HIV Alarm in Central Asia

Nigora discovered she was HIV-positive when she had a blood test in her seventh month of pregnancy. When her doctors spoke to her husband, he revealed that he had unprotected sex while working abroad, and his test showed up positive as well.

“I wasn’t even aware of the disease, so I didn’t take precautions,” he said.

Nigora’s baby was born HIV-free, but her first child was infected through breast milk.

Her story fits a pattern that is becoming increasingly in this region. Hundreds of thousands of people from Tajikistan, Kyrgyzstan and Uzbekistan, generally but not always men, spend long periods of time abroad, often in Russia. There they are at risk of contracting HIV through high-risk behaviour such as unprotected sex, or in some cases sharing needles to inject drugs. When they come home, ignorance of HIV or shame about discussing it can mean they unwittingly pass on the virus to their partners.

Statistics show a steep rise in HIV infection rates across the Central Asian states. The statistics show the highest incidence among drug users who share hypodermic needles, followed by sexual contact, in some cases involving commercial sex workers. Although comprehensive statistics are not available, it is clear that HIV is not nearly as prevalent among migrants as a group.

However, what sets the migrants apart from other categories is that when infection occurs, families in their home towns and villages across the Central Asian countries are potentially vulnerable.

Kyrgyzstan, Tajikistan, and Uzbekistan – the subjects of this report – stand out among the five regional states because exceptionally large sections of the population are either migrants themselves or have family members who are. Given the low level of public knowledge about the issues, unless a migrant’s wife undergoes testing during pregnancy, she and her family may remain unaware they are HIV-positive.

Experts say population mobility can lead to more rapid and wide-ranging transmission than, say, the use of shared needles, which occurs within a narrower section of the community.

“If we consider the size of labour migration from Central Asia – as an example, it is estimated that one-fifth of the population of Kyrgyzstan and Tajikistan are currently in labour migration – it is possible to imagine the significance of the problem,” said Vasily Esenamanov, HIV programme advisor with the Central Asia office of DanChurchAid and ICCO, aid groups from Denmark and The Netherlands, respectively. “Labour migrants are [part of the] general population, not marginalised, and not so locked within their own stratum like injecting drug users or men who have sex with men.

“What is visible from the official statistics is that the virus is bridging to the general population, meaning that new cases are not isolated to risk groups such as IDUs, but also found among women who are not using drugs and children. This is a critical issue as the virus can then catch speed and spread more rapidly in the population in general.”

According to Zamira Akbagysheva, head of the Congress of Women in Kyrgyzstan, “Labour migrants are more susceptible to HIV than static populations. Mobility…. frequently provokes riskier behaviour. Separation from family and from long-term partners, the sense of liberation from social constraints, and receptiveness to one’s new environment – all tend to encourage frequent changes of sexual partners.”

HIV ON THE MARCH IN CENTRAL ASIA

As of the end of December, Tajikistan had 1,853 people recorded with HIV, 80 per cent of them male. In Kyrgyzstan, the number of recorded cases stood at 2,837 as of March 2010; 70 per cent were men.

In both countries, the commonest route for infection was via reused hypodermic syringes. Most cases involve users of injected drugs. Infection through dirty needles used in hospitals is another route – around 120 children were infected in this manner in southern Kazakstan in 2006 and 170 in Kyrgyzstan two years later. In March, the regional news site Fergana.ru reported that around 150 children in the Namangan region of eastern Uzbekistan were infected through medical negligence in 2007 and 2008.

In Tajikistan and Kyrgyzstan, sexual contact accounted for about a quarter of cases.

In Uzbekistan, the most recent figure is for 2008, and indicates that 1,250 people were officially recorded as HIV-positive, a very low figure given that Uzbekistan had some 27 million people that year compared with Tajikistan’s seven million and Kyrgyzstan’s five million.

A human rights activist told IWPR that the overall figures for HIV/AIDs appeared to be grossly underestimates, and no figures disaggregated by risk category had been issued in the last two years.

He said work done by him and his colleagues suggested that migrants would amount to a low percentage of an accurate overall figure. At the same time, “bearing in mind that the number of labour migrants is incomparably larger than that of [specific] risk groups, the total number of migrants infected is of course much larger…. Another facet of the problem is that increasing numbers of women are going abroad to work and many unfortunately engage in prostitution, which of course increases the risk of HIV infection.”

An Uzbek analyst who asked not to be identified said surveys conducted by local NGOs suggested there were at least 7,500 people living with HIV in 2009, and the percentage of those who were migrants was “approximately 25 to 30 per cent”.

