contacts. and domestic workers (45.8%). Almost a quarter of these If we need a patient desperately we call their treatment migrants (n = 126) had defaulted on ART with default supporter and ask them to inform our patients that we rates significantly higher in urban than rural areas. The would like to see them as soon as possible.” barriers to getting ART while in South Africa ranged from failing to get to Lesotho, not affording transport costs, not Nurse, LDF health centre, Maseru knowing where to get treatment, not being legally regis- tered in South Africa, ARV regimen not being available at “There are no specific systems in place that we use facility, and being discriminated against by healthcare pro- to mark our migrant workers who are on ART.” viders because they were foreigners. Most of the migrants (93%) preferred to collect their medications primarily in Adherence Counsellor, Tsh’akolo health centre Lesotho and in terms of the frequency of collecting ARV’s, 6.7% opted for the standard-of-care 1–2month 7. Health passports and ART road map as new anti-retroviral (ARV) refills whereas 30.2 and 63.1% indi- proposed tools for migrants cated a preference for 3–4 month and 5–6 month refills, respectively. Service providers indicated a lack of transfer “The ART cards are kept by the health facilities and letters, or poor medical history related to ART treatment patients are only provided with health booklets as the major drawback in facilitating care and treatment (bukana) which contain very brief information for migrants followed by discrimination based on nation- about the patients’ status unlike the ART card.” ality or language. Regarding migrants’ preferred ARVs col- lection site, service providers indicated that most patients Pharmacist, Mafeteng hospital, Mafeteng preferred all treatment services to be rendered in Lesotho, as they perceive the treatment provided in South Africa to “It may be beneficial for them to have their health be different often less strong or with more serious side ef- passport ready in case of unplanned or sudden fects. A need for mHealth systems or telephone tracking migration.” to track patients abroad was suggested in combination Faturiyele et al. BMC Public Health (2018) 18:668 Page 8 of 10 with multi-month dispensing of ART and harmonizing due to not being legally documented, coupled with lan- documentation among neighbouring states, and making guage barriers. Some migrants also claimed that they are referral processes easier. refused service in South Africa because of being a for- Several studies on HIV-infected migrants found signifi- eigner. Some said that they are afraid that their medication cantly higher default rates among migrants compared to would be confiscated at the border between Lesotho and non-migrants [6], including a community cohort study in South Africa. Lesotho [7]. Our study found a high default rate of almost This study had some limitations. As this is a 25% among migrants. However we did not collect data to cross-sectional study, we cannot determine cause and effect; compare with non-migrants. Another study found higher de- and therefore conclusions from this study could be biased. fault rates among migrants compared to Spanish born popu- The study is geographically limited to the three districts in lations (9.2% versus 6.3%) [13]. On the contrary, a study in Lesotho where most of the migrant population is thought to Johannesburg, South Africa, found default rates to be signifi- reside; hence, it may not capture dynamics occurring in cantly lower in foreigners compared to local citizens (12% other cross-border regions of the country. The assumption versus 31%) [14]. This implies that our default rate was was made that rural high-volume sites within a district serve higher compared to studies from other countries, thereby similar populations and that urban high-volume sites within giving hope that there is potential to reduce the default rate a district serve similar populations as well: should this as- in Lesotho. sumption not hold true, skewed results may occur if the Thefactthatthe majority of themigrants werewomen population served by a certain facility presented characteris- speaks to the plight of women living with HIV who experi- tics that are significantly different from those of the other ence specific barriers to HIV treatment and care because of populations served by facilities in the same group. The study their gender identity and socially acceptable employment focusesmainlyonmigrantstoSouthAfrica anditisthere- pathways (such as domestic work) within the region’s polit- fore expected not to capture a marginal part of migration ical economy. The qualitative findings revealed that these flows from Lesotho to other countries. A non-probabilistic women find it difficult to disclose their HIV status for the sample for selecting high-volume ART facilities raises the fear of losing their jobs. As a result, they are unable to re- possibility that the responses may not be independent and quest leave to visit health care facilities to access their treat- potentially systematically different from a broader group of ment. There is therefore need to educate the HIV infected individuals. However, the large sample size utilized in this migrants regarding their sexual and reproductive health and study gives it enough statistical power to infer significant as- rights, as well as issues pertaining to gender based violence. sociations found in the paper. The barriers to receiving ART for migrants have also been well-documented. Barriers that we have identified in Conclusion this study such as legal and administrative issues, language In conclusion,wesurveyedHIV-infectedmigrants inthree barriers in communicating in the native language of the borderland districts of Lesotho and found a high ART de- host country, and failing to afford transport costs to return fault rate of almost 25%. We also identified barriers to acces- to the home country, have also been identified in a review sing ART, including lack of information on where to get article [6]. However, what is unique about this study is ARVs in South Africa, transport costs of travelling to that we have identified that the migrants in Lesotho prefer Lesotho to collect medications, legal and administrative bar- a multi-month (≥3) supply of medication to cater for them riers, and discrimination of migrants in foreign countries. while they are in South Africa. The current status quo is Also, most of the migrants preferred collecting their medica- that it is at the discretion of the healthcare professionals tions in Lesotho and indicated preference of ≥3months’ sup- to give the migrants ARV’s covering more than the ply of ARV refills to cater for when they are in South Africa. standard-of-care 1–2months’ supply. The healthcare pro- Service providers’ perspectives indicate the need to modify viders in Lesotho also provide the migrants with transfer and re-structure HIV care among migrants. Specifically, in letters to allow them to continue their treatment in South relation to differentiated model of care that will support Africa; however, most migrants indicated that they do not multi-month supply of treatment, tracing and mHealth plat- know where to obtain the ARV’s in South Africa. The fact forms to improve various HIV outcomes including retention, that 29.7% of the migrants defaulted in ART because they adherence, virologic suppression and ultimately mortality. did not know where to get treatment in South Africa We recommend a differentiated model of care specific speaks to a lack of information that could support mi- to HIV infected migrants such as a multi-month scripting grants in accessing treatment and care when they are away and dispensing of treatment. We also recommend the from home. There is therefore need to promote education harmonization of treatment protocols for ART between and distribution of pamplets and notices at country bor- the Lesotho and South African governments and the edu- ders to educate migrants regarding where they are able to cation and sharing of accessible information across SADC access treatment. There is also the fear of discrimination borders on resources, health facilities, and health systems Faturiyele et al. BMC Public Health (2018) 18:668 Page 9 of 10 relevant to migrants. We also emphasize that both coun- PTP Conceptualization, writing the manuscript, literature search, and data interpretation. All authors read and approved the final manuscript. tries should adhere to the United Nations High Commis- sioner for Refugees recommendations that ART should Ethics approval and consent to participate not be withheld from displaced persons [14]. We also rec- Ethics approval for the study was obtained from the Lesotho Ministry of ommend a qualitative study on the HIV infected migrants Health Research and Ethics Committee, Maseru, Lesotho, with Reference Number (ID50–2017). All the enrolled migrants provided written informed to obtain an in-depth understanding of the issues sur- consent to participate in the study. rounding the barriers to receiving ART. In order to ensure confidentiality, data were stored in locked cabinets and all Since there is such limited data on migrant populations databases were password protected and only authorized personnel were granted permission to access participant information. Identifying information in this SADC region, health systems and HIV treatment such as participant names, addresses, phone numbers and ID/passport and care, we advocate for evidence-based policy change numbers were never collected and were not part of the analysis dataset. that would meet the healthcare needs of migrant popula- This study poses no risk to the participants. Although there was no direct benefits for the participants, the findings of this study will be used to further tions in the region. This can include longer-term policy scientific knowledge, and relevant stakeholders will be informed so that the change that align with regional strategies and frameworks, health of the HIV infected migrants can be improved. and actions such as training all staff on migration, mobility and health, coordination, and migrant-awareness response Competing interests to HIV treatment and care. The authors declare that they have no competing interests. Additional file Publisher’sNote Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Additional file 1: Survey data from 524 HIV infected migrants, Lesotho, 2016. (XLSX 44 kb) Author details 1 2 EQUIP-Innovation for Health, Maseru, Lesotho. Ministry of Health, Maseru, Lesotho. EQUIP – Innovation for Health, 1006 Lenchen Avenue North, Abbreviations Centurion, South Africa. Department of Human Nutrition and Dietetics, AIDS: Acquired Immuno-Deficiency Syndrome; ART: Antiretroviral Treatment; Sefako Makgatho Health Sciences University, Ga-Rankuwa, Pretoria, South ARV: Antiretrovirals; EQUIP: Evaluation and Quality Improvement Program; H/ Africa. C: Health Centre; HIV: Human Immuno-Deficiency Virus; IOM: International Organization for Migration; NSP: National Strategic Plan; PHIA: Population-based Received: 20 December 2017 Accepted: 23 May 2018 HIV Impact Assessments; PLHIV: People Living with HIV; SADC: Southern African Development Community; SANAC: South African National AIDS Council; UNAIDS: The United Nations Joint Programme on HIV and AIDS; USAID: United States Agency for International Development References 1. WHO Glob Health Observatory (GHO) data. Available from http://www.who. Acknowledgements int/gho/hiv/en/. Accessed 2 Oct 2017. The Ministry of Health Lesotho for granting ethical clearance and permission to 2. UNAIDS AIDSinfo. People living with HIV. Available from http://aidsinfo. use health facilities. We acknowledge all the individuals who participated in this unaids.org/. Accessed 2 Oct 2017. study. 3. UNAIDS 90–90–90 - An ambitious treatment target to help end the AIDS epidemic. Available from http://www.unaids.org/en/resources/documents/ 2017/90-90-90. Accessed 2 Oct 2017. Funding 4. UNAIDS UNAIDS Data 2017. Available from http://www.unaids.org/sites/ This work was supported by the U.S. Presidential Emergency Plan for AIDS default/files/media_asset/20170720_Data_book_2017_en.pdf. Accessed 2 Relief (PEPFAR), through United States Agency for International Development Oct 2017. (USAID) Cooperative Agreement Number AID-OAA-A-15-00070. USAID had 5. UNAIDS UNAIDS congratulates Lesotho and Uganda for progress towards no role in the design of the study and collection, analysis, and interpretation achieving their Fast-Track Targets. Available from http://www.unaids.org/en/ of data and in writing the manuscript. resources/presscentre/pressreleaseandstatementarchive/2017/september/ 20170920_PHIA. Accessed 2 Oct 2017. Availability of data and materials 6. Tanser F, Barnighausen T, Vandormael A, Dobra A. HIV treatment All data generated or analysed during this study are included in this cascade in migrants and mobile populations. Curr Opin HIV AIDS. published article (Additional file 1). 2015;10:430–8. 