1. Making Migrant Friendly Health Services a Reality in Thailand Brahm Press Raks Thai Foundation PHAMIT Program

2. Overview of presentation Situation of Migrant Workers and HIV in Thailand PHAMIT Project Accomplishments / Gaps Migrant Friendly Health Services?

3. Reasons migrants come to Thailand Economic prosperity: GDP per capita(USD) 2007: Camb 440; Lao 485; Thai 2,750 Myn 220; Thai 2,750 Long, porous borders Chain migration Thais reject unskilled low- paying jobs, or go abroad

4. Current Situation of Migrant Workers in Thailand documented Currently, 1.45 million documented migrant workers from three countries as of Feb. 2013: Myanmar: 1,086,734 Cambodia: 263,706 Lao PDR: 99,567 undocumented Estimated twice as many undocumented = over 3 million migrants in total Documented by sex: Men 57% Women 43%

7. Migrants Vulnerability to HIV Migration is not a risk factor for HIV, but does increase conditions that contribute to vulnerability: Limited rights due to legal status as non-citizen (related to being low-skilled labor) Removed from traditional social controls and in prime reproductive years Limited access to information and services due to language barriers and restrictions on mobility Inaccurate knowledge and sub-culture norms contribute to engaging in behaviors that increase their risk of HIV, STIs and unplanned pregnancy

9. HIV Prevalence among Migrant Workers and Fishermen in Thailand (1997-2007) fishermen migrant workers

10. HIV Prevalence 2010: Migrant workers (6 provinces) MaleFemaleTotal Age 15-241.0%1.4%1.1% All ages1.7%2.1%1.9% IBBS, Bureau of Epidemiology 2010, MOPH, Thailand (Unofficial)

11. HIV prevalence among migrants all ages by nationality in 6 provinces IBBS, Bureau of Epidemiology 2010, MOPH, Thailand (Unofficial)

12. HIV prevalence among migrants all ages by occupation (6 provinces) IBBS, Bureau of Epidemiology 2010, MOPH, Thailand (Unofficial)

13. PHAMIT Project Prevention of HIV and AIDS among Migrant Workers in Thailand 2003 extended to 2014 – supported by Raks Thai Foundation and DDC are PR w/ 7 partner NGOs and local health office Have reached over 800,000 migrants with direct interventions Covering 36 Provinces (almost half the country)

14. Scale up comprehensive HIV prevention for migrants Goal - Scale up comprehensive HIV prevention for migrants Objective 1: To strengthen and scale up delivery of comprehensive HIV prevention services Objective 2: To build a strong enabling environment Objective 3: To strengthen strategic information systems for program and policy improvement

15. HIV prevention interventions – Outreach at workplaces and communities Development of Migrant Field Officers and Migrant Health Workers linked to networks of migrant volunteers Provide small group outreach activities Language appropriate communication materials (diverse media) Condom distribution (direct, volunteers, boxes) Drop-in centers (activities, referral) – Referral for VCCT and STI

16. Condom Use Last Time Had Sex by Partner Type - Average of All Sites, 2004-2008 (Phase 1) Institute for Population and Social Research, Mahidol University, 2009

17. Condom use last sex episode by type of sex partner past 12 months – 2010 Baseline Phase 2 Institute for Population and Social Research, Mahidol University, 2011

18. Referral to VCCT Agreements made with local hospitals to receive migrants for HIV testing and STI diagnosis and treatment Referral made through MHW, FO / FOM or volunteers Pre-pre and post-post test counseling provided at drop-in centers by FOM / MHW HIV counseling and testing provided at hospital with translation by MHW Approx 8,000 migrants have tested for HIV and know their results over the past 4 years…

19. Migrants in need of ART Quota of ART for 2,000 migrants supported by GF under NAPHA-Ex Program by Thai Govt is filled PMTCT for all (if enter ANC on timely basis), but no guarantee of treatment for mother after birth Estimated that at least another 3,000 migrants are currently in need of ART (could be much higher) Pay out of pocket 2,000 THB / month for first line (almost 1/2 month salary) Migrants wait until health fails to test or buy treatment

20. Cross-Border ART? Return home, start treatment but then return to work in Thailand… Arrangements w/ Cambodia to receive ART at the border Some purchase large quantities in Myanmar to take with them Lao come to Thai side to initiate treatment But, currently no cross-border referral system

22. Policy Goal: Migrant Health Workers (MHW) Achieved: Occupation to register migrants doing social work Verbal agreement with Ministry of Labour to allow hospitals to use MHW Around 10 hospitals utilize MHW for counseling (ANC, VCCT) and other services – some paid by hospital others by NGO Missing: Lack of formal National-level policy leaves hospitals reluctant to hire MHW, hinders expansion Changes in health insurance policies have reduced migrant health prevention budgets

23. Policy Goal: ART for Migrants Achieved ARV for around 2,000 migrants (both doc and undoc) – around half referred through PHAMIT Covered by Social Security (w/passport) receive ART Missing Questions of sustainability and coverage of ARV currently supported by GF Changes are being made to compulsory insurance scheme to include ART – price needs to remain low enough to encourage subscription Transferable or portable ART service package intra- and inter-national

24. Earlier HIV testing Improved health outcomes