Far from home: migration and HIV

With the recent media and government attention on HIV and immigration, ABI GROVES looks at the reality facing HIV positive people attempting to migrate to Australia.

In December 2006, Pauline Hanson announced her intention to run for parliament again with an attack on immigrants with HIV. "We're bringing in people from South Africa at the moment, there's a huge amount coming into Australia who have diseases, they've got AIDS," she said, adding that black Africans should be barred from Australia. "They are of no benefit to this country whatsoever, they'll never be able to work", she said.

Pauline Hanson is not known for her getting her facts right, but just how many HIV positive migrants are coming to Australia? The available data does not provide an exact number, but the short answer is: very few. And even fewer of them come from Africa. The long answer is the same, but the picture becomes more complicated.

Between 2002 and 2005, about 60 per cent of new HIV diagnoses were among Australian-born people . With Australian-born people making up over 75 per cent of the population, this means that those born overseas are over-represented among new HIV diagnoses. But migrants with HIV don't belong to just one 'type', one sexuality or 'exposure category', or indeed one region of the world. Instead, the relationship between HIV and migration is complicated, and requires careful analysis.

Australia requires all prospective migrants to undergo health screening, which includes (for those over 15) an HIV test. People with HIV are usually excluded, although applicants in some visa classes (e.g. partner and family or humanitarian) can seek a 'waiver' of the health requirement. For logistical reasons, seeking a waiver is generally easier for people who are already living in Australia and apply 'onshore'. The largest numbers of people applying for permanent residency onshore come from India, China and the UK.

It is true that in recent years increasing numbers of immigrants have come from Africa (though by 2005 people from sub-Saharan Africa still made up only seven per cent of arrivals) . The high prevalence of HIV in Africa may mean that there are more people being refused entry to Australia because they are HIV positive, but the Department of Immigration does not collect statistics on this.

It is also true that Australians born in sub-Saharan Africa have a higher incidence of HIV and AIDS than the Australian-born population, as do Australians born in other regions such as Asia, North America and Latin America. However, the relatively low prevalence of HIV in Australia (930 new diagnoses in 2005) and the small size of the African community means that real numbers of Africans with HIV in Australia are tiny.

Further, statistics regarding HIV diagnoses in Australia provide little detail about the ethnicity of people with HIV. In Australia, HIV transmission continues to occur primarily through sex between men - over 86 per cent of newly acquired infections between 2001 and 2005 - though migrants are likely to be under-represented in cases of newly acquired HIV as people who test regularly for HIV - mostly gay men - are more likely to be diagnosed with newly acquired HIV. These include men born in Australia and, presumably, all other countries from which migrants come - the largest groups of which are from the UK and New Zealand. This diversity makes education or prevention work more complex, as many gay men from non-English speaking backgrounds may primarily identify with the 'gay' community rather than their ethnic community. Many others may identify with what social researcher Maria Pallotta-Chiarolli called an "an interweaving of categories" which includes gay and ethnic identities as well as class and religion .

Among people who acquired HIV through heterosexual contact, who make up about 20 per cent of HIV notifications over the past five years, the picture is even more complicated. One third of heterosexual people with HIV are reported to be from high prevalence countries, and another 27 per cent reported acquired the virus through a partner from a high-prevalence country.

But these figures only point to a much more complicated relationship between migration and HIV. Recent figures from Western Australia, for example, show a different pattern. Last year 63 people were diagnosed with HIV in Western Australia. In contrast to other states, only 40 per cent of transmissions were attributed to homosexual contact. Almost 50 per cent - with roughly equal numbers of men and women - were attributed to heterosexual contact. And nearly 40 per cent of transmissions were reported to have been acquired overseas. The reasons for this pattern are not clear. They could include the relatively large Indigenous community in Western Australia, a significant South African community, and a booming mining industry with increasing numbers of people entering and leaving the state both for work and leisure.

Refugees

In recent years the public debate about refugees in Australia has been intense. In fact, humanitarian entrants make up only a small proportion - about 10 per cent - of overall migrants. These people come from all over the world. The composition of Australia's humanitarian program (which makes up about 10 per cent of the total migrant intake) changes according to where applications come from. During the 1990s, for example, large numbers of applicants came from the former Yugoslavia. In the last 10 years increasing numbers of people have come from the Middle East (mostly Iraq and Afghanistan) and from Africa - particularly Sudan. The composition of Australia's humanitarian program is determined through representations made to the Australian Government by organisations such as UNHCR and through an annual consultation process with the community.

Those applying for humanitarian entry must meet the same health requirement as other applicants in the general migration stream. In 2005-2006, there were 81,682 offshore applicants for humanitarian entry and around 12,000 of these were successful. Most people who apply for humanitarian entry to Australia do so from outside the country.

Asylum seekers

'Asylum seekers' - those who arrive in Australia seeking humanitarian entry - are an even smaller number. During 2005-06, for example, 10 per cent of humanitarian entrants were onshore applicants, with 1,272 protection visas granted.