7. Bygrave H, Kranzer K, Hilderbrand K, Whittall J, Jouquet G, et al. Trends in Disclaimer loss to follow-up among migrant workers on antiretroviral therapy in a The findings and conclusions in this article are those of the authors and do community cohort in Lesotho. PLoS One. 2010;5:e13198. not necessarily represent the official position of PEPFAR, Department of 8. ECDC Migrant health: Access to HIV prevention, treatment and care for Health and Human Services, or the US government. migrant populations in EU/EEA countries. Available from https://ecdc. europa.eu/sites/portal/files/media/en/publications/Publications/0907_TER_ Authors’ contributions Migrant_health_HIV_Access_to_treatment.pdf. Accessed 4 Oct 2017. IF Leadership and oversight in protocol development, survey design, 9. SADC Policy Framework for Population Mobility and Communicable Implementation, data analysis, and manuscript writing. DK Data analysis, Diseases in the SADC Region. Available from http://www.arasa.info/files/ generating figures, and manuscript writing. KNS Protocol development, 6613/7574/3254/SADC_Policy_Framework_FINAL.pdf. Accessed 1 Apr 2018. implementation, analysis and manuscript writing. AM Manuscript writing, 10. SANAC South Africa's National Strategic Plan on HIV, TB and STIs 2017– data analysis, data interpretation, generating figures, and co-ordinating 2022. Available from http://sanac.org.za/wp-content/uploads/2017/05/NSP_ manuscript writing. MK Protocol development, survey implementation and FullDocument_FINAL.pdf. Accessed 1 Apr 2018. manuscript writing. MM Survey implementation, data collection and analysis 11. IOM Migrants' right to health in Southern Africa. Available from http://www. and manuscript writing. PM Writing and critically reviewing the manuscript. migration.org.za/wp-content/uploads/2017/08/Migrants-Right-to-Health-in- TX Protocol development, survey design, and critically reviewing the paper. Southern-Africapdf. Accessed 1 Apr 2018. Faturiyele et al. BMC Public Health (2018) 18:668 Page 10 of 10 12. Vearey J, Thomson K, Sommers T, Sprague C. Analysing local-level responses to migration and urban health in Hillbrow: the Johannesburg migrant health forum. BMC Public Health. 2017;17:427. 13. Reyes-Uruena J, Campbell C, Hernando C, Vives N, Folch C, et al. Differences between migrants and Spanish-born population through the HIV care cascade, Catalonia: an analysis using multiple data sources. Epidemiol Infect. 2017;145:1670–81. 14. McCarthy K, Chersich MF, Vearey J, Meyer-Rath G, Jaffer A, et al. Good treatment outcomes among foreigners receiving antiretroviral therapy in Johannesburg, South Africa. 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Access to HIV care and treatment for migrants between Lesotho and South Africa: a mixed methods study

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Medicine & Public Health; Public Health; Medicine/Public Health, general; Epidemiology; Environmental Health; Biostatistics; Vaccine
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Abstract

Background: HIV treatment and care for migrants is affected by their mobility and interaction with HIV treatment programs and health care systems in different countries. To assess healthcare needs, preferences and accessibility barriers of HIV-infected migrant populations in high HIV burden, borderland districts of Lesotho. Methods: We selected 15 health facilities accessed by high patient volumes in three districts of Maseru, Leribe and Mafeteng. We used a mixed methods approach by administering a survey questionnaire to consenting HIV infected individuals on anti-retroviral therapy (ART) and utilizing a purposive sampling procedure to recruit health care providers for qualitative in-depth interviews across facilities. Results: Out of 524 HIV-infected migrants enrolled in the study, 315 (60.1%) were from urban and 209 (39.9%) from rural sites. Of these, 344 (65.6%) were women, 375 (71.6%) were aged between 26 and 45 years and 240 (45.8%) were domestic workers. A total of 486 (92.7%) preferred to collect their medications primarily in Lesotho compared to South Africa. From 506 who responded to the question on preferred dispensing intervals, 63.1% (n =319) preferred 5– 6 month ARV refills, 30.2% (n =153) chose 3–4 month refills and only 6.7% (n = 34) opted for the standard-of-care 1– 2 month refills. A total of 126 (24.4%) defaulted on their treatment and the primary reason for defaulting was failure to get to Lesotho to collect medication (59.5%, 75/126). Treatment default rates were higher in urban than rural areas (28.3% versus 18.4%, p = 0.011). Service providers indicated a lack of transfer letters as the major drawback in facilitating care and treatment for migrants, followed by discrimination based on nationality or language. Service providers indicated that most patients preferred all treatment services to be rendered in Lesotho, as they perceive the treatment provided in South Africa to be different often less strong or with more serious side effects. Conclusion: Existing healthcare systems in both South Africa and Lesotho experience challenges in providing proper care and treatment for HIV infected migrants. A need for a differentiated model of ART delivery to HIV infected migrants that allows for multi-month scripting and dispensing is warranted. Keywords: HIV care and treatment, Migrants, ART, Lesotho, South Africa, Multi month scripting and dispensing * Correspondence: alfred.musekiwa@gmail.com EQUIP – Innovation for Health, 1006 Lenchen Avenue North, Centurion, South Africa Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Faturiyele et al. BMC Public Health (2018) 18:668 Page 2 of 10 Background populations with customized and targeted interventions, in- Globally, it is estimated that there were 36.7 [30.8–42.9] cluding mobile populations, migrants, and undocumented million people living with HIV (PLHIV) in 2016, with two foreigners. In particular, the proposed interventions include thirds from Sub-Saharan Africa [1]. South Africa has the strengthening cross-border collaborations with neighbouring highest number of PLHIV estimated at 7.1 [6.4–7.8] mil- countries and other stakeholders [10]. Furthermore, the lion, although its prevalence of 18.9% [16.6–21.0%] is South African Constitution provides the right of access to lower than Swaziland and Lesotho, which bear the highest health care to all South African residents including migrants HIV prevalence estimates in the world at 27.2% [24.9– and, in particular, the National Department of Health issued 29.1%] and 25.0% [22.7–26.5%], respectively. Lesotho had a memo in September 2007 to clarify that refugees and asy- 330,000 [300000–360,000] PLHIV in 2016 [2]. lum seekers should be given equal access to ART as citizens The United Nations Joint Programme on HIV and AIDS [11]. However, irrespective of this progressive legislation (UNAIDS) introduced the 90–90-90 targets to reduce the affording migrants and non-nationals the right to access of burden of HIV/AIDS globally. This translates to the follow- health-care, there is lack of effective response to migration ing targets to be reached by 2020: 90% of all PLHIV will and health, especially in Johannesburg, which is home to a know their HIV status; 90% of all people diagnosed with diverse of migrants from Southern Africa [12], including