The People's Republic of China
As a result of economic reforms, a surplus of rural labor and desperate rural poverty, internal migration has drastically increased in China in recent years. As of December 31, 2008, 140.4 million internal migrants in China worked outside their home village or township [13], an increase from only two million internal migrant workers two decades earlier [14]. Internal migrants make up a sizeable percentage of the urban population and workforce [15].
Through the system of hukou, the People's Republic of China requires the registration of every Chinese resident with the local authorities. Although the Chinese government has announced plans for its elimination [16], hukou allows individuals to live and work only where they are officially permitted [15], with one place of permanent hukou registration. Hukou status is inherited, so that children of rural-to-urban migrants are, like their parents, not registered urban residents [17]. Procedures to obtain temporary residence can be time-consuming, expensive, and difficult [18]. Only an estimated 40% of China's internal migrants typically obtain temporary or permanent permits [14].
While urban permit-holding residents in China have long been entitled to state-sponsored social welfare benefits including retirement pensions, food, education, and medical care, internal migrants still registered in their rural household of origin are denied such benefits [19]. Individuals without hukou are unable to access basic public services such as education [20] and health care [21], and therefore are forced to pay all costs [15, 21]. Amnesty International has noted that the vast majority of internal migrants in China cannot afford insurance schemes and rarely visit doctors or hospitals [18]. Human Rights Watch has documented widespread lack of insurance coverage for migrant construction workers, despite government guarantees of medical and accident insurance [19]. Furthermore, lack of health care coverage for sick migrants has, in the past, been compounded by additional, harsh consequences: For example, internal migrant workers have been returned to their home province under armed guard after being found to be HIV positive [22]. Though China announced the abolition of such "custody and repatriation" in 2003 [23], recent reports suggest that similar practices of detention and removal purportedly for health reasons are still practiced, particularly during periods of heightened political concern [24].
A range of studies have documented the disproportionately high prevalence of HIV among internal migrants: Multi-city HIV surveillance data between 1995 and 2000 revealed that over two-thirds of the HIV cases were found among rural-to-urban migrants. In 2000, 85.4% of Beijing's and 74.4% of Shanghai's new HIV infections occurred among migrants [25, 26]. Despite such high prevalence, and nationwide prevention campaigns in recent years, as well as studies calling urgently for HIV prevention programs addressing the particular circumstances of migrants [27], internal migrants in China have disproportionately low access to HIV/AIDS-related information [18, 26, 28]. United Nations reports have also remarked on the special vulnerability and difficulty of reaching with prevention programs the children of migrants, who lack access to the formal Chinese schooling system [29].
HIV-positive internal migrants' access to treatment remains extremely limited, confounded in part by the effects of the hukou system. Prior to 2003, ART was only available to the wealthy elite, as hospitals and clinics passed along to all patients the cost of HIV/AIDS examinations, tests, hospitalizations, treatment for opportunistic infections and ART treatment [22]. In 2003, the Chinese government announced a national HIV/AIDS treatment program--free to rural residents and poor urban residents--funded by national and provincial authorities [30]. However, despite such broad policy statements, universal HIV/AIDS treatment is far from a reality among the general population: In 2007, UNAIDS estimated that 190,000 people living with HIV were unable to access urgently needed ART in China, representing 81% of those in need [31]. Even when free treatment is ostensibly offered, delays in diagnosis and referral can create significant costs for the patient prior to the availability of free treatment, thus particularly disadvantaging migrants, who are not entitled to free basic health care [32].
The negative health consequences of the restrictive hukou system and related gaps in HIV/AIDS prevention and treatment for internal migrants have been exacerbated by the recent crisis in the world financial markets. For example, the loss of jobs in the export manufacturing sector, such as in the Pearl River Delta region, is anticipated to increase the number of migrant women working in the sex industry [33]. As unemployed internal migrants return to rural areas there is a potential for increased HIV transmission, as well as a risk that inadequate and weakened rural health systems will become overburdened [30]. Recognizing the current disparity in health care access, and widespread dissatisfaction, the Chinese government has recently announced plans for significant investment in basic health care services [35].
The Russian Federation
Vestiges of an internal registration system also plague access to health care for internal migrants in Russia. In the former Soviet Union, propiska--a residence permit stamp on internal Soviet passports--strictly limited movement and residence. Although propiska was officially abolished by the federal government in the 1990s, local and regional governments retain restrictive systems of registration for both temporary visitors and residents [36]. While reliable statistics are unavailable, government officials have estimated that over a million unregistered individuals may live in Moscow alone [37].
