Saving migrants from HIV/AIDS

By Dr. Deborah L. Birx and Hannah Johnson

PEPFAR is one of the most successful foreign aid programs in history. Here’s how it can help those who fall through the cracks.

A sugar cane worker shows his hands at a plantation near El Seibo, in eastern Dominican Republic, in March 2023. (Photo by Erika Santelices/AFP via Getty Images)

The President’s Emergency Plan for AIDS Relief (PEPFAR), launched by the George W. Bush Administration in 2003, is one of the most successful U.S. foreign aid programs in history. Since its inception, PEPFAR has saved more than 25 million lives, strengthened local health systems, served as the essential platform for the global response to COVID-19, helped reduce the stigmatization surrounding HIV/AIDS, improved America’s standing in the world, and moved humanity closer to achieving the program’s goal of eradicating that disease by 2030.

Impressive as the progress has been, plenty of work still needs to be done; more than 600,000 people die from AIDS each year, and more than a million are infected. Among those at greatest risk are migrants and displaced persons, who are often denied access to health care in their host countries, have trouble accessing it for language or other reasons, or simply fall between the bureaucratic cracks. But with PEPFAR’s help, two countries, the Dominican Republic and Haiti, have made great strides in addressing the issue. By emphasizing local ownership and partnership with civil society, including trusted faith-based organizations, PEPFAR’s work in Hispaniola shows how even the most marginalized groups can be cared for and saved from death – and offers a valuable roadmap for other countries and regions still failing to care for the health of migrants on their shores.

Inequitable infections

Since 1970, the number of people living in countries other than the land of their birth is estimated to have more than tripled. The reasons for this trend are the obvious ones: war, civil conflict, political instability, and economic insecurity. Although the COVID-19 pandemic temporarily reduced the number of individuals crossing borders, migrant flows are once again rising as more and more people leave home in search of peace, safety, and opportunity.

Although a new country may (eventually) provide migrants with services, the instability and isolation many migrants face also increase the likelihood that they will be exposed to transmissible diseases, including HIV/AIDS. As a consequence, in some countries migrants have higher rates of HIV infection than the population at large. Migrants can be infected by HIV prior to travel, in transit, or at their destination. And once they have the disease, things often get very difficult: Being separated from one’s family, lack of fluency in the local language, exploitation by employers, and the stigma attached to HIV/AIDS can all make it hard for migrants to access adequate health care. In many countries, moreover, migrants are denied coverage by national health insurance plans; they are often also barred from public health institutions or (if undocumented) avoid them due to fear of deportation. Even migrants who have lived in their host country for many years struggle with many of these problems. As a result, many of them must turn to multilateral institutions, such as the United Nations, or to nongovernmental, faith-based, or community-service organizations.

The first place PEPFAR recognized this particular set of problems was the Dominican Republic, which shares the island of Hispaniola with Haiti. Although the island is less than 30,000 square miles in size, its two countries are very different. Thanks to its booming tourism and agriculture industries, the Spanish-speaking Dominican Republic boasts a GDP six times higher than that of French-speaking Haiti. Indeed, Haiti is the poorest country in the Americas and one of the poorest in the world. Political instability, gang violence, and a series of earthquakes have all caused havoc there, including enormous health problems. As a result, the average Dominican now lives 10 years longer than the average Haitian.

Although a new country may (eventually) provide migrants with services, they also face a greater likelihood that they will be exposed to transmissible diseases.

One result of these disparities is that large numbers of Haitians have been moving to the Dominican Republic for generations, seeking greater opportunity and stability. Although many of them have now lived in the Dominican Republic for decades, and entered the country when the border was ill-defined and porous, they continue to suffer so much discrimination and violence that locals have coined a term for it: “antihaitianismo.” The prejudice goes all the way to the top: In 2013, Santo Domingo revoked the citizenship of approximately 200,000 Dominicans of Haitian descent, claiming their ancestors had entered the country illegally. And just last year, it deported more than 108,000 Haitians, including undocumented migrants and former Dominican citizens that had lived in the country for many years. Haitians of all immigration statuses still living in the Dominican Republic report being subjected to constant surveillance by authorities and being denied access to public services, including education and health care. Many Haitians work in the Dominican Republic’s large sugarcane industry, where they’re typically segregated into “bateyes,” or small rural communities that have developed around plantations. Bateyes suffer from a lack of access to safe drinking water, electricity, and health infrastructure; as a consequence, the rates of HIV infection there are the highest of any communities in the country.

