HIV positive migrants living in Switzerland all face similar issues, such as stigmatization, the experience of migration and sexual violence. They are challenged by difficulties concerning the residence permit status, the organisation of their personal life and the trauma therapy.
HIV and stigmatization
A lot of HIV positive people are confronted with stigmatization and ostracism in their personal environment due to wrong information and images about the illness and a lack of information about risk situations, infection paths and therapy. Migrants in Switzerland are under a lot of pressure to adapt quickly and be successful. On one hand, this pressure comes from their country of origin where their family is expecting them to have a successful lifestyle and give their family regular financial support. On the other hand, the pressure also comes from the destination country, where quick integration and adaption is required.
Migrants are often living under difficult circumstances like inequality of chances, insecure residence permit status, and racism. In these stressful conditions illness and health problems are often not accepted and worsen the situation even more. Most of the migrants are also afraid that their families or friends in their country of origin could learn about their infection and therefore experience negative consequences from their communities. The fear of negative reactions can lead to isolation and solitude. That’s why people are hiding their diagnosis and keeping HIV as a secret. This can cause depressions and other psychiatric problems. Because of all this, migrants often contact doctors and clinics only reluctantly. As a consequence, most HIV positive migrants are late presenters (late testing and late begin of therapy). To sum it up, migrants are often suffering from multiple discrimination due to their status as a foreigner and the HIV infection.
Migration
Generally, migration is not a voluntary choice of the clients. Most clients who seek support at Aids-Hilfe Bern are suffering from the consequences of forced and transnational migration:
- Forced migration is defined by 3 characteristics: emigration due to political, ethical, social prosecution or poverty; an illegal and often dangerous escape; and an insecure residence permit status in the receiving country
- Transnational migration means that migrants have to escape over big distances and into a completely new cultural context, where they need to learn a foreign language and adapt in a new value and different social and legal system
Manifestation pour le droit des migrant-e-s, Lausanne, 11 juin 2014 (Photos: Gustave Deghilage/Flickr, Public License)
The most frequent consequences of forced and transnational migration are extreme social and emotional stress and physical and sexual violence during the escape and afterwards, which can provoke traumas and psychiatric problems. Also, the lack of integration in the receiving contry causes problems to find an accommodation and work, and brings financial difficulties due to a small budget during the asylum procedure and afterwards according to the residence permit or the salary. This also can aggravate the mental and living conditions.
Sexual violence
A third issue is sexual violence. Sexual violence is a traumatic experience and can lead to posttraumatic stress disorder. The possibility to cope with the resulting trauma depends on the degree of psychological resilience, which means the ability of a person to adapt to stress and adversity. The long-term consequences of the trauma can be: angst, flashbacks, nightmares, insomnia, solitude, identity problems, sexual problems, depression, addictions, psychosomatic pain, suicidal tendencies, etc.
Before a trauma therapy can be started, clients need mental and social stabilization. The trauma treatment generally consists in different methods such as psychotherapy, medication, social support. The aim of the therapy is to reduce the negative emotions which are related to the trauma, and to restore a feeling of security and control in the personal environment.
Difficulties concerning the law of residence
In Switzerland there are different residence permits with different possibilities of integration:
- The N permit is for asylum seekers.
- The F permit is for provisionally admitted foreigners, that means rejected asylum seekers: provisionally admitted foreign nationals are persons who have been ordered to return to their native countries but in whose cases the execution of this order is inadmissible (i.e., a violation of international law), unreasonable (due to concrete endangerment of the foreign national) or impossible (for technical reasons of enforcement).
- The B permit for resident foreigners requires a working contract or the person has to be a recognized refugee.
- The C permit is for settled foreign nationals only.
Most of my clients have permit N and F, a few have the B permit. N and F permits implicate restrictions concerning a working permit, budget and the choice of domicile. Generally, it is not possible to move from one canton to another. The asylum procedure is long and exigent and brings insecure living conditions. It can last up to two years.
HIV is not a reason to get a residence permit anymore. Nowadays, the authorities check 3 aspects: the stage of the illness (AIDS), the availability of treatment, and the social integration in the country of origin which means having a family or friends and the possibility to work. If for example the stage of the illness is not AIDS, if treatment is available and the social integration is guaranteed, asylums seekers can be sent back home as long as there are no other reasons to recognize them as refugees. However, if treatment is not available in the country of origin, it is possible to obtain an F permit.
The living conditions during the asylum procedure are very difficult. There are frequent problems concerning the accommodation, the medical supply and the day structure. Asylum seekers are living in big asylum centers without privacy, this is especially difficult when they have to hide their treatment from other migrants. They are often afraid to experience stigmatization because of HIV in the centers. Asylum seekers do not have a free choice of doctor. There is a voucher system that does not allow them to contact a doctor without informing the asylum authorities. They need to get a voucher and with the voucher they can make an appointment with the general practitioner of the center. This often leads to late testing and treatment.
Personal problems
In addition, there are several personal difficulties. Coping with the HIV diagnosis is very hard: The difficulties to integrate the disease in life and the fear of stigmatization get migrants to hide the disease and keep them from sharing their distress with friends and family. HIV positive migrants are often very lonely.
Migrants living with HIV have very different knowledge about the disease and attitudes towards it. Some clients have a very good level of education and are able to accept and integrate HIV very quickly into their life, others have no sufficient information about sexual health, diseases and treatment possibilities or they consider HIV as a punishment from god. They all share a great anxiety about the future, as they think that they have lower perspectives with HIV especially concerning family planning, partnership and work.
The people concerned need to deal with the trauma which often means low resilience and coping strategies, lack of social support in the receiving country and insecure living conditions during the asylum procedure and afterwards according to the permit. They also often experience problems with sexuality and family planning. A lot of clients have problems with relationships and having a safe and satisfying sexuality, they feel that they have lower chances of finding a partner and having a family.
Trauma therapy
Last but not least they face problems concerning the trauma therapy. Therapeutic treatment during the asylum procedure is complicated. During the asylum procedure clients do not know if they will get a permit or if they have to leave the country. This means that most of the people concerned are not feeling secure enough and ready to start confrontation with the trauma. This can aggravate their mental health.
Most of the time, the therapy is only possible with translation and there are only two therapeutic centers in Bern that provide therapy with translation. The waiting list is usually very long. Different knowledge and images about therapy determine the motivation to start a therapy.
The requirements for a trauma therapy are