HIV infection will receive antiretroviral therapy (ART), and Lesotho where most citizens migrate to seek jobs which are 90% of all people on ART will achieve viral suppression [3]. not easily available in their country. In this study, we assessed The UNAIDS Report 2017 show that, in Lesotho, 72% of healthcare needs, preferences and accessibility barriers of all PLHIV knew their status and 74% of these were on ART HIV-infected migrant populations in high HIV burden, bor- [4]. The results of the recent Lesotho Population-based derland districts of Lesotho. Furthermore, we assessed ser- HIV Impact Assessments (PHIA) survey reveal that 68% of vice providers’ knowledge around healthcare services PLHIV aged 15–59 years were virally suppressed [5]. While provision to migrant HIV patient populations. The findings it seems that Lesotho is on track in achieving the 90–90-90 of this study are needed to inform the design of targeted in- targets, innovative interventions are still needed especially terventions that can help Lesotho reach its 90–90-90 targets. as we are fast approaching the target year of 2020. To meet the UNAIDS 90–90-90 targets, marginalized Methods subpopulations such as migrants need to be reached. Study design, population and setting HIV-infected migrants interact with HIV treatment pro- We used a cross-sectional survey design to assess needs, grams and healthcare systems in different countries and preferences and barriers to HIV care and treatment among this negatively impacts the success of the HIV treatment HIV-infected migrants from 15 facilities in Lesotho. In this cascade [6]. HIV treatment requires strict adherence to study, we defined a migrant as a Lesotho national who is prevent drug resistance and treatment failure; however, currently living or has been living in South Africa for at migrants often default in their treatment [7], due to fac- least three consecutive weeks in the past six months. tors such as legal and administrative issues limiting access Lesotho is a small landlocked country surrounded by to treatment for foreign nationals, language and cultural South Africa. It covers an area of 30,355 km with an esti- barriers, failure to afford transport costs to collect medica- mated population slightly above 2.2 million in 2017. The tions, discrimination from healthcare providers in foreign gross domestic product per capita for Lesotho was countries, and the lack of protocols that allow continuity US$2808.20 in 2016 and its economy relies on remittances of HIV care across borders of neighbouring countries [8]. from migrant labourers who mainly work in neighbouring The Policy Framework for Population Mobility and Com- South Africa. It is divided into 10 districts of which municable Diseases in the Southern African Development Maseru is the country’s capital city and about 27.3% of the Community (SADC), from which South Africa and Lesotho population is urban as of 2015. are member states, acknowledges gaps in plans and strategies We focused on three borderland districts of Lesotho for controlling communicable diseases in the region, includ- where migration flows are thought to be the highest, tar- ing HIV/AIDS. The particular gaps and barriers include geting high patients’ volume health facilities in Maseru, higher fees for migrants, lack of information on where the Leribe and Mafeteng. The geographic distribution of the services are provided, health care providers not willing to selected sites in the three districts are indicated by red provide long-time treatment such as ART, differing treat- dots on the map (Fig. 1). The facilities ranged from ment protocols between countries, reluctance of health care clinics, health care centres, to hospitals. providers in dealing with undocumented migrants, and under-resourced health care systems in either source or des- tination country leading to lack of sufficient drugs [9]. Goal 3 Survey sampling size and sampling allocation of South Africa’s National Strategic Plan (NSP) for HIV, TB Facilities were selected among high-volume ART sites, and STIs 2017–2022 is to reach all key and vulnerable using a non-probabilistic quota sampling methodology Faturiyele et al. BMC Public Health (2018) 18:668 Page 3 of 10 Fig. 1 Map of Lesotho showing 15 health facilities included in HIV-infected migrant survey, 2016 with proportional allocation across groups, based on dis- physicians, nurses, pharmacists, or counsellors). In order to trict and urban versus rural catchment area. prevent skewed results, only one cadre per type was selected at each facility: this approach ensured sufficient representa- Data collection and analysis tiveness within the sample of service providers. Service pro- HIV-infected individuals who self-identified as migrants were viders as such identified were interviewed in either English asked to complete the actual survey, which included ques- or Sesotho by a trained English or Sesotho speaker, accord- tions on needs, preferences, and experienced barriers to ing to their preferences. accessing healthcare services, as well as socio-demographic Data were analysed using STATA version 15 and indicators such as occupation, age and gender. Survey ques- NVIVO for quantitative and qualitative data, respectively. tionnaires were administered within the premises of the 15 Descriptive statistics were used to summarize the data, selected facilities in the districts of Maseru, Leribe and Mafe- utilizing frequency distribution tables, bar and pie charts teng, by either nurses, pharmacy personnel, or counsellors, to visualize the data. Association between categorical vari- depending on the processes in place at each facility. Data col- ables was tested using the Chi-square test or Fisher’sexact lection was undertaken during two consecutive weeks over test, where expected frequency was less than 5. P-value of the Easter holidays, at which time most HIV infected mi- less than 0.05 was considered statistically significant. For grants return home to Lesotho to collect their antiretroviral the qualitative component, interviews were recorded digit- (ARV) medications. As for the qualitative component, pur- ally, and the interviewer captured written notes during the posive sampling was used to recruit health care providers for interview. The interviewer used an interview guide and in-depth interviews across facilities. Two service providers at were trained to pursue new themes that came up during each facility were identified among those with highest inter- the discussion, in order to explore areas of interest to the action with HIV-positive patients on ART (e.g. clinicians, respondent and the interviewer. Faturiyele et al. BMC Public Health (2018) 18:668 Page 4 of 10 Results could not afford transport costs, 29.4% (n = 37) did not A total of 2784 