In recent years, legislative and other changes have led to the simplification and relaxation of some registration requirements [36–38]. Federal law and policy provide for freedom of movement and, while requiring registration [39], envision it as a non-discretionary, notice-based system open to all. However, in practice, registration is cumbersome and expensive, and lack of registration status may have serious official or unofficial consequences for internal migrants. Instances of unregistered migrants unable to legally marry, vote, send their children to school, and receive public assistance, have all been reported [36]. Indeed, individuals who are legally in the country but lack local registration have also reportedly faced such harsh consequences as detention, police abuses or deportation [36, 40, 41].
While the Russian government is constitutionally required to provide free medical care to all citizens [42, 43], regional authorities, responsible for the organization and financing of medical programs in their territories, regulate the conditions for access to medical care. Federally funded HIV treatment is officially provided free of charge to citizens [44, 45], but in practice major challenges exist in access to free health care generally as a result of inadequate federal and regional funding [46]. UNAIDS estimated in 2007 that 159,000 individuals needing ART were not receiving it, as only 16% of those requiring ART had access to treatment [47]. Internal migrants especially face barriers, as registration is a precondition for entitlement to many free health services [48, 49].
Human Rights Watch research has documented that internal migrants without registration are often denied both short-term (for purposes of Prevention of Mother to Child Transmission) and long-term antiretroviral treatment [50]. In Moscow, individuals must produce temporary registration and an official certificate of HIV-status in order to obtain ART at the Moscow AIDS Center. While unregistered international migrants may, in some cases, receive antiretrovirals for free, a non-resident requiring antiretrovirals will typically be directed to his or her city of origin to receive the treatment. Despite these barriers to accessing care, currently applicable Russian federal law on HIV/AIDS does not specifically address the particular challenges involved in providing HIV prevention, care and treatment services to migrants [44].
There is some preliminary indication that the global financial crisis may in fact lead to an increased movement into Russian cities, where the remaining registration systems prevent internal migrants from accessing some social services: According to the head of the Moscow Directorate of Internal Affairs, increasing unemployment as a result of the global financial crisis in Russia has lead to an influx of migrants from regions surrounding Moscow into the city in search of work. In addition to facing the restrictions detailed above, these internal migrants have been blamed for an increase in crime [51], and have encountered significant hostility and attacks [52].
Republic of India
India, like China and Russia, has high rates of internal migration--both rural-rural and increasingly rural-urban [1]--complicated by diverse cultural and linguistic traditions. An estimated 258 million adults in India are migrants [53]. While poverty and internal mobility itself does not lead to HIV transmission, unsafe sex and a change in sexual networks may [54, 55]. The World Bank has characterized migration and mobility, particularly for work purposes, as one of the major risk factors for HIV in India [56]. The national government's response to HIV/AIDS has recognized the key role that migrants have played in the on-going epidemic [57]. While the correlation between migration status and HIV infection in India may have been weakening in recent years [55], rising unemployment as a result of the financial crisis and the existence of return migration may have the potential to increase transmission [58].
Approximately 2.4 million people were living with HIV/AIDS in India in 2008 [59]. HIV prevention is seriously hindered by the low awareness of the disease among internal migrants, particularly from rural areas [56, 57]. UNAIDS India representatives have called for awareness campaigns specifically targeting the sending areas for internal migrants [54], however HIV prevention activities can be hindered by the mobile nature of this population [60], language, and cultural barriers [53].
Significant HIV/AIDS treatment gaps exist for all groups throughout the country, but migrants also face particular challenges in accessing health care [59, 61]. Health care is administered on a state-by-state basis in India, and in some states significant uncertainty exists among government officials as to whether state authorities are responsible for social welfare services to temporarily resident workers and their families [62]. Furthermore, internal migrants are often unable to use the government-issued "ration cards" outside their local home authority in order to access social services [63], and migrants may face significant logistical challenges and delays in procuring a new ration card [64]. Absent a ration card, it can be difficult to access even programs designed to provide health care to the poor, as some such services specifically target ration card holders [65]. Indeed, some local authorities reportedly refuse to provide ART entirely to individuals without ration cards [66]. In one area with extensive seasonal out-migration, a study concluded that internal migrants reported poorer health-seeking behavior than their non-migrant counterparts, a difference attributed to ignorance of behavioral risk factors, lack of knowledge of health facilities, and cultural and linguistic barriers [55].
Though not as severe as in some countries worldwide, the current global financial crisis has slowed economic growth in India and threatened to exacerbate preexisting levels of internal inequality [67]. Internal migrants are particularly vulnerable to increased unemployment and poverty, and the process of reverse migration has already begun [68]. The Governor of the Reserve Bank of India noted in February 2009 that social safety net programs in rural areas could help to mitigate the impact of the crisis for migrant workers who return home [69]; however, ART coverage throughout the country is plagued by broad gaps and failures and interruptions in treatment must be expected.