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HIV/AIDS |
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HIV Prevention in Mobile Populations |
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Extended or repeated overnight travel away from home and community is associated with HIV infection. This travel can be divided into three types: voluntary and job-related (truckers, traders, freelance sex workers); legally required (members of the military, deported immigrants); or coerced (political refugees, trafficked sex workers, persons displaced due to war-related population shifts). Work-related mobility often creates an imbalance in the ratio of women to men, which facilitates the sharing of sex partners. Extreme examples are truck stops where female sex workers, vendors and drink shop owners outnumber the men who may be transiting through. The reverse is true in military and mining camps, where men greatly outnumber women. Mobile populations that regularly cross international borders need access to a complete spectrum of HIV prevention options, including diagnosis and treatment of sexually transmitted infections (STI), affordable condoms and information on assessing, reducing and eliminating one's risk of infection. Many settings with mobile populations especially need policy-focused, contextual interventions to foster individual behavior change. One approach to cross-border HIV prevention is to concentrate interventions at international border crossings because they are high-risk environments where national prevention programming is weak. The experiences of numerous agencies in cross-border STI/HIV/AIDS prevention activities have produced the following program guidelines:
Implementing cross-border interventions requires: Listing cross-border locations. Cross-border sites are not only contiguous land borders; water transportation can connect "sister" port towns. Compiling a complete list of cross-border crossings is impossible because sites change by the month. With the building or expansion of roads and bridges, new sites open while others may close or temporarily shut down. But it is important to try to establish a working list, mindful that including some unofficial sites may jeopardize refugees' welfare. Selecting sites for format assessment. Based on the established list, selecting sites for further intervention requires making an informed judgment on the role of each site as a contributor or potential contributor to the regional HIV epidemic. This judgment is made after considering the population, the historical STI and HIV incidence, the commercial sex industry, the availability of drugs and alcohol, the presence of an established entertainment sector, the number of uniformed service personnel and migrant laborers, and existing coverage with medical and social services. Conducting a preliminary rapid assessment and prioritization. Because cross-border areas tend to be remote and receive less coverage than major cities, there are limited resources to support cross-border activities. Identifying priorities based on a quick data collection effort — a "rapid assessment" — is important. The methods used in rapid assessments are most often qualitative, including in-depth focus group discussions, but also can be quantitative. Rapid assessment guidelines can be found in the UNAIDS publication "APICT Task Force on Migrant Labor and HIV Vulnerability and Initiating Cross-Border HIV/AIDS Prevention Programmes: Practical Lessons from Asia." Preparing the intervention program. While the rapid assessment will generate information needed for selecting and prioritizing intervention sites, designing an intervention program requires more detailed information about the cross-border community. In Asia, where the bulk of cross-border HIV implementation activity has occurred, two methods have been used. In one, the Participatory Rural Appraisal and the Participatory Learning and Action methodologies have been adapted to allow maximum community input. In the other, multi-disciplinary teams have performed technical assessments of communities, reviewing data with key local informants to design strategies that local groups will implement. In choosing between the two methods, the degree of urgency to implement prevention interventions must be weighed against long-term community development. Implementing interventions. The special challenges of cross-border settings require adaptations of state-of-the-art interventions used elsewhere. The most successful projects started locally before gradually sought the support of national governments. As early as possible, identify and engage the key stakeholders in the cross-border areas and forge partnerships among agencies across borders. Establish a project advisory committee whose members -- from both sides of the border -- can guide and support the implementing agencies. Evaluating the program. Evaluation, an essential component of all programs, is particularly difficult in cross-border programs because the populations' high mobility limits contact time for prevention activities. The great number of languages and dialects spoken in border areas is another complicating factor. And the relative absence of social and legal controls in border areas means that interventions designed to modify norms in migrant communities will be especially challenging. Evaluation efforts might be best focused on tracking risk behaviors and STI/HIV prevalence rates in certain community subgroups over time; qualitative methods could be used to assess the risk environment in the community as a whole. International border trade towns and seaports consistently have the highest HIV prevalence among societies around the world. Epidemics tend to originate in these sites before progressing inland. If effective prevention programs are implemented in these locations, the return on investment (in terms of fewer new infections) should be one of the greatest in the field of prevention. Resources
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