Key findings from the 2023 ‘ACT NOW on Global HIV Migration, Mobility and Health Equity’ community forum

Introduction

In 2021, it was estimated that there were >281 million international migrants, representing ~3.6% of the global population.¹ Although many migrated of their own volition, ~84 million people were displaced and seeking refuge due to conflict, natural disasters, and/or climate change.¹ Considering the importance of a global, united HIV response, it is crucial to consider displaced communities and migrants, particularly in response to the growing issues of environmental emergencies, conflict and climate change.

Migration and entry policies are not equal for people living with HIV, and discriminatory barriers are in place in many jurisdictions that limit cross-border movement specifically in relation to HIV. In 2023, nine countries explicitly banned short-term entry of people living with HIV.² Thirteen countries restricted stays of <90 days for people living with HIV, while stays of >90 days were restricted in 54 countries for people living with HIV.² A total of 160 countries have no official restrictions on entry based solely on an individual’s HIV-positive status (Table 1).²

Despite some countries not imposing restrictions based on HIV status alone, people living with HIV continue to face laws and policies, as well as explicit and implicit practices, that impact their migration potential. These laws include mandatory HIV testing and involuntary disclosure of HIV, as well as a lack of access to affordable HIV-related health care, treatment and counselling. These restrictions often fail to mention HIV explicitly, but characterise HIV as a threat to public health or present people living with HIV as placing undue burdens on healthcare systems. This is stigmatising and misleading. Laws restricting the entry and stay of people living with HIV do not reflect the current context of HIV, whereby effective treatments have transformed HIV into a chronic, manageable condition and, by reducing viral load to undetectable levels, also eliminate the risk of HIV sexual transmission.^3,4

HIV migration law and policy were the topic of a community forum held as part of the 12th International AIDS Society Conference on HIV Science held in Brisbane, Australia, in July 2023. Over 150 delegates attended, including representatives from community-based HIV organisations, health care, research, policymakers, and HIV activists and advocates. After a series of presentations, delegates were invited to participate in structured conversations about issues related to policy, health and law concerning migration of those living with HIV. In this paper, we report on key themes from those discussions, identify areas for ongoing investigation and offer several recommendations (Box 1). Although discussions were organised around specific topics, the themes identified intersected across all three domains. Given this, in what follows we do not report by specific topic and instead report key areas thematically.

Stigma and discrimination

Despite significant medical advances in HIV treatment, management and prevention, HIV remains a highly stigmatised condition.^5,6 Migrants living with HIV also experience intersecting stigma owing to their migration status.^7–9 HIV-related stigma and stigma towards migrants also intersects with other forms of discrimination relating to identities and practices sometimes considered ‘morally transgressive’, including sex work, trans and gender diverse identities, same-sex relationships, and intravenous drug use.¹⁰ For migrants, this discrimination is often interrelated with pre-existing negative perceptions and stigmatising assumptions about ‘the other,’ a fear of so-called ‘outsiders,’ and unfounded concerns about migrants ‘taking what is not theirs.’

Australia’s migration health requirement

Perceptions of migrants as placing an increased burden on collective health and social services is evident in Australia’s immigration policy. Under this policy, most people seeking to migrate to Australia must undergo a health examination to determine whether they meet the health requirement. Those with existing and/or chronic health conditions are then assessed to determine whether that condition will prevent Australian citizens or permanent residents accessing services in short supply (the Prejudice to Access test), or whether their condition could result in excess expenditure on healthcare and community services (the Significant Cost test).¹¹ The provision of HIV care and medication exceeds the Significant Cost Threshold (A$51,000 over 10 years in 2023), meaning potential migrants living with HIV are automatically excluded from acquiring most visa types. Although potential migrants can apply for a waiver to the health requirement, these can be costly and time consuming to obtain, and create an additional barrier to an already complex process.^12,13 Given the potential cost, time and complexity of navigating this process such policies effectively perpetuate inequalities, particularly for those who are most socially and economically marginalised.

