Othoman MelloukITPC-MENA/ALCS Maroc

HIV and Migration in MoroccoCase 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• 2012-2013: 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

26%

19%

19%

14%

5%

4%

4%

2%

2% 1% 1% 3%

NigeriaDemocratic Republic of CongoCamerounCote I’voireGuinee ConakryCongo BrazzavilleMaliWest Africa otherGhanaEast AfricaLiberiaOther

15.4

7.7

25.2

8.75.3

33.5

4.3

Francophones

Cameroun

Congo Brazzaville

Cote I’voire

Guinee Conakry

Mali

Democratic Republic of Congo

Other

3.7 4.42.6

66.9

17.2

5.1

Anglophones

GhanaWest Africa otherLiberiaNigeriaCamerounEast Africa

Global

78%

Reasons of migration

Francophone Anglophone

14.7 15.420.1 18.518.8

46.542.7

16.6

3.8 3

PoliticalSocialEconomicWarOther

Perc

enta

ge

Sociodemographics

63,9%

36,1%

HommesFemmes

25,9%

74%

<25 ans>=25 ans

70,9%

29,1%

33%

67%

Francophone Anglophone

78,7%

15,6%5,7%

CélibataireMariéeDivorcée, veuve 71,3%

27,3%

1,4%

Francophones Anglophones n % (IC 95%) n % (IC 95%)

Date last arrival in Morocco Before 2009 33 6.6 % (3.8, 9.3) 38 12.9% (9.0, 16.8) 2009-2011 112 25.2 % (20.9, 29.4) 91 35.5% (29.7, 41.3) 2012-2013 261 68.3% (62.8, 73.7) 142 51.6% (46.0, 57.2) Point of entry Mauritanian border 74 19.7% (14.2, 25.3) 14 4.3% (1.5, 7.2) Algerian border 270 66.8% (60.9, 72.6) 248 91.6% (88.5, 94.8) Airport 64 13.2% (9.1, 17.2) 12 3.4% (1.8, 5.0) Seaport 1 0.3% (0.0, 0.6) 1 0.6% (0.1, 1.3) City of arrival Oujda 273 67.2% (61.7, 72.8) 250 92.2% (89.1, 95.3) Casablanca 66 14.2% (9.7, 18.7) 13 4.0% (2.2, 5.9) Dakhla 59 16.5% (11.6, 21.3) 9 2.5% (9.8, 4.1) Autre 12 2.1% (0.9, 3.3) 4 1.3% (0.0, 2.6) Mean of travel to Morocco Plane 69 15.4% (10.8, 19.9) 11 3.3% (1.5, 5.0) Vehicle 340 84.6% (80.1, 89.2) 264 96.1 % (94.4, 97.8) Ship 0 -- 1 0.6% (0.1, 1.3) Accompagnant at arrival Alone 160 41.6% (35.3, 48.0) 74 28.2% (23.3, 33.1) Group 209 53.3% (47.1, 59.5) 183 65.0% (59.2, 70.8) Membres de la famille 26 5.1% (2.9, 7.3) 15 6.8% (3.0, 10.6)

Entry in Morocco

Life conditions

Francophone Anglophonen %, (IC 95% ) n % (IC 95% )

Live with partner /conjoint Oui 275 68.6% (63.1, 74.2) 127 45.5% (39.6, 51.4)Number of children living with respondaant 0 152 74.2% (67.3, 81.1) 48 53.2% (42.1, 64.4) 1 30 14.8% (9.9, 19.7) 34 39.4% (25.5, 53.3) 2 + 29 11.0% (6.5, 15.5) 8 7.3% (1.4, 13.3)Number of adult men living with respondant 0 96 24.5% (20.0, 29.0) 58 22.3% (16.1, 28.5) 1 à 3 191 49.7% (43.3, 56.1) 148 55.9% (49.5, 62.3) 4 + 121 25.8% (20.6, 31.0) 69 21.8% (16.1, 27.6)Number of adult women living with respondant 0 215 54.4% (48.6, 60.1) 159 58.4% (51.6, 65.1) 1 à 3 171 38.7% (33.0, 44.4) 99 36.7% (30.4, 43.0) 4 + 22 6.9% (3.6, 10.2) 17 4.9% (2.6, 7.2)