HIV-infected patients on ART were surveyed know where to get ARV’s, 23.8% (n =30) were afraid be- at 15 selected facilities over a period of two weeks (Table 1). cause they were not legally registered, 19.8% (n =25) had Of the total respondents, 524 (18.8%) self-reported as be- other reasons, 15.1% (n = 19) said that their ARV regimen ing migrants. Most of the 524 HIV-infected migrants were was not available at the facility they visited, 14.3% (n =18) from Maseru (n = 217, 41.4%), followed by Leribe (n = 183, were being charged for the ARVs, and 11.1% (n = 14) were 34.9%) and Mafeteng (n = 124, 23.7%) districts of Lesotho. refused service (Fig. 2). Themajoritywerefromurbanareas(n = 315, 60.1%), Out of the 524 HIV infected migrants, the barriers to women (n = 344, 65.7%), aged 26–45 years (n = 375, 71.6%), getting ART while in South Africa included the follow- and domestic workers (n = 240, 45.8%). Rural areas had sig- ing: 35.7% (n = 187) did not afford transport costs; 23.7% nificantly higher percentage of women (69.4% versus 63.2%, (n = 124) did not know where to get ARV’s, 19.3% (n = p = 0.047) and more domestic workers (58.9% versus 37.1%, 101) were afraid because of not being legally registered p < 0.001) than urban areas. There was no significant differ- in South Africa; 15.8% (n = 83) felt discriminated as a ence in ages between rural and urban areas (p =0.585) foreigner, 8.6% (n = 45) were refused health service; 8.4% (Table 2). (n = 44) were afraid that the ARV’s would be confiscated Out of the 517 HIV-infected migrants for which at the border; 6.1% (n = 32) had their ARV’s regimen not defaulting status was known, 126 (24.4%) had defaulted available at facility; and 5.9% (n = 31) had to pay for on their treatment. We describe the demographic health services (Table 4). characteristics by default status (Table 3). Out of the 524 migrants, 93% (n = 486) preferred to col- Default rates were significantly higher in urban areas lect their medications primarily in Lesotho. From 506 mi- compared to rural areas (28.3% versus 18.4%, p =0.011). This grants who responded to the question regarding preferred is also reflected in the differences between districts (p < frequency of collecting ARV’s, 6.7% (n = 34) opted for the 0.001) due to the different number of urban and rural standard-of-care 1–2 month ARV refills whereas 30.2% facilities in the different districts. There was no significant (n = 153) and 63.1% (n =319) indicated a preference for difference in default rates between different genders (p = 3–4 month and 5–6 month refills, respectively (Fig. 3). 0.567), ages (p = 0.081), and occupation (p =0.322). Quotes under various themes from the in depth inter- We also asked the 126 migrants who defaulted regarding views with healthcare service providers are summarised their reasons for defaulting on ART while in South Africa: below and they confirm and support the quantitative 59.5% (n = 75) could not get to Lesotho, 51.6% (n = 65) findings. Table 1 Sample distribution for HIV-infected migrants enrolled in the study, by site, Lesotho, 2016 District Location Health Facility Patients on ART N Surveyed N (%) Migrants N (%) Leribe Rural Matlameng H/C 315 30 (9.5) 7 (23.3) Leribe Rural Pontmain H/C 1337 119 (8.9) 50 (42.0) Leribe Rural Seshote H/C 1136 70 (6.2) 11 (15.7) Leribe Urban Maputsoe Filter Clinic 2074 347 (16.7) 100 (28.8) Leribe Urban Maputsoe SDA H/C 1539 260 (16.9) 15 (5.8) Mafeteng Rural Matelile H/C 667 99 (14.8) 10 (10.1) Mafeteng Rural Ts’akholo H/C 591 235 (39.8) 24 (10.2) Mafeteng Urban Mafeteng Hospital 3277 424 (12.9) 90 (21.2) Maseru Rural Nazareth H/C 1960 441 (22.5) 26 (5.9) Maseru Rural Scott Hospital 1239 136 (11.0) 16 (11.8) Maseru Urban Domiciliary H/C 1550 28 (1.8) 28 (100) Maseru Rural Paki H/C 1185 61 (5.1) 52 (85.2) Maseru Urban RLDF H/C 1247 243 (19.5) 34 (14.0) Maseru Rural St Joseph Hospital 1399 13 (0.9) 13 (100) Maseru Urban Thamae H/C 2178 278 (12.8) 48 (17.3) TOTAL 21,694 2784 (12.8) 524 (18.8) H/C – Health Care; At Domiciliary H/C and St Joseph Hospital, surveys were administered only to self-reported migrants; At Paki H/C the same held true, except for the last three days of data collection Faturiyele et al. BMC Public Health (2018) 18:668 Page 5 of 10 Table 2 Socio-demographics of HIV-infected Lesotho migrants Table 3 Socio-demographics of HIV-infected Lesotho migrants by location by defaulting status Characteristic All N Urban N Rural N P-value* Characteristic All N Defaulted Not defaulted P-value** (col %) (col %) (col %) N (row %) N (row%) Patients 524 315 209 All patients* 517 126 391 Sex 0.047 Location 0.011 Men 150 (28.6) 101 (32.0) 49 (23.4) Rural 206 38 (18.4) 168 (81.6) Women 344 (65.7) 199 (63.2) 145 (69.4) Urban 311 88 (28.3) 223 (71.7) Unknown 30 (5.7) 15 (4.8) 15 (7.2) District < 0.001 Age (years) 0.585 Leribe 181 34 (18.8) 147 (81.2) 18–25 38 (7.3) 20 (6.3) 18 (8.6) Mafeteng 123 49 (39.8) 74 (60.2) 26–35 173 (33.0) 105 (33.3) 68 (32.5) Maseru 213 43 (20.2) 170 (79.8) 36–45 202 (38.6) 121 (38.4) 81 (38.8) Sex 0.567 46–55 71 (13.5) 42 (13.3) 29 (13.9) Men 148 35 (23.6) 113 (76.4) 55+ 17 (3.2) 13 (4.1) 4 (1.9) Women 341 89 (26.1) 252 (73.9) Unknown 23 (4.4) 14 (4.4) 9 (4.3) Unknown 28 2 (7.1) 26 (92.9) Occupation < 0.001 Age (years) 0.081 Domestic worker 240 (45.8) 117 (37.1) 123 (58.9) 18–25 37 3 (8.1) 34 (91.9) Construction worker 87 (16.6) 60 (19.0) 27 (12.9) 26–35 172 45 (26.2) 127 (73.8) Textile worker 52 (9.9) 43 (13.7) 9 (4.3) 36–45 200 53 (26.5) 147 (73.5) Farmer 24 (4.6) 19 (6.0) 5 (2.4) 46–55 70 19 (27.1) 51 (72.9) Miner 23 (4.4) 9 (2.9) 14 (6.7) 55+ 17 2 (11.8) 15 (88.2) Health-care professional 2 (0.4) 2 (0.6) 0 (0.0) Unknown 21 4 (19.0) 17 (81.0) Student 6 (1.1) 3 (1.0) 3 (1.4) Occupation 0.322 Other occupation 49 (9.4) 32 (10.2) 17 (8.1) Domestic worker 238 67 (28.1) 171 (71.9) Unknown 41 (7.8) 30 (9.5) 11 (5.3) Construction worker 85 21 (24.7) 64 (75.3) *P-value excludes unknown Textile worker 52 15 (28.8) 37 (71.2) Farmer 23 5 (21.7) 18 (78.3) Miner 23 4 (17.4) 19 (82.6) 1. Cultural and nationality-based discrimination Health-care professional 2 2 (100.0) 0 (0.0) Student 6 1 (16.7) 5 (83.3) “They say they even face discrimination in some of Other occupation 49 9 (18.4) 40 (81.6) the health facilities just because they are foreigners Unknown 39 2 (5.1) 37 (94.9) and some travel very far in order to access services *7 had no default status, ** P-value excludes unknown while others do not know where to go at all for example those that work at farms.” “There are several challenges: most ladies that work as Pharmacy Technician, St. Joseph hospital, Maseru housekeepers fear possible discriminatory attitudes of their employers because they know that they will be “Some [migrant workers] say that they live very far expelled as soon as they are found to be HIV positive.” from the health centres, some believe that the HIV treatment from South Africa is not the same as the Pharmacy Technician, St. Joseph hospital, Maseru one provided in Lesotho (the side effects are extreme), some say that people from Lesotho are not allowed “They have issues accessing health care services to access the services.” because most of them do not have permanent jobs and they can be fired any time. They have been Nurse, St. Joseph hospital, Maseru discriminated against so disclosing their statuses have become a problem.” 