This post features a runner-up entry in All the Russias' inaugural Graduate Student Essay Competition.
Daniel Bromberg is a second-year doctoral student at the Yale School of Public Health and a predoctoral fellow at the Yale Center for Interdisciplinary Research on AIDS. His research focuses on opioid use disorder and its relation to the HIV and hepatitis C epidemics in the United States and Eastern Europe/Central Asia.
One of our interviewees complained of throat and chest pain. She knew full well what was causing her symptoms; she had known since she was diagnosed with HIV in Russia four years prior. She also knew what was needed to get better so she had just returned to Tajikistan to start on a course of treatment. What had taken her so long?
I went to Dushanbe in the summer of 2019 to conduct interviews with HIV-positive patients, most of whom had worked as migrants in the Russian Federation. While it was not our goal to study or comment on Russian migration policy, the content of the interviews made it clear that this policy drove HIV treatment outcomes in this population.
In 2007, the Russian Federation first instituted work permit quotas for labor migrants. While the specifics of the Russian migration and quota systems have evolved in the dozen years since, the underlying rationale has not. Russian policy makers created their quota laws to assuage public opinion and potential political ramifications, not necessarily to manage the market demands for labor or the realities of migration in the Commonwealth of Independent States (CIS). As a result, Russia allows (and arguably encourages) a great deal of informality in its migration system. Of the estimated six million migrants in the Russian Federation, approximately two million are eligible for legal registration under the quota system. For most migrants, lacking registration leads to lower wages and increased police harassment. For people living with HIV, it creates even more problems.
Central Asians living in Russia as migrants have consistently experienced higher rates of HIV incidence. They enter a land with a much higher prevalence of HIV than their native Central Asian republic and their migration itself creates risks for HIV infection.
Russia’s reliance on foreign labor for largely "low-skill," physically-demanding work encourages the inflow of single, low-income men who are very likely to engage in HIV sexual risk behavior, like purchasing the services of commercial sex workers, having multiple sexual partners, and not using condoms. In my own interviews, those migrants who use drugs reported being unable to find the types of smokable or snortable opioids that they were accustomed to in Tajikistan once they had migrated to Russia, forcing them to switch to riskier, injectable opioids.
So what happens when a migrant in Russia goes to a clinic and leaves with an HIV diagnosis? Russia does not provide any form of federally funded HIV treatment to migrants. While some interviewees reported receiving basic information about HIV at time of diagnosis, others did not. HIV counseling seems to be left to the discretion of the test administrator. A number of interviewees reported being told that they must “return to their homeland [rodina]” if they want to live.
Migrants’ responses to the warning were mixed. Feeling themselves in generally good health and having little to no previous knowledge about HIV, some respondents concluded that the test results were simply mistaken. Others cited an absence of economic opportunities back home in Tajikistan, making leaving Russia a practical impossibility.
While Russian law in theory calls for HIV-positive migrants to be expelled when their status is disclosed, in reality the government evinces little enthusiasm and allocates few resources to following through with deportation. Instead, migrants are added to a list of individuals barred from re-entering the Russian Federation. Fearing the financial consequences of losing access to the Russian labor market, migrants are strongly incentivized to remain in-country illegally until their health deteriorates, forcing their return home.
Staying in Russia did not prove particularly challenging for HIV-positive migrants. Interviewees reported staying for months or years after diagnosis. In light of these facts, it is no surprise that the time Tajik migrants spend in the Russian Federation is one of the only correlates of late presentation for HIV when they do return in search of treatment. Indeed, according to Tajikistan’s HIV registry, 28% of HIV-positive migrants who return from Russia present with frank AIDS.
Central Asian nations, Tajikistan included, have lifted the immigration ban on people living with HIV and guaranteed antiretroviral therapy to citizens and non-citizens alike. Russian civil society is aware of the growing problem, and in 2018, thirty-five community leaders drafted and signed a petition calling for an end to the deportation policy of HIV-positive migrants. In April 2019, AFEW international reported that one of its partner organizations drafted “an expert report for a project to ensure migrant access to HIV treatment and abolish the provision on deportation of foreigners living with HIV who enter the Russian Federation.” If the government responds positively to these calls for change, we may see a more sensible Russian policy towards HIV-positive migrants developed soon.
Of the millions of Central Asian migrants in the Russian Federation, it is not clear how many are HIV-positive. However, that number is likely on the order of thousands, not more. While the Russian government may have a financial incentive to refuse to pay for these people’s HIV treatment, it can avoid paying by having the migrants’ home countries provide it, since most Central Asian nations already provide free antiretroviral therapy to their citizens.
One interviewee reported returning to Tajikistan every three months to stockpile antiretrovirals, bringing them to the Russian Federation to continue working informally. If a similar process is legalized, it could save significant unnecessary mortality and morbidity.
Given the Russian Federation’s interest in protecting the health of its own population and the ambiguous results of banning HIV-positive migrants from the country, the Russian Federation should reconsider its policy in the coming years. If it does not, it will continue to endanger the lives of its migrant population and risk a spillover effect into its own population, as well as those of the migrants’ home countries. As Russia and Central Asia comprise the only region in the world where the HIV epidemic continues to get worse, every bit of sensible policy should be considered.
