Othoman Mellouk ITPC-MENA/ALCS Maroc HIV and Migration in Morocco Case Study

Introduction In the middle of the XXth century: Morocco is principal country of « Emigration » Moroccans constitute a community of migrants among the largests and more dispersed in Western Europe Morocco used to be a transit country for migrants from Subsaharan Africa to Europe More recently it became a country of immigration for many migrants from sub-Saharan Africa (EU migration policies) Migration is a sensitive political issue in Morocco both in relationships with EU and internally High social vulnerability Little information is available about migrants (clandestinity) Myths about HIV and Migration…

Since years 2000: NGOs (ALCS, Médecins du Monde, Médecins Sans Frontières…) launched HIV programs targeting migrants NGOs also succedded to obtain the right for migrants to same healthcare services as nationals However, no data available about HIV and migrants : MoH and NGOs launched a study

Studied population Migrants in irregular administraive situation -Originally from a sub-saharan country -Irregular administraive situation (refugee, asilum seeker, undocumented) -Aged + 18 ans yo -Living in Rabat/Salé or Témara and more than 3 months in Morocco -Speaking French or English -Able to provide consent TWO studies: Francophone (n=410) and Anglophone (n=277) populations. Formative research showed that the two communities were socially dissociated with limited interaction

Origin Country of Migrants Global 78 %

Reasons of migration

Sociodemographics Francophone Anglophone

FrancophonesAnglophones n % (IC 95%)n Date last arrival in Morocco Before % (3.8, 9.3)3812.9% (9.0, 16.8) % (20.9, 29.4)9135.5% (29.7, 41.3) % (62.8, 73.7) % (46.0, 57.2) Point of entry Mauritanian border7419.7% (14.2, 25.3)144.3% (1.5, 7.2) Algerian border % (60.9, 72.6) % (88.5, 94.8) Airport6413.2% (9.1, 17.2)12 3.4% (1.8, 5.0) Seaport10.3% (0.0, 0.6)1 0.6% (0.1, 1.3) City of arrival Oujda % (61.7, 72.8) % (89.1, 95.3) Casablanca6614.2% (9.7, 18.7)13 4.0% (2.2, 5.9) Dakhla5916.5% (11.6, 21.3)9 2.5% (9.8, 4.1) Autre12 2.1% (0.9, 3.3)4 1.3% (0.0, 2.6) Mean of travel to Morocco Plane6915.4% (10.8, 19.9)11 3.3% (1.5, 5.0) Vehicle % (80.1, 89.2) % (94.4, 97.8) Ship % (0.1, 1.3) Accompagnant at arrival Alone % (35.3, 48.0)7428.2% (23.3, 33.1) Group % (47.1, 59.5) % (59.2, 70.8) Membres de la famille26 5.1% (2.9, 7.3)15 6.8% (3.0, 10.6) Entry in Morocco

Life conditions FrancophoneAnglophone n%, (IC 95% )n% (IC 95% ) Live with partner /conjoint Oui % (63.1, 74.2) % (39.6, 51.4) Number of children living with respondaant % (67.3, 81.1)4853.2% (42.1, 64.4) % (9.9, 19.7)3439.4% (25.5, 53.3) % (6.5, 15.5)8 7.3% (1.4, 13.3) Number of adult men living with respondant % (20.0, 29.0)5822.3% (16.1, 28.5) 1 à % (43.3, 56.1) % (49.5, 62.3) % (20.6, 31.0)6921.8% (16.1, 27.6) Number of adult women living with respondant % (48.6, 60.1) % (51.6, 65.1) 1 à % (33.0, 44.4)9936.7% (30.4, 43.0) % (3.6, 10.2)174.9% (2.6, 7.2)

Sources of income Francophone

Health conditions

FrancophoneAnglophone n% IC 95% n Symptoms of cough with mucus, fever, sweat, loose of weight Yes26 7.1% (4.5, 9.6)4115.6% (11.1, 20.1) No % (90.4, 95.5) % (79.9, 88.9) High fever since last 6 months Yes9522.8% (17.3, 28.2)8428.0% (22.0, 34.0) No % (71.8, 82.7) % (66.0, 78.0) Malaria episode since arrival Yes6916.9% (11.9, 21.9)8530.6% (24.4, 36.8) No % (78.1, 88.1) % (63.2, 75.6) Have seen a doctor for this symptoms since last 6 months Yes1932.1% (19.4, 44.8)1614.7% (8.2, 21.3) No5067.9% (55.2, 80.6)6785.3% (78.7, 91.8)