Health and wellbeing impacts of anti-HIV migration policy

HIV-related stigma undermines treatment adherence by compromising general psychological processes, such as adaptive coping and social support.¹⁴ Policies limiting migration of people living with HIV have negative impacts on the mental and physical health of individuals living with HIV and their families.^15,16 Restrictive migration policies also deter some migrants from seeking sexual health care and HIV-related care, including HIV testing.^17,18 HIV testing is a core aspect of Australian and global HIV responses^19,20 and delays in testing may lead to some migrants being diagnosed with advanced HIV, increasing the impact of HIV on an individual’s physical health and wellbeing.^21–23 From a purely public health perspective, delayed HIV diagnoses also mean delayed access to treatment and viral suppression. This delay extends the possible window for HIV transmission and could ultimately undermine efforts to virtually eliminate HIV transmission by 2030.²⁴

Inconsistent and unsupported migration policies

As noted, people living with HIV seeking to migrate to Australia can apply for a waiver of the health requirement for certain permanent visa types. However, this can be a lengthy and costly process not only for the individual, but also diverts resources away from healthcare, legal and migration services.¹⁶ In the experiences of some authors, the majority of people living with HIV who apply for a waiver to the health requirement are approved, suggesting that on balance, people living with HIV are not considered to place an undue cost burden on health and community services.

When seeking a waiver of the health requirement, individuals must demonstrate compelling and compassionate reasons that they will not place undue cost burdens on the healthcare system.¹² In this paradigm, individuals are considered purely on economic cost with no consideration of their potential economic and social contribution to the Australian community. Modern HIV treatments have increased the life expectancy of people living with HIV to virtually the same as that of individuals not living with HIV. Moreover, many visa types restrict migration to Australia for those who are aged >45 years unless certain conditions, such as earning above the high-income threshold, are met. It can reasonably be expected, then, that migrants living with HIV will be able to work for a significant number of years and contribute to the Australian economy through income tax while also contributing to their communities.

Definitions of what constitutes compelling circumstances and undue cost are also vague, and may be interpreted differently depending on who is interpreting migration law or policy. By using vague terminology, Australia allows for the possibility of harm to those who already occupy economically and/or socially marginalised positions, without consideration the communities they are a part of.

Hidden barriers

Although some policies are explicit in their restriction of migration for people living with HIV, others remain hidden. For example, requirements for mandatory HIV testing before leaving one’s home country carries risks for those seeking to migrate, particularly in countries where HIV is highly stigmatised. Furthermore, breaches of confidentiality can be common in certain healthcare settings.²⁵ It is crucial that healthcare professionals conducting health checks as part of the migration process are equipped with the necessary resources to support individuals who receive an HIV-positive diagnosis.

A need for global advocacy

There is an urgent need for a connected and well-organised global network to advocate for changes to discriminatory HIV migration law and policy. This network must involve local and international organisations, including community-based HIV organisations, healthcare workers, HIV advocates, policymakers and researchers. As the cost of HIV treatment and care is often cited as a significant reason for limiting migration of people living with HIV, public health policy and advocacy needs to ensure expanded and equitable access to therapeutics and diagnostics for both treatment and pre-exposure prophylaxis.

Any advocacy for changes to migration policies and laws should be grounded in a human rights approach that challenges all forms of stigma, discrimination and disadvantage. However, it is also necessary for those advocating for change to adopt a degree of pragmatism. In some regions, appeals to human rights, particularly the rights of stigmatised individuals and communities, may be an ineffective strategy to encourage policymakers to reconsider migration law and policy. As these laws discourage some migrants from undergoing HIV testing, an emphasis on the negative economic and community-level health impacts of undiagnosed and untreated HIV may be more effective in advocating for change. Moreover, promoting the potential positive economic and social benefits of migration, regardless of HIV status, may also be an effective strategy to encourage changes to HIV migration laws.

Conclusion

Laws and policy that restrict the migration of people living with HIV are underpinned by outdated understandings of HIV that do not account for advances made in HIV treatment and prevention. These policies also disregard the positive contributions, both socially and economically, people living with HIV make to the communities they migrate to. Rather than being grounded in scientific fact, such policies are instead driven by intersecting forms of stigma and discrimination. In today’s political climate, migration has become more politicised than ever, and migrants and refugees are often blamed for negative social and economic challenges. More than just a human rights concern, laws that limit the migration of people living with HIV actively discourage individuals from seeking HIV testing, treatment and care. The world is striving to end AIDS as a public health concern and to virtually eliminate HIV transmission by 2030. This goal cannot be achieved unless all individuals, regardless of migration status, have access to appropriate and non-judgemental HIV treatment and care. Removing any barrier to such care, including restrictive migration policies, is one crucial step in minimising the impact of HIV globally.

For more information regarding the forum and to watch the summary video, please follow the link: https://vimeo.com/870112866/5d8abd3af1?share=copy.

Ethical approval

This report is based on a community-organised event and, as such, institutional ethics was not sought. All participants were informed prior to the event, and agreed, that discussions during this even would be reported in a public-facing document.