2. Experienced barriers: Discrimination based on HIV status Nurse, LDF health centre, Maseru Faturiyele et al. BMC Public Health (2018) 18:668 Page 6 of 10 Fig. 2 Reasons for defaulting ART amongst HIV infected Lesotho migrants 3. Experienced barriers: Transport costs access healthcare services abroad and most of the times they do not have such documents.” “They [migrant workers] mainly complain about transport costs as they come here for refills. They say Professional Counsellor, Maputsoe filter clinic, Leribe they cannot afford to take days off because it reduces their wages.” “Sometimes when they [migrant workers] get to the health centres, they are normally required to present Professional Counsellor, Maputsoe filter clinic, Leribe some legal documents which allow them to stay in the foreign country and it may happen that some of them “It is mainly transport costs and they are always might not have it, while others are required to present required to present legal documents like passport their bukana [health booklets] which they may have with work permits.” left behind.” Pharmacy Technician, Domiciliary health centre, Nurse, Matelile health centre, Mafeteng Maseru 4. Experienced barriers: Legal requirements and referring abroad “Furthermore, they [migrant workers] are required [to produce] the legal documents and to provide reasons why they are in the foreign countries if they want to Table 4 Barriers to getting ART in SA among Lesotho migrations Barrier N % Cannot afford transport costs 187 35.7 Do not know where to get ARVs 124 23.7 No barrier 174 33.2 Afraid if not legally registered in South Africa 101 19.3 Feel discriminated as foreigner 83 15.8 Refused health services 45 8.6 Afraid medications confiscated at the border 44 8.4 ARVs regimen not available at facility 32 6.1 Fig. 3 Preferred months of ARV’s refills amongst HIV infected Lesotho migrants Have to pay for health services 31 5.9 Faturiyele et al. BMC Public Health (2018) 18:668 Page 7 of 10 “Some [migrant workers] say that they are being Nurse, Thamae health centre, Maseru refused to access their ARV treatment if they do not present referral letters.” 8. Other proposed interventions for improving migrants’ treatment adherence Counsellor, Matelile health centre, Mafeteng “We should increase treatment supply so that they 5. Preferences on ARVs collection site: Perceived do not come often to the health facilities. Also there treatment differences should be a well written document focusing on ART patients flow. There should also be a binding legal “I normally hear them [migrant workers] complaining document between the two countries to curb racism.” about the severe side effects that are incurred by using ARVs from South Africa. They say that they Adherence Counsellor, LDF health centre, Maseru disfigure their bodies, causing them to have Kyphosis.” “I suggest that we provide them with treatment to last them six months because they incur so much Counsellor, Matelile health centre, Mafeteng transport costs having to come for re fills every month.” “They [migrant workers] prefer Lesotho since there are not as many barriers as in South Africa. Also they Pharmacy Technician, St. Joseph hospital, Maseru believe the medication from Lesotho is much stronger than the one supplied in South Africa.” Discussion Nurse, Paki health centre, Maseru The objective of this study was to assess healthcare needs, preferences and accessibility barriers of HIV-infected mi- 6. Current processes for tracking patients who are grant populations in high HIV burden, borderland dis- migrants tricts of Lesotho. We surveyed 524 HIV-infected migrants from 15 facilities in the districts of Maseru, Leribe, and “We use the appointment book to assess whether they Mafeteng. Most of the migrants were from urban areas are adhering to their appointments because they usually (60.1%), were women (65.6%), aged 26–45 years (71.6%), do not give their foreign country of destination contacts. and domestic workers (45.8%). Almost a quarter of these If we need a patient desperately we call their treatment migrants (n = 126) had defaulted on ART with default supporter and ask them to inform our patients that we rates significantly higher in urban than rural areas. The would like to see them as soon as possible.” barriers to getting ART while in South Africa ranged from failing to get to Lesotho, not affording transport costs, not Nurse, LDF health centre, Maseru knowing where to get treatment, not being legally regis- tered in South Africa, ARV regimen not being available at “There are no specific systems in place that we use facility, and being discriminated against by healthcare pro- to mark our migrant workers who are on ART.” viders because they were foreigners. Most of the migrants (93%) preferred to collect their medications primarily in Adherence Counsellor, Tsh’akolo health centre Lesotho and in terms of the frequency of collecting ARV’s, 6.7% opted for the standard-of-care 1–2month 7. Health passports and ART road map as new anti-retroviral (ARV) refills whereas 30.2 and 63.1% indi- proposed tools for migrants cated a preference for 3–4 month and 5–6 month refills, respectively. Service providers indicated a lack of transfer “The ART cards are kept by the health facilities and letters, or poor medical history related to ART treatment patients are only provided with health booklets as the major drawback in facilitating care and treatment (bukana) which contain very brief information for migrants followed by discrimination based on nation- about the patients’ status unlike the ART card.” ality or language. Regarding migrants’ preferred ARVs col- lection site, service providers indicated that most patients Pharmacist, Mafeteng hospital, Mafeteng preferred all treatment services to be rendered in Lesotho, as they perceive the treatment provided in South Africa to “It may be beneficial for them to have their health be different often less strong or with more serious side ef- passport ready in case of unplanned or sudden fects. A need for mHealth systems or telephone tracking migration.” to track patients abroad was suggested in combination Faturiyele et al. BMC Public Health (2018) 18:668 Page 8 of 10 with multi-month dispensing of ART and