Access to Health Services Received health services in Morocco Yes % (41.0, 53.5)8433.0% (27.2, 38.8) No % (46.5, 59.0) % (61.2, 72.9) Evaluation of quality of services

Family Planning Used contraception methods during past 6 months Yes4030.8% (20.4, 41.1)1924% (10.5, 37.5) No8969.2% (58.9, 79.6)5676% (62.5, 89.5) FrancophoneAnglophone

Pregnancy and Delivery FrancophoneAnglophone n% IC 95%n Been pregnant in Morocco Yes3432.8% (20.4, 45.3)3558.0% (43.3, 72.8) No7167.2% (54.7, 79.6)2842.0% (27.2, 56.8) Received antenatal services in Mor Yes1126.6% (15.4, 37.9)1631.3% (5.1, 57.5) No2573.4% (62.1, 84.6)1968.7% (42.5, 94.9) Location of antenatal services Public hospital / Health center1035.0% (15.9, 54.0)938.1% (13.4, 62.8) Médecin privé213.3% (0.8, 27.3)1 4.0% (2.4, 5.5) ONG1251.8% (36.6, 67.0)1057.9% (33. 4, 82.6) Delivered in Morocco Yes2158.4% (36.3, 80.4)1739.7% (20.7, 58.7) No1541.6% (19.6, 63.7)1860.3% (41.3, 79.3) Location of delivery Public hospital/ Health center2094.4% (91.7, 97.2)1695.9% (87.9, 103.9) Private clinic15.6% (2.8, 8.3)1 1.1% (0.5, 1.7) At home % (4.6, 10.6) Child received birth certificate1458.1% (37.8, 78.4)1154% (37.4, 70.5)

Sexual Partners

Use of Condoms Sources of condom procurement

HIV Testing Taken HIV Test during past 12 months and received results Yes % (25.7, 37.1)6726.0% (20.1, 31.9) No % (63.0, 74.3) % (68.1, 79.9) Location of HIV test for those tested in Morocco

Violence FrancophoneAnglophone n % IC 95%n Experienced physical violence while in Moroccoi Yes % (37.9, 47.7)6925.1% (18.2, 32.1) Forced sexual relationships during past 12 months Yes3710.1% (5.6, 14.5)208.0% (4.2, 11.9) No (85.5, 94.4)25692% (88.2, 95.8)

Stigma and discrimination FrancophoneAnglophone n %, (95% CIs)n Services refused during past 12 months due to migrant status Health center4010.3% (6.7, 13.9)3011.9% (7.1, 16.8) Condoms21 5.0% (2.5, 7.6)216.9% (4.3, 9.5) Employment % (27.9, 40.2)13247% (39.2, 54.8) Education4011.6% (7.3, 15.9)6322.9% (17.9, 27.9) Public transports, Taxi4910.8% (7.6, 14.0)4012.9% (9.5, 16.4) Religious service27 6.5% (4.1, 8.9)2910.9% (7.2, 14.6) Resataurants30 6.4% (4.7, 8.1)2910.1% (6.0, 14.3) Assistance from police % (16.0, 25.7)5619.8% (14.9, 24.7)

HIV and Syphilis Prevalence

Recommendations  Increase coverage of migrants populations by public health programs, family planning, antenatal and PMTCT services  Implementation of a gender based approach given the high vulnerability of migrant women especially the anglophones. Streghtening sexual and reproductive health services for migrants.  Operaationnalization of the concept of combined prevention and strenghtening of networking of NGOs/Services providers working with migrants  Integration of Prevention/Testing services in public health centers

Recommendations  Train healthcare workers to increase capacity, impove services aand reduce stigma and dicsrimination  Icrease programs against violence and address sexual violence  Develop tools and adapted services to enable anglophone migrants access health services  Generalize free access to treatment and care espacially ART for ALL migrants eligible to treatment  Conduct other studies on migrants in other cities in Morocco

Aknowledgements: Investigators -Ministry of Health, Morocco (PNLS, INH, SMP, SMR) -ALCS, OPALS -GFATM Management Unit -UNAIDS Country Office in Morocco -Lisa Johnston Partners : FOO, CARITAS, Action Urgence, UNHCR, OIM Funders: UNAIDS, DDC Suisse, GFATM

Thank you Merci