The Ministry of Labour and Employment reports that a staggering 93% of India’s workforce operates in the informal sector. Many of these workers, including migrant laborers, endure difficult living conditions and struggle to access essential healthcare and social safety nets.’It is imperative that we prioritize the healthcare and social protection needs of informal sector workers,’ emphasized Syed Mohammad Afsar, head of the global HIV/AIDS program at the International Labour Organization (ILO). As one of the oldest UN agencies, ILO champions social and economic justice through promoting labor standards.
“Gujarat is an Indian state that receives many migrant workers – they
include those coming from neighbouring states as well as those who come
from different districts of Gujarat. These migrants work in the informal
sector and face a lot of hardships and challenges- such as violence,
inadequate income, or vulnerable situations where their rights may not
be protected. That is why since the last almost three years now, we have
focussed on Gujarat to promote HIV testing among informal sector
workers,” added Afsar. Addressing gender-based violence, income
disparities which make people vulnerable to HIV, and other
vulnerabilities is also vital.
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Breaking the Stigma: HIV Treatment and Prevention
Scientific evidence shows that if a person living
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What Are HIV and AIDS?
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Afsar shared that ILO intervention in Gujarat has been developed
together with the government’s Ministry of Labour and Employment,
local employers and trade unions, and other partners to address both:
HIV and TB among informal sector workers. Ending discrimination and
building capacities is so key, says Afsar. Community-based HIV testing
was one of the hallmarks of these efforts.
One such project of ILO was implemented by organisations like GAP
(Gujarat AIDS awareness and Prevention unit – GAP – which is part of
the International Society for Research on Civilization Diseases and on
Environment – ISRCDE).
“GAP has reached out to those who were unreached,” said Afsar while
speaking with CNS founder head Shobha Shukla on the sidelines of
world’s largest AIDS conference this year (25th International AIDS
Conference or AIDS 2024). “It is critically important to reach the
first HIV target – which is to ensure that at least 95% of people
living with HIV should know their status. People need to get diagnosed
to receive the lifesaving treatment.”
GAP-led initiative found that the HIV rate in the informal sector
workers they served was 0.36%, which is higher than the national average
of 0.23%.
GAP leaders Jogendra Upadhyay and Pankaj Patel both spoke to CNS. They
also serve on the leadership of INN – a pan-India network of over 350
groups working on issues related to HIV/AIDS- and were among the
distinguished presenters at AIDS 2024.
“Well-planned targeted interventions of National AIDS Control
Organisation (NACO) of the government of India also serve the migrant
workforce. But it has perhaps not reached everyone, such as construction
workers, small scale industry workers, farm workers, agriculture market
informal workers, fruit and vegetable market workers, quarry workers,
among others. We have to reach them with full cascade of comprehensive
health and social protection services so that no one is truly left
behind,” said Jogendra Upadhyay.
“Put human being first is a mantra of our founder late Dr Radium
Bhattacharya as our first accountability is to the people we serve who
are our first stakeholder too,” said Pankaj Patel.
“One problem is that migrant workers in unorganised or informal
workforce change every year. They work for a few months and then go back
to their native place because of ‘seasonal migration’. One example
is of those who work in cold storage warehouses in Gujarat. Cold storage
warehousing involves the storing of perishable or other temperature
sensitive goods like food, at a specific temperature range to maintain
their shelf-life and quality. About 10,000 workers from eastern Uttar
Pradesh, Bihar, Odisha, and other states, work in cold storages in
Gujarat for six months. Next year, all those who turn up to work could
be different. This increases vulnerability to HIV, TB, sexually
transmitted infections (STIs), and also breaks the continuum of care,”
said Jogendra.
GAP engaged employers and employers’ associations at local and state
level, along with trade unions, district TB offices (DTOs), Gujarat
State AIDS Control Society of the government, and other partners who
could help provide comprehensive care to the workers. “Engaging the
local contractor who hires labour workforce is also very important,”
points out Jogendra.
GAP organised over 15 meetings of all those who had a role to play in
helping support the initiative to reach the unreached informal sector
workers.
“First step was to survey over 1,200 people from labour workforce for
a range of vulnerability-related factors,” said Pankaj. “20% of them
reported to have multiple sexual partners. We could also connect with
few who reported to be gay men and other men who have sex with men or
female sex workers. These were hidden communities,” rightly says Pankaj
and Jogendra of GAP as these people were not able to benefit from the
existing interventions for migrants.
“Our survey shows that 78% of these persons did not go to the health
centres of integrated counselling and testing centres of the government
as they did not want to lose their daily wages – and rather preferred
if such a service was available at their workplace,” said Jogendra.
“That is why, all programmes of GAP are done at the workplace of
workers,” emphasised Jogendra.
Community-based HIV and TB screening, community-based HIV testing,
linkage to HIV and TB care services, and a range of comprehensive
support services are key elements which makes GAP’s intervention at
workplaces of migrant workers so successful.
GAP not only uses flipcharts for raising awareness, but also uses the
widely popular ‘snakes and ladders’ board game, but with a
difference: ladder is for those who give the right answer (they move
upwards in the game), and snake is for those who give a wrong one (they
go downwards in the game).
Games help us engage people more and convey important messages related
to HIV (and STIs, TB, hepatitis) prevention, testing and treatment in a
more effective way, says Jogendra.
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Innovative Approaches to Health Education
Agrees Afsar of ILO: “I have seen how GAP volunteers use ‘snakes and
ladders’ game to engage people at workplaces. If you give the right
answer, you go upwards, and if you give the wrong answer, you go
downwards. These are inter-educational approaches that need to be
leveraged upon to enhance health seeking behaviour.”
In a span of three years, GAP (via its community-based intervention),
has screened almost 40,000 migrant workers for HIV and TB at the
workplace of informal or unorganised workforce in few districts of
Gujarat. Out of those screened and tested, 87% were first-time testers
for HIV in their lifetime, informed Jogendra.
Thanks to GAP’s important work in bridging the divide between the
reached and unreached with services, 116 people were diagnosed with HIV
and 37 with active TB disease (and one worker with drug-resistant form
of TB, HIV and cervical cancer) – and all of them were linked to the
nearest government-run treatment and care services.
“It is important to note that 96% of those diagnosed with HIV were
asymptomatic – they had no symptom. Worksite interventions help find
people early and link them with public care services,” said Jogendra.
Once found positive for HIV (or active TB disease), every person is
linked to the government-run programmes without any delay. We link those
with HIV to the nearest centre which provides antiretroviral treatment,
and those with active TB disease to the district TB programme, said
Jogendra.
“In addition, we also help them avail of the benefits from
government-run social protection schemes, such as e-Shram Card (for
labour and employment) and Ayushman Bharat Card (for health
coverage),” said Jogendra.
Afsar shares that “Community-based HIV testing was an important part
of migrant workers testing project – they got rapid test kits from
Gujarat State AIDS Control Society of the government. These kits were
given to community volunteers after proper training, so that they could
take those test kits and offer a test in communities.”
Jogendra reflects: “Our next step is testing family members (spouse,
children, or others) for HIV and TB – and linking them to care as
needed. But our project is a humble initiative whereas India is a large
and diverse nation. There is an urgent need to scale up interventions to
reach the unreached workers of informal or unorganised sector in every
other state and ensure continuum of care.”
GAP partners with local district TB office of the government’s
National TB Elimination Programme, which trains them in doing
community-based TB screening (looking for classical TB symptoms),
collecting sputum samples and handing them to laboratory of primary
health centre or sub-centre for TB testing. If active TB disease is
detected, then GAP supports the person through the TB treatment and
ensures completion. GAP also ensures that the person is availing
government-support schemes such as those that provide INR 500 per month
of financial support (directly in the bank account of the patient)
during treatment. GAP also provides supplementary nutritional support
like protein powder, vitamin syrup, or other local nutritious food.
Over 96% of people screened for HIV were also screened for TB
voluntarily, says Jogendra. Many were also screened (and referred as
indicated) for hepatitis and a range of STIs.
One recent example of a person-in-need supported by GAP is of a female
labour worker of a cold storage warehouse. She was diagnosed with HIV,
multidrug-resistant TB, and cervical cancer. She received her treatment
through local government-run antiretroviral clinic, treatment for
drug-resistant TB through local government-run TB clinic, and referred
to a gynaecologist for cervical cancer management, informed Jogendra.
“Her son was linked to government-run scholarship programme for
education in Gujarat state.”
Comprehensive care is vital, feel Jogendra and Pankaj. For instance,
they also screen people for diabetes and blood pressure. Diabetes can
heighten risk for TB as well as complicate outcomes of HIV care.
No wonder that ILO has recognised GAP’s work several times as a best
practice example, share Jogendra and Pankaj – for helping make a
difference and doing justice to the legacy of Dr Radium Bhattacharya and
GAP.
We are aiming to reach 95% of people living with HIV by 2025 so that
they can know their status, and 95% of those who know their status
should receive the treatment, and 95% of those on treatment should be
virally suppressed. But do we have the right programmatic mix to reach
those we are leaving behind- the unreached?
“We must reach the places where we have not reached earlier – such as
places where migrant workers sit, work or live. They often do not have
time to go to a health facility and get tested – if they go there then
there is an opportunity cost – they do not get the daily wage for that
day – therefore we have to take the services where they are,”
reemphasises Afsar.
“A large number of people have been tested (for HIV), and those who are
found positive are put on treatment. These are the people who were
asymptomatic and a lot of them were young people, who are now on
treatment and virally suppressed so that they can lead happy and
productive lives,” rightly says Afsar.
We have to enhance risk perception for both TB and HIV so that people
consider taking a TB test or HIV test and linkage to public services.
“That is why in our workplace programmes we take help of peer
educators, who go and create awareness, and enhance risk perception -
this cannot be done in a lecture-driven or PPT driven approach,” said
Afsar.
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Respecting Rights, Empowering Workers
“We never impose HIV (or TB) testing. Testing is not the first step.
First step is awareness generation – and do it in an environment where
people’s rights are protected. That is why we engage and sensitise the
employers and government agencies too along with other stakeholders to
give confidence to workers that if they are found positive (for HIV or
TB) they will not risk losing their job. Instead, they will get support,
care and treatment to live healthy and well,” said Afsar.
We all have to strive for health justice, and eventually social justice,
which is ecologically sustainable. HIV, TB, hepatitis or STIs responses
are part of this overarching approach. Let us hope GAP continues to
bridge the gap in access to healthcare and social protection for those
in informal or unorganised sector – and such people-centred approaches
get scaled up everywhere.
Reference:
- What Are HIV and AIDS? – (https://www.hiv.gov/hiv-basics/overview/about-hiv-and-aids/what-are-hiv-and-aids)
Source-CNS