Sources of income

Salarié Coiffure / Massage

Commerce ONG / Service

Mendicité Aidé par la famille/amis

1622.2

5.6 8.34.4

43.446.4

2.69.7

5.7 2.9

32.7

Femmes Hommes %

%

Salarié Coiffure / Massage

Commerce ONG / Service

Mendicité Aidé par la famille/amis

010203040506070

313

1.6

60.3

22.1

39.3

4 9.13.3

24.719.6

Femmes Hommes %

%

Anglophone

Francophone

Health conditions

41.9

2.4

9.3

16.3

7.5

3.3

6.9

17.9

12.4

FrancophonesMaladie de la peau

Paludisme aiguë

Tuberculose

Problèmes pulmonaires

Les problèmes digestifs

Problèmes gynécologiques

Maladie sexuellement transmissible

Forts maux de tête

Les problèmes psychologiques

Autre

7.14.9

0.9

14.3

22.1

8.90.9

4

24.7

14

Anglophones

Health conditions

Francophone Anglophone n % IC 95% n % IC 95%

Symptoms of cough with mucus, fever, sweat, loose of weight Yes 26 7.1% (4.5, 9.6) 41 15.6% (11.1, 20.1)

No 380 92.9% (90.4, 95.5) 232 84.4% (79.9, 88.9)

High fever since last 6 months Yes 95 22.8% (17.3, 28.2) 84 28.0% (22.0, 34.0) No 308 77.2% (71.8, 82.7) 191 72.0% (66.0, 78.0)Malaria episode since arrival Yes 69 16.9% (11.9, 21.9) 85 30.6% (24.4, 36.8) No 340 83.1% (78.1, 88.1) 190 69.4% (63.2, 75.6)Have seen a doctor for this symptoms since last 6 months Yes 19 32.1% (19.4, 44.8) 16 14.7% (8.2, 21.3) No 50 67.9% (55.2, 80.6) 67 85.3% (78.7, 91.8)

Access to Health Services

Received health services in Morocco Yes 191 47.3 % (41.0, 53.5) 84 33.0% (27.2, 38.8) No 215 52.8% (46.5, 59.0) 191 67.0% (61.2, 72.9)

22.44.6

10.965.5

Francophones

Hôpital public / centre de santé

Médecin privé

Pharmacie

ONG

36.3

5.714.2

57.3

Anglophones

10.3

18.5

59.2

12

Mauvaismoyennebonnetrès bon

7.1

22.7

53

17.1

Evaluation of quality of services

Family Planning

Used contraception methods during past 6 months Yes 40 30.8% (20.4, 41.1) 19 24% (10.5, 37.5) No 89 69.2% (58.9, 79.6) 56 76% (62.5, 89.5)

29.2

52.6

18.2

Pilule

Préservatif masculin

autre

18.1

38.4

43.6

Francophone Anglophone

Pregnancy and DeliveryFrancophone Anglophone

n % IC 95% n % IC 95% Been pregnant in Morocco Yes 34 32.8% (20.4, 45.3) 35 58.0% (43.3, 72.8) No 71 67.2% (54.7, 79.6) 28 42.0% (27.2, 56.8) Received antenatal services in Mor Yes 11 26.6% (15.4, 37.9) 16 31.3% (5.1, 57.5) No 25 73.4% (62.1, 84.6) 19 68.7% (42.5, 94.9) Location of antenatal services Public hospital / Health center 10 35.0% (15.9, 54.0) 9 38.1% (13.4, 62.8) Médecin privé 2 13.3% (0.8, 27.3) 1 4.0% (2.4, 5.5) ONG 12 51.8% (36.6, 67.0) 10 57.9% (33. 4, 82.6)

Delivered in Morocco Yes 21 58.4% (36.3, 80.4) 17 39.7% (20.7, 58.7) No 15 41.6% (19.6, 63.7) 18 60.3% (41.3, 79.3)Location of delivery Public hospital/ Health center 20 94.4% (91.7, 97.2) 16 95.9% (87.9, 103.9) Private clinic 1 5.6% (2.8, 8.3) 1 1.1% (0.5, 1.7) At home 0 -- 1 3.0% (4.6, 10.6) Child received birth certificate 14 58.1% (37.8, 78.4) 11 54% (37.4, 70.5)

Sexual Partners

Francophone Anglophone Female Male Female MaleSexual relationships during past 12 months Oui 92 69.9% (60.2, 79.7) 166 61.2 (52.7, 69.8) 5991.7% (86.1, 97.3)12874.8% (67.8, 81.9)