In Tajikistan, the number of recorded cases grew by 30 per cent year on year in 2009 and 35 per cent in 2008, although doctors say the increase is partly attributable to better diagnosis, thanks to funding from the United Nations Global Fund to Fight Aids, Tuberculosis and Malaria.

Dr Katoyon Faromuzova, Tajikistan national coordinator for the International Organisation for Migration, notes that some experts believe that official statistics need to be multiplied by a factor of ten to arrive at more accurate figures. But she personally thinks the official figures are close to the truth, thanks to more effective testing that targets groups like pregnant women.

Zuhra Nurlaminova of Tajikistan’s official Republican AIDS Centre agrees that people are much more ready to come forward now that there are dozens of test clinics around the country.

“Previously, there wasn’t any express-service testing….there wasn’t the required equipment. Public awareness was very low,” she told IWPR. “But now there are public-service ads on television and banners in the streets, so there’s a lot more people coming in,” she said. “Whereas it used to be that virtually no one would come in for an anonymous test, now there are a lot more admissions.”

HOW IMPORTANT IS MIGRATION TO HIV SPREAD?

Measuring the number of cases involving migrant workers contracting HIV abroad is a lot more difficult. Officially, there were 197 such cases in Tajikistan in 2009, or 11 per cent of the total. Kyrgyzstan does not separate out figures for migrant workers, although the authorities recognise this category is a high-risk one.

Sagynbu Abduvalieva, head of infant pathology for Kyrgyzstan’s National Centre for Mother and Child Protection, estimates that migrants account for up to 20 per cent of HIV-positive people in the country.

In Uzbekistan, the analyst who spoke to IWPR said the available evidence indicated that as elsewhere in the region, intravenous drug users were the most at-risk category, but “migrants and prostitutes come in equal second place, with not much between them”. He noted that the overall number of migrants from Uzbekistan – predominantly consisting of male manual labourers – includes some women travelling to other countries to work as prostitutes.

Potential HIV carriers among the families of migrants are even harder to track given the paucity of official data, he said. “It’s precisely these ‘family” carriers who are the group that is most hidden and hard to capture in the statistics,” he said. “They are latent [carriers] and because of the stereotypes that have grown up, they don’t generally fall within the risk group as it is commonly conceived.”

In Tajikistan and Kyrgyzstan, Esenamanov said, “There is no evidence supported by official statistics. However, many local organisations working in the area of HIV in Kyrgyzstan and Tajikistan state that there is evidence of a rapidly growing number of infections among wives of men who return from labour migration…. This can indicate that number of infections through labour migrants is growing rapidly and that HIV is bridging to the general population. “

Mohira Hamidova, an HIV prevention specialist with the national AIDS Centre in Tajikistan, also sees a correlation between migration and the rise in sexual transmission rates.

“It used to be that injecting accounted for more than 70 per cent of cases, but now that has gone down to 54 per cent, while the sexual transmission route has risen as a proportion,” she said.

“My work involves working with pregnant women infected with HIV. Of the total number now under observation at the Centre, 102 are pregnant and 70 per cent of that number are the wives of labour migrants. We identify them among all the women who undergo testing at clinics and maternity hospitals, and only then does it become apparent that they were infected by their labour migrant husbands.”

Nurlaminova was less certain that migrants play a pivotal role in transmission.

“It would be wrong to say labour migration is the basic problem; instead, it is drug users. Labour migrants account for just 11 per cent,” she said.

Faromuzova says that in Tajikistan, migrants do constitute a risk group.

“If young men are cut off from their families and go away for a long period, they become at risk. For one thing, it occurs because they find themselves in that social environment. For another, they are cut off from their families but still have psychological and other needs. Young people are away from their parents’ influence and feel liberated. So they are at risk for that reason.”

The reason the migrants are an important group to watch, said Esenamanov, is that they represent such a large proportion of the total population – one fifth of the populations of Kyrgyzstan and Tajikistan.

The numbers of people involved in migration are staggering – from 400,000 to one million from Kyrgyzstan, anywhere between 600,000 and 1.5 million from Tajikistan, and between one and four million from Uzbekistan. Most go to Russia, and smaller numbers to Kazakstan. As Esenamanov noted, “This is incomparable [larger than] the number of sex workers, injecting drug users, men who have sex with men, and other risk groups.”

LACK OF AWARENESS AMONG MIGRANT COMMUNITIES

Migrant workers in Russia and Kazakstan are typically engaged in low-status manual work, and are vulnerable to rights violations by employers and local police.

While immigration authorities in Russia and Kazakstan now demand HIV tests as a condition of entry, a high percentage of workers from Kyrgyzstan, Tajikistan and Uzbekistan avoid these procedures and work illegally in the grey economy.