Haitian citizens hoping to return to their country queue at the border post in Dajabon, Dominican Republic, on Sept. 18, 2023. (Photo by STR/AFP via Getty Images)

Between 1996 and 2015, the Dominican Republic managed to reduce the HIV rate in its general population from 10,000 new infections per year to 3,500 new infections per year. But then things began to change for the worse. After years of rapid decline, new infections began increasing again, and by 2018, they had reached 4,100 per year. The increase in infections and deaths spurred officials to consider a new approach. PEPFAR officials realized that there was a need to ensure access to treatment for everyone residing in the country.

As recently as 2018, people of Haitian descent living in the Dominican Republic (regardless of their status or the length of time they’d been in the country) suffered an HIV infection rate 3% to 5% higher than any other segment of the population. That’s because, until 2019, the country had virtually no HIV-prevention programs targeting the various groups of Haitians living there. Antiretrovirals, the lifesaving drugs that combat AIDS, were mostly available in urban areas and to Dominican citizens only. Most educational materials printed by the government were in Spanish, not Creole, and many health care providers refused to speak the latter language. International health workers also heard that Dominican officials were stigmatizing HIV among migrants by requiring testing and the disclosure of infection status for all noncitizens prior to granting them work permits.

The power of a pair

In 2017, PEPFAR officials looked at the situation and realized they needed to find a creative solution. Working with just one of the island’s two governments wouldn’t do much. Instead, after analyzing the data, PEPFAR administrators decided to launch an approach that emphasized collaboration across the border and intense involvement with preexisting local organizations.

The first step in trying to combat HIV infection in the Dominican Republic’s Haitian community was to develop a more sophisticated understanding of the scope of the disease. In 2021, HIV prevalence across the border in Haiti was almost double the rate in the Dominican Republic. Part of the reason for the difference is that Haiti lacks adequate health infrastructure. Haiti has the lowest number of health workers in the Americas: As of 2019, there were only 1.4 physicians and 1.8 nurses for every 10,000 people in the public health care system. This was one-fourth of the global average nurse-to-population ratio. The 2010 and 2021 earthquakes, meanwhile, destroyed much of the country’s physical infrastructures. Not only does the Dominican Republic offer greater safety and economic opportunity, it also offers more functional institutions, including health care providers. That all makes it a natural draw for Haitians, especially those living with HIV. If they hoped to control the spread of HIV in Hispaniola, therefore, PEPFAR officials realized that they needed both countries to collaborate.

To foster such cooperation, in 2018, PEPFAR officially designated Haiti and the Dominican Republic a country pair and created a cross-border task force to ensure that the two governments made the best use of their respective health services, shared best practices, and worked together to control the epidemic. Haiti focused on testing and treatment and educating those crossing the border on how best to prevent transmission and to handle infection if it occurred. The Dominican Republic, meanwhile, began working to improve care for migrants and Dominicans of Haitian descent. By 2020, Haiti had made great strides: 84% of its population knew their status, up from 67% in 2018, while 86% of those infected were in treatment, up from 58% in 2018.

Getting any two countries to cooperate – let alone two with such a complicated history and on an issue as controversial as HIV – can be difficult. PEPFAR also had to find ways to overcome the Dominicans’ reflexive antihaitianismo. PEPFAR’s answer was to directly fund HIV-related services for individuals of Haitian descent. It also decided to funnel much of that money through trusted faith-based and local organizations that had been serving that population for decades. Such organizations were able to provide a sense of dignity and community, both of which are essential for increasing access and overcoming structural barriers.

