Complex routes into HIV care for migrant workers: a qualitative study from north India

ABSTRACT

Migrant workers are designated a bridge population in the spread of HIV and therefore if infected, should be diagnosed and treated early. This study examined pathways to HIV diagnosis and access to care for rural-to-urban circular migrant workers and partners of migrants in northern India, identifying structural, social and individual level factors that shaped their journeys into care. We conducted a qualitative study using in-depth interviews with HIV-positive men (n = 20) and women (n = 13) with a history of circular migration, recruited from an antiretroviral therapy centre in one district of Uttar Pradesh, north India. Migrants and partners of migrants faced a complex series of obstacles to accessing HIV testing and care. Employment insecurity, lack of entitlement to sick pay or subsidised healthcare at destination and the household's economic reliance on their migration-based livelihood led many men to continue working until they became incapacitated by HIV-related morbidity. During periods of deteriorating health they often exhausted their savings on private treatments focused on symptom management, and sought HIV testing and treatment at a public hospital only following a medical or financial emergency. Wives of migrants had generally been diagnosed following their husbands' diagnosis or death, with access to testing and treatment mediated via family members. For some, a delay in disclosure of husband's HIV status led to delays in their own testing. Diagnosing and treating HIV infection early is important in slowing down the spread of the epidemic and targeting those at greatest risk should be a priority. However, despite targeted campaigns, circumstances associated with migration may prevent migrant workers and their partners from accessing testing and treatment until they become sick. The insecurity of migrant work, the dominance of private healthcare and gender differences in health-seeking behaviour delay early diagnosis and treatment initiation.

KEYWORDS:

• Transients and migrants
• HIV infections/prevention & control
• India
• qualitative research
• care pathways

Acknowledgements

We are grateful to Dr Kavita S. Agarwal for arranging introductions with local contacts at the HIV clinics and for facilitating in the fieldwork. Thanks also to Professor Peter Piot for providing feedback on previous drafts of this manuscript.

Disclosure statement

No potential conflict of interest was reported by the authors.

Notes

1. Areas with an estimated antenatal HIV prevalence of >1%.

2. The remaining woman was diagnosed following illness after her marriage dissolved.

Additional information

Funding

This work was supported by a Medical Research Council – Doctoral Training Award (grant code: G24038) studentship held by T.R. during her PhD and a Wellcome Trust grant (grant code: 090285/Z/09/Z) held by H.W.