Matluba Rahmanova of Tajikistan’s AIDS Centre said that while the clinic tested dozens of migrants taking the legal route every day, and less than one per cent of them tested positive, “One should not forget most migrants leave the country without these certificates – those who are working abroad illegally.”

“It’s important to understand the labour migrants are a vulnerable group,” explained Esenamanov. “They seek work abroad in order to feed their families, often end up in very low paid and insecure jobs, and are harassed by authorities and local citizens in Russia. Many, but not all, have a low education and come from rural areas. There are few and limited educational programs and materials available about reproductive health - sexually transmitted diseases [STD] and how to prevent them – and our extensive baseline study shows a very low level of knowledge about the risk of HIV and other STD, which of course increase the risk, and high-risk sexual behaviour such as non-use of condoms.”

Esenamanov said HIV infection could come through contact with prostitutes. He cited a study by the Humanitarian Action Foundation in St. Petersburg which showed that 50 per cent of local sex workers are intravenous drug users, and 95 of that category are HIV-positive.

“Therefore, the risk of contracting HIV is quite high when visiting commercial sex workers. [The migrant] does not use a condom as he is simply not aware of the need to do so, or does not think this is necessary, and contract HIVs,” he said. “After returning home not aware of having HIV they infect their wives.”

Labour migrants who inject drugs through shared needles can also contract acquire HIV, and pass it on to their wives. In Kyrgyzstan, Akbagysheva said husband-to-wife transmission was a significant factor.

IWPR interviews with migrant workers past and present suggest widespread ignorance about HIV, its transmission, and preventive methods.

“We ‘gastarbeiters’ only seek [medical] help under extreme circumstances, for example for industrial injuries,” said Yoldash, a young man back from Moscow and living in Jalalabad in the south of Kyrgyzstan. “There’s a class of people who are educated, and they safeguard themselves against HIV, but those who are uneducated don’t protect themselves.”

Jasur, now at medical school in the Kyrgyz capital Bishkek, also spent time working in Russia. He said that most of his fellow-workers there had little education and were uninformed about HIV. While some might put themselves at risk by injecting drugs, he said he believed “the sexual transmission route for HIV infection took first place.”

The rights activist from Uzbekistan agreed that “the overwhelming majority of labour migrants have a very weak understanding of HIV/AIDS and the risks, infection routes, and preventive measures. Many don’t have a clue what HIV is.”

WIVES INHIBITED BY SHAME FACTOR, LACK OF AWARENESS

Women in traditional rural communities, said Esenamanov, “cannot demand that their husbands get tested or use condoms; nor do they know of HIV at all. Women infected by their husbands give birth to HIV-positive children, as these women are not aware of prevention of vertical, mother-to-child transmission.”

Nurlaminova agreed that male labour migrants were commonly unaware of their HIV status. “They discover they are ill when their pregnant wives undergo testing.”

She said dealing with couples was more straightforward when the husband was aware he was HIV-positive, but added that “it’s a lot more complex when it’s the wife who’s the first to discover she is infected. Fearing that she will be unjustly accused of adultery, she will wait for months while she thinks about how to tell her husband.”

Awareness levels are generally low in the rural communities from which migrants often come.

“Urban people are better informed about the issue. They’ve heard of AIDS, they know the transmission routes and many take precautions for sexual contact,” said Nurlaminova, adding that the majority, young people from rural areas, “generally don’t know much about it, or else they know nothing at all.”

She went on, “Another feature of labour migrants here is that most of these ordinary village lads never use condoms. When you talk to them, some of them don’t even know what those are, and neither do their wives.”

Pia Dyrhagen, who was a programme officer with DanChurchAid in Central Asia until December, initiated a project on HIV/migration for together with local organisations about two years ago. She says anyone identified as HIV-positive faces high levels of discrimination. “Neighbours, villagers and even family members refuse to talk to them and turn their back on them if meeting them in the street,” she said. “There are cases of chidren not being admitted to school when the head of school found out the child was HIV-positive. In Tajikistan [our NGO] partners speak of cases of suicide among women who were HIV infected by their husbands who returned from migration.

“All this because people don’t know enough about the virus.”

This lack of awareness is in part due to education programmes that have hitherto focused on narrower high-risk categories.

“The fact that this transmission route takes place among the general population is the most critical issue,” said Esenamanov. “Whereas intravenous drug users and commercial sex workers in Central Asia have been receiving targeted information for the last seven years, nobody has been disseminating information about sexually transmitted diseases among the general population, at least not in a very structured and engaging way, as this group had not been prioritised… by the donor organisations. The high level of taboo surrounding sex and the use of condoms makes it a difficult topic to talk about, especially in schools and other official institutions.”