harmonizing due to not being legally documented, coupled with lan- documentation among neighbouring states, and making guage barriers. Some migrants also claimed that they are referral processes easier. refused service in South Africa because of being a for- Several studies on HIV-infected migrants found signifi- eigner. Some said that they are afraid that their medication cantly higher default rates among migrants compared to would be confiscated at the border between Lesotho and non-migrants [6], including a community cohort study in South Africa. Lesotho [7]. Our study found a high default rate of almost This study had some limitations. As this is a 25% among migrants. However we did not collect data to cross-sectional study, we cannot determine cause and effect; compare with non-migrants. Another study found higher de- and therefore conclusions from this study could be biased. fault rates among migrants compared to Spanish born popu- The study is geographically limited to the three districts in lations (9.2% versus 6.3%) [13]. On the contrary, a study in Lesotho where most of the migrant population is thought to Johannesburg, South Africa, found default rates to be signifi- reside; hence, it may not capture dynamics occurring in cantly lower in foreigners compared to local citizens (12% other cross-border regions of the country. The assumption versus 31%) [14]. This implies that our default rate was was made that rural high-volume sites within a district serve higher compared to studies from other countries, thereby similar populations and that urban high-volume sites within giving hope that there is potential to reduce the default rate a district serve similar populations as well: should this as- in Lesotho. sumption not hold true, skewed results may occur if the Thefactthatthe majority of themigrants werewomen population served by a certain facility presented characteris- speaks to the plight of women living with HIV who experi- tics that are significantly different from those of the other ence specific barriers to HIV treatment and care because of populations served by facilities in the same group. The study their gender identity and socially acceptable employment focusesmainlyonmigrantstoSouthAfrica anditisthere- pathways (such as domestic work) within the region’s polit- fore expected not to capture a marginal part of migration ical economy. The qualitative findings revealed that these flows from Lesotho to other countries. A non-probabilistic women find it difficult to disclose their HIV status for the sample for selecting high-volume ART facilities raises the fear of losing their jobs. As a result, they are unable to re- possibility that the responses may not be independent and quest leave to visit health care facilities to access their treat- potentially systematically different from a broader group of ment. There is therefore need to educate the HIV infected individuals. However, the large sample size utilized in this migrants regarding their sexual and reproductive health and study gives it enough statistical power to infer significant as- rights, as well as issues pertaining to gender based violence. sociations found in the paper. The barriers to receiving ART for migrants have also been well-documented. Barriers that we have identified in Conclusion this study such as legal and administrative issues, language In conclusion,wesurveyedHIV-infectedmigrants inthree barriers in communicating in the native language of the borderland districts of Lesotho and found a high ART de- host country, and failing to afford transport costs to return fault rate of almost 25%. We also identified barriers to acces- to the home country, have also been identified in a review sing ART, including lack of information on where to get article [6]. However, what is unique about this study is ARVs in South Africa, transport costs of travelling to that we have identified that the migrants in Lesotho prefer Lesotho to collect medications, legal and administrative bar- a multi-month (≥3) supply of medication to cater for them riers, and discrimination of migrants in foreign countries. while they are in South Africa. The current status quo is Also, most of the migrants preferred collecting their medica- that it is at the discretion of the healthcare professionals tions in Lesotho and indicated preference of ≥3months’ sup- to give the migrants ARV’s covering more than the ply of ARV refills to cater for when they are in South Africa. standard-of-care 1–2months’ supply. The healthcare pro- Service providers’ perspectives indicate the need to modify viders in Lesotho also provide the migrants with transfer and re-structure HIV care among migrants. Specifically, in letters to allow them to continue their treatment in South relation to differentiated model of care that will support Africa; however, most migrants indicated that they do not multi-month supply of treatment, tracing and mHealth plat- know where to obtain the ARV’s in South Africa. The fact forms to improve various HIV outcomes including retention, that 29.7% of the migrants defaulted in ART because they adherence, virologic suppression and ultimately mortality. did not know where to get treatment in South Africa We recommend a differentiated model of care specific speaks to a lack of information that could support mi- to HIV infected migrants such as a multi-month scripting grants in accessing treatment and care when they are away and dispensing of treatment. We also recommend the from home. There is therefore need to promote education harmonization of treatment protocols for ART between and distribution of pamplets and notices at country bor- the Lesotho and South African governments and the edu- ders to educate migrants regarding where they are able to cation and sharing of accessible information across SADC access treatment. There is also the fear of discrimination borders on resources, health facilities, and health systems Faturiyele et al. BMC Public Health (2018) 18:668 Page 9 of 10 relevant to migrants. We also emphasize that both coun- PTP Conceptualization, writing the manuscript, literature search, and data interpretation. All authors read and approved the final manuscript. tries should adhere to the United Nations High Commis- sioner for Refugees recommendations that ART should Ethics approval and consent to participate not be withheld from displaced persons [14]. We also rec- Ethics approval for the study was obtained from the Lesotho Ministry of ommend a qualitative study on the HIV infected migrants Health Research and Ethics Committee, Maseru, Lesotho, with Reference Number (ID50–2017). All the enrolled migrants provided written informed to obtain an in-depth understanding of the issues sur- consent to participate in the study. rounding the barriers to receiving ART. In order to ensure confidentiality, data were stored in locked cabinets and all Since there is such limited data on migrant populations databases were password protected and only authorized personnel were granted permission to access participant information. Identifying information in this SADC region, health systems and HIV treatment such as participant names, addresses, phone numbers and ID/passport and care, we advocate for evidence-based policy change numbers were never collected and were not part of the analysis dataset. that would meet the healthcare needs of migrant popula- This study poses no risk to the participants. Although there was no direct benefits for the participants, the findings of this study will be used to further tions in the region. This can include longer-term policy scientific knowledge, and relevant stakeholders will be informed so that the change that align with regional strategies and frameworks, health of the HIV infected migrants can be improved. and actions such as training all staff on migration, mobility and health, coordination, and migrant-awareness response Competing interests to HIV treatment and care. The authors declare that they have no competing interests. Additional file Publisher’sNote Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Additional file 1: Survey data from 524 HIV infected migrants, Lesotho, 2016. (XLSX 44 kb) Author details 1 2 EQUIP-Innovation for Health, Maseru, Lesotho. Ministry of Health, Maseru, Lesotho. EQUIP – Innovation for Health, 1006 Lenchen Avenue North, Abbreviations Centurion, South Africa. Department of Human Nutrition and Dietetics, AIDS: Acquired Immuno-Deficiency Syndrome; ART: Antiretroviral Treatment; Sefako Makgatho Health Sciences University, Ga-Rankuwa, Pretoria, South ARV: Antiretrovirals; EQUIP: Evaluation and Quality Improvement Program; H/ Africa. C: Health Centre; HIV: Human Immuno-Deficiency Virus; IOM: International Organization for Migration; NSP: National Strategic Plan; PHIA: Population-based Received: 20 December 2017 Accepted: 23 May 2018 HIV Impact Assessments; PLHIV: People Living with HIV; SADC: Southern African Development Community; SANAC: South African National AIDS Council; UNAIDS: The United Nations Joint Programme on HIV and AIDS; USAID: United States Agency for International Development References 1. WHO Glob Health Observatory (GHO) data. Available from http://www.who. Acknowledgements int/gho/hiv/en/. Accessed 2 Oct 2017. The Ministry of Health Lesotho for granting ethical clearance and permission to 2. UNAIDS AIDSinfo. People living with HIV. Available from http://aidsinfo. use health facilities. We acknowledge all the individuals who participated in this unaids.org/. Accessed 2 Oct 2017. study. 3. UNAIDS 90–90–90 - An ambitious treatment target to help end the AIDS epidemic. Available from http://www.unaids.org/en/resources/documents/ 2017/90-90-90. Accessed 2 Oct 2017. Funding 4. UNAIDS UNAIDS Data 2017. Available from http://www.unaids.org/sites/ This work was supported by the U.S. Presidential Emergency Plan for AIDS default/files/media_asset/20170720_Data_book_2017_en.pdf. Accessed 2 Relief (PEPFAR), through United States Agency for International Development Oct 2017. (USAID) Cooperative Agreement Number AID-OAA-A-15-00070. USAID had 5. UNAIDS UNAIDS congratulates Lesotho and Uganda for progress towards no role in the design of the study and collection, analysis, and interpretation achieving their Fast-Track Targets. Available from http://www.unaids.org/en/ of data and in writing the manuscript. resources/presscentre/pressreleaseandstatementarchive/2017/september/ 20170920_PHIA. Accessed 2 Oct 2017. Availability of data and materials 6. Tanser F, Barnighausen T, Vandormael A, Dobra A. HIV treatment All data generated or analysed during this study are included in this cascade in migrants and mobile populations. Curr Opin HIV AIDS. published article (Additional file 1). 2015;10:430–8. 7. Bygrave H, Kranzer K, Hilderbrand K, Whittall J, Jouquet G, et al. Trends in Disclaimer loss to follow-up among migrant workers on antiretroviral therapy in a The findings and conclusions in this article are those of the authors and do community cohort in Lesotho. PLoS One. 2010;5:e13198. not necessarily represent the official position of PEPFAR, Department of 8. ECDC Migrant health: Access to HIV prevention, treatment and care for Health and Human Services, or the US government. migrant populations in EU/EEA countries. Available from https://ecdc. europa.eu/sites/portal/files/media/en/publications/Publications/0907_TER_ Authors’ contributions Migrant_health_HIV_Access_to_treatment.pdf. Accessed 4 Oct 2017. IF Leadership and oversight in protocol development, survey design, 9. SADC Policy Framework for Population Mobility and Communicable Implementation, data analysis, and manuscript writing. DK Data analysis, Diseases in the SADC Region. Available from http://www.arasa.info/files/ generating figures, and manuscript writing. KNS Protocol development, 6613/7574/3254/SADC_Policy_Framework_FINAL.pdf. Accessed 1 Apr 2018. implementation, analysis and manuscript writing. AM Manuscript writing, 10. SANAC South Africa's National Strategic Plan on HIV, TB and STIs 2017– data analysis, data interpretation, generating figures, and co-ordinating 2022. Available from http://sanac.org.za/wp-content/uploads/2017/05/NSP_ manuscript writing. MK Protocol development, survey implementation and FullDocument_FINAL.pdf. Accessed 1 Apr 2018. manuscript writing. MM Survey implementation, data collection and analysis 11. IOM Migrants' right to health in Southern Africa. Available from http://www. and manuscript writing. PM Writing and critically reviewing the manuscript. migration.org.za/wp-content/uploads/2017/08/Migrants-Right-to-Health-in- TX Protocol development, survey design, and critically reviewing the paper. Southern-Africapdf. Accessed 1 Apr 2018. Faturiyele et al. BMC Public Health (2018) 18:668 Page 10 of 10 12. Vearey J, Thomson K, Sommers T, Sprague C. Analysing local-level responses to migration and urban health in Hillbrow: the Johannesburg migrant health forum. BMC Public Health. 2017;17:427. 13. Reyes-Uruena J, Campbell C, Hernando C, Vives N, Folch C, et al. Differences between migrants and Spanish-born population through the HIV care cascade, Catalonia: an analysis using multiple data sources. Epidemiol Infect. 2017;145:1670–81. 14. McCarthy K, Chersich MF, Vearey J, Meyer-Rath G, Jaffer A, et al. Good treatment outcomes among foreigners receiving antiretroviral therapy in Johannesburg, South Africa. Int J STD AIDS. 2009;20:858–62.

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BMC Public HealthSpringer Journals

Published: May 29, 2018

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