Temporary protection visas are for those who arrive unauthorised seeking asylum. Most unauthorised entries to Australia are people who arrive by air without a visa - many are sent home on the next available flight. Numbers of people arriving by sea - "boat people" - have fallen dramatically in the last few years. For instance, in 2000-2001 there were over 4,000 boat arrivals - but in 2004-2005 there were none.

People who arrive in Australia without documentation are placed in detention. During 2005-06 there were 7,375 people detained at some point: over 40 per cent of these were illegal foreign fishermen who were usually sent home within a few weeks. People who had overstayed visas made up the majority of detainees. Only one per cent were people who arrived unauthorised by boat and sought asylum, compared to11per cent who arrived unauthorised by air.

The profile of people applying for humanitarian entry once they are in Australia is quite different, with more onshore applicants coming from China, India and south-east Asia. Most arrive in Australia legally on other kinds of visas (e.g. student visas). If they subsequently apply for humanitarian entry they are referred to a Medical Officer of the Commonwealth for health screening, including an HIV test.

Some migrants become aware of their HIV status only through this process.
Henrike Korner, a researcher from the National Centre in HIV Social Research, conducted a study about HIV and immigration among people from culturally and linguistically diverse backgrounds. Her study included a number of people who tested positive for HIV during immigration health screening. In the study she found that the management of this process was less than ideal. One Cambodian woman says,

'I came to Australia as a [visa type] and then I applied to live permanently in Australia…And then the paperwork went through and the last part they asked me to do the blood test and then one day they call me to tell me about my results and they told me that I'm positive with this and then I feel shocked. I fell unconscious right away…I did not have any idea that I might have this. So unpredictable, it really make me shock…And since then I cannot sleep every night'.

In fact, none of Korner's respondents reported receiving any pre or post-test counseling. However, it is worth noting that in Australia, Health Services Australia (HSA) has a contractual obligation to provide this service. In addition, HSA provides statistical reports about the frequency of services provided, including pre-post test counseling.

Immigration Detainees with HIV

Information about the number of immigration detainees with HIV is not made public. Privacy of individuals' medical information is paramount, therefore it is not appropriate for this type of information to be made available by the health service providers. Anecdotal evidence suggests that it is very small. Asylum seekers who arrive in Australia illegally are screened when they enter detention centres; all people admitted to detention centres receive a medical check on arrival.

Because detention centres are privately operated, information about health services and the health of detainees is difficult to obtain. One study of 7,000 people in detention centres in Western Australia and South Australia found four people who tested positive for HIV (though two of these tests were inconclusive) . This rate of HIV prevalence is actually lower than in the general community.

Because of the high proportion of visa overstayers held in detention, HIV cases diagnosed in detention centres are more likely to be among people who arrived in Australia legally. It is possible that these people - many of them gay men - also seroconverted while in Australia, and may or may not be aware of their status when they arrive in detention.

The policy for HIV screening adopted by the detention health service providers is in line with the National HIV/AIDS Strategy- Revitalising Australia's Response 2005-2008 and is based on the six National Guiding Principles. All people entering Immigration Detention Centres are offered screening for a range of conditions, including non-compulsory, voluntary and confidential testing for HIV with associated pre- and post-test counselling.
Should a person in detention become successful in being granted residence in Australia, they will undertake a health screening process as part of their approval process. Currently, this includes compulsory testing for HIV.

Pre- and post-testing counseling is provided by trained counsellors in all cases where HIV testing has been undertaken or is proposed, and treatment associated with testing, diagnosis and ongoing care of any diagnosed illness to enable optimal immediate clinical management.

However, detainees with HIV have access to antiretrovirals, thought health services may be less than ideal. Ratu , an asylum seeker who was detained at Villawood in Sydney says that,

'No facilities there for positive people. I have special diet, but can't do that in there so my cholesterol go way up in there. I tell them I go to clinic every month and after so much …so much argue and explaining… they take me to clinic'.

The Albion St HIV clinic in Sydney, New South Wales, has occasionally treated detainees such as Ratu, who are transported to the clinic under police guard. From time to time HIV services such as the AIDS Council of New South Wales and the AIDS Council of South Australia have also had contact with clients in Villawood in Sydney and Baxter detention centre in South Australia. Both organisations have found the process of gaining access to clients in detention centres difficult and time-consuming, which may impact on service delivery. The lack of information about health services in detention also makes advocacy difficult, though the small number of asylum seekers with HIV means that services are dealing with a handful of cases.

The diverse but comparatively small numbers of immigrants with HIV in Australia suggests that the relationship between HIV and migration is much more complex than critics such as Pauline Hanson might suggest. Tadgh McMahon, Manager of Sydney's Multicultural HIV and Hepatitis C Service, says that, "The patterns in migration and HIV are complex and need to be considered in the context of the HIV epidemic in Australia and globally. Sweeping generalisations about HIV and migration are neither appropriate or useful."

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