Specialized Land Border Security Corps (Cesfront) observes Haitian citizens during a military operation in Dajabon, Dominican Republic, on Sept. 18, 2023. (Photo by STR/AFP via Getty Images)

At the same time, the decision to designate the two states a country pair linked their respective U.S. embassies and ambassadors, allowing PEPFAR to facilitate dialogue between the two governments and help them coordinate their efforts. This approach also helped ensure joint accountability and the real-time resolution of conflicts. Lessons learned were shared between the programs quickly, and both countries facilitated testing and made information available at the border crossing. PEPFAR also made it clear that continued funding was dependent on achieving results – and that neither country would be deemed a success unless both were.

Think local

When governments anywhere try to introduce bold new programs to the public, working with and through community-based organizations can prove invaluable. That’s especially true in places where parts of the population are wary of the government. Organizations such as churches and grassroots nonprofits tend to be closer to, and are often comprised of, members of the societies they serve, so trust is much easier to establish. They also tend to have more frequent interactions with marginalized people, which makes them a better avenue for access and information sharing. Placing ownership in the hands of the people rather than in multilateral organizations or government, finally, can make programs more sustainable. Rather than relying on U.S.-built health infrastructure and foreign service providers, PEPFAR has consistently allowed partner countries to utilize their own innovations, experts, and service providers to ensure that people receive the care they need far beyond the program’s lifespan.

To capitalize on these benefits, in 2018, PEPFAR started creating community care teams – groups made up of volunteers with long-standing relationships to the population. These teams started with two great advantages: They were trusted by the public and able to speak Creole. Their work included connecting migrants with PEPFAR care facilities; providing digestible and relatable information about HIV testing, treatment, and care; and helping build trust between beneficiaries and service providers.

The local nature of these groups proved to have several other advantages. They were able to collect detailed data and information about those they aimed to help, allowing them to identify gaps in service. By developing good metrics to track progress, they also helped improve accountability. Localization also led to better strategies for testing locals. In 2019, only 42% of HIV-positive individuals among the migrant and Dominican Haitian population knew their status. Thanks to innovations such as partner and social-network testing, by 2021, that figure had increased to 93%.

As community organizations convinced their clients to bring in their family members for testing, they were able to increase the number of people in treatment. This approach also helped get more children access to lifesaving care. And it provided pregnant women with access to services that could help them avoid passing on HIV to their babies.

Patients of the HIV/AIDS health clinic Geskio Center wait for their medicine at the clinic's pharmacy in Port-au-Prince on March 12, 2008. (Photo by Thony Belizaire/AFP via Getty Images)

Values in action

Across the globe, as the number of people leaving their home countries has grown, transient and migrant camps have become small cities with makeshift schools, community-based clinics, and unofficial police forces. To help reach those populations, PEPFAR has supported partnerships not just in Hispaniola but in Africa – between South Sudan and Uganda, and among Tanzania, Rwanda, and Burundi – as well as in Europe, with Ukraine after the invasion of Crimea.

As the global migrant population grows, the international community should use the lessons learned from PEPFAR’s engagement in Haiti and the Dominican Republic to ensure that marginalized populations have equitable access to care, that policies are coordinated, and that communities are engaged with directly – and their concerns are heeded. Program implementation must include community-led and local organizations, international support, and partnerships among neighbors. Countries that lack the resources to care for their own citizens, however – let alone large migrant groups – will struggle to capitalize on partnerships, even with PEPFAR’s help. As mentioned above, local nonprofits can help fill the gaps, and in countries where such groups don’t exist or aren’t robust, U.S. organizations such as PEPFAR should help them develop and expand their reach.

In countries that lack both funding and civil society, outside help from countries such as the United States is even more critical. Such aid creates foundations that local governments can build on over time. U.S. intervention benefits both partner countries and the United States. PEPFAR accounts for only a fraction of the United States’ annual foreign assistance expenditures, which amount to a mere 1% of the total U.S. budget. Programs such as PEPFAR create an enormous return on this small investment. Countries where PEPFAR operates are more economically and politically stable, and their populations have a higher opinion of the United States. Building strategic partnerships abroad therefore serves both the United States’ national security interests and its ideals.

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