Number of sexual partners during past 12 months 1 70 76.6% (67.4, 85.8) 72 43.8% (30.4, 57.2) 9 42.6% (6.0, 91.1) 59 43.9% (34.4, 53.5) 2-4 18 18.9% (10.4, 27.4) 65 40.6% (28.5, 52.6) 6 16.5% (6.9, 39.9) 56 48.4% (37.8, 59.0) 5-9 4 4.5% (1.2, 7.8) 17 8.2% (3.7, 12.8) 14 41% (7.6, 89.5) 11 6.7% (1.4, 12.0) 10+ - - 11 7.4% (2.9, 11.9) - - 2 0.9% (0.1, 1.9)

Use of Condoms

Francophone Anglophone

n %, (95% CIs) n %, (95% CIs)

Frequency of condom use during past 12 monthsAlways 80 48.4% (37.8, 59.0) 70 54.7% (46.6, 62.8)Sometimes 94 51.5% ( 40.9, 62.0) 69 44.5% (36.6, 52.5)Never 1 0.1% (0.1, 0.1) 1 0.8% (0.2, 1.7)

11

14.1

65.2

2.9 6.8Francophone

Pharmacie

Pair éducateur / ONG

Centre de santé

Partenaire / ami / client sexuelle

Kiosque / Hôtel

4.3

23.5

53.4

8.88.7

Anglophones

Sources of condom procurement

HIV Testing

33

61.3

2.3 2.3

Francophones

Centre hospitalier / santé

ONG

Centre mobile de dépistage

Laboratoire / clinique privée

55.644.4

Anglophones

Taken HIV Test during past 12 months and received results Yes 125 31.4% (25.7, 37.1) 67 26.0% (20.1, 31.9) No 285 68.6% (63.0, 74.3) 210 74.0% (68.1, 79.9)

Location of HIV test for those tested in Morocco

Francophone Anglophone

n % (95% CIs) n % (95% CIs) Taken an HIV Test Yes 240 57.6% (51.4, 63.8) 155 56.9% (50.2, 63.7) No 169 42.4% (36.2, 48.6) 121 43.1% (36.3, 49.8)

Violence

Francophone Anglophonen % IC 95% n % IC 95%

Experienced physical violence while in Moroccoi Yes 179 42.8% (37.9, 47.7) 69 25.1% (18.2, 32.1)

Forced sexual relationships during past 12 months Yes 37 10.1% (5.6, 14.5) 20 8.0% (4.2, 11.9) No 373 89.9 (85.5, 94.4) 256 92% (88.2, 95.8)

20.9%

79.1%

Femmes Francophones

Oui Non

4%

96%

Hommes francophones

12.4%

87.6%

Femmes Aglophones

Oui Non

6.30%

93.70%

Hommes Anglophones

Stigma and discrimination

Francophone Anglophone n %, (95% CIs) n %, (95% CIs)

Services refused during past 12 months due to migrant status

Health center 40 10.3% (6.7, 13.9) 30 11.9% (7.1, 16.8)

Condoms 21 5.0% (2.5, 7.6) 21 6.9% (4.3, 9.5)

Employment 146 34.1% (27.9, 40.2) 132 47% (39.2, 54.8)

Education 40 11.6% (7.3, 15.9) 63 22.9% (17.9, 27.9)

Public transports, Taxi 49 10.8% (7.6, 14.0) 40 12.9% (9.5, 16.4) Religious service 27 6.5% (4.1, 8.9) 29 10.9% (7.2, 14.6)

Resataurants 30 6.4% (4.7, 8.1) 29 10.1% (6.0, 14.3) Assistance from police 101 20.9% (16.0, 25.7) 56 19.8% (14.9, 24.7)

HIV and Syphilis Prevalence

Francophone Anglophone n %, (95% CIs) n %, (95% CIs)

HIV Positif 17 3.4% (1.8, 5.0) 6 3.2% (0.0, 6.4) Negatif 381 96.0 (95.0, 98.2) 262 96.8 (93.6, 100.0)

Syphilis Positif 11 2.8% (0.2, 5.4) 1 0.3% (0.0, 0.6) Negatif 387 97.2 (95.6, 99.8) 267 99.7 (99.4, 100.0)

Francophone Anglophone

Female Male Female Male n %, (95% CIs) n %, (95% CIs) n %, (95% CIs) n %, (95% CIs)

HIV positif 11 6.6% (3.2, 9.9) 6 1.4% (0.1, 2.7) 2 7.1% (5.3, 9,0) 4 1.8% (0.1, 3.6)

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