He noted that people living with HIV tended to be stigmatised “in medical institutions, among representatives of authorities and religious leaders, but also among the local population”.

“If the spread of HIV should be curbed, it is necessary to engage all the parties involved in a dialogue where all problems can be discussed openly and with mutual respect,” he added.

GOVERNMENTS START TO TAKE ACTION

There are signs that governments in the region are becoming aware that migrants constitute a risk category, and need to be targeted with special awareness-raising campaigns.

Hamidova pointed out that in Tajikistan, the wives of labour migrants were now counted as one of five categories of women subject to mandatory testing when they visit gynaecological clinics or maternity hospitals.

“Doctors refuse to examine them unless they undergo the test,” she said, adding that the provision of rapid HIV testing facilities in all such institutions last year has greatly helped identify HIV cases, and women not included in the five key categories, which also includes women who inject drugs or have partners who do so and commercial sex workers.

According to Esenamanov, “the Kyrgyz and Tajik governments have both made migrants a priority group in their respective national strategies for HIV”. He said his organisation had found the authorities in Kyrgyzstan and Tajikistan responsive, and the main challenge now was “finding effective measures to curb the spread of HIV and finding the resources to carry these out”.

In Uzbekistan, a recent law stipulates that HIV tests for certain groups should be free and confidential. But it has yet to focus on migrants as a particular category.

“The [Uzbek] authorities’ failure to recognise migrants as a risk group alongside prostitutes and drug abusers is one of the reasons why they have not to date been included in mandatory prevention work and registration,” said the analyst interviewed in Uzbekistan.

The human rights activist also in Uzbekistan said that while the government was trying to tackle the spread of HIV, it placed severe restrictions on information and statistics relating to the problem. Some of the leaflets produced to help people understand the issues had been denounced as “pornographic” by officials, he said.

In one case reported by IWPR earlier this year, psychologist Maxim Popov was sentenced to seven years imprisonment after a court in Uzbekistan found that a book he produced to educate young people about sexually transmitted diseases and shared needle use was illegal because it allegedly encouraged young people to use narcotics. Popov headed a group called Izis which worked with drug users and sex workers to prevent HIV/AIDS, and ran a needle exchange programme for addicts.

Esenamanov told IWPR that donor organisations in Central Asia did not prioritise labour migrants as a specific target group until recently. That was now changing and a range of international and local NGOs were working together to curb the spread of HIV among labour migrants and those with whom they come into contact.

“So far – one year after project start – there are many positive results and it is the hope that it will be possible to continue the project and expand the scope,” he said.

Bonivur Ishemkulov, project coordinator with the United Nations Global Fund to Fight Aids, Tuberculosis and Malaria in Kyrgyzstan, said a number of NGOs were now focusing on migrants as well as other groups.

A project to prevent HIV specifically among migrant workers was launched last December, as a component of the Central Asia AIDS Control Project, a 27-million US dollar initiative funded by the International Development Association and Britain’s Department for International Development. An education centre in the Tajik capital Dushanbe will coordinate work in in Kyrgyzstan, Kazakstan and Uzbekistan as well as Tajikistan.

Meanwhile, the HIV prevention project launched by the Congress of Women in Kyrgyzstan in February is trying to provide information direct to migrant workers.

“Our trainers are now going round the markets, airports and railway stations giving out leaflets and posters for migrants to read and find out how to protect themselves,” she said.

Many of the experts interviewed for this report were at pains to point out that while targeted awareness campaigns were essential, that did not mean the large number of Uzbeks, Kyrgyz and Tajiks people travelling abroad to earn a living should be lumped together as some kind of dangerous group.

Dr Faromuzova expressed concern that migrants, often the most enterprising part of the labour force, should not become the target of “fear, discrimination and stigma”.

“It isn’t enough that they are providing for their families, easing social tensions and helping develop their country – they could have this label slapped on them as well,” she warned.

Akbagysheva agreed, saying, “We can’t make scapegoats out of the labour migrants. But we definitely have to work with them.”

Dina Tokbaeva is IWPR editor in Kyrgyzstan. Beksultan Sadyrkulov is a pseudonym for a reporter in Bishkek and Aslibegim Manzarshoeva is an IWPR-trained journalist in Dushanbe.

This article was produced jointly under two IWPR projects: Building Central Asian Human Rights Protection & Education Through the Media, funded by the European Commission; and the Human Rights Reporting, Confidence Building and Conflict Information Programme, funded by the Foreign Ministry of Norway.

The contents of this article are the sole responsibility of IWPR and can in no way be taken to reflect the views of either the European Union or the Foreign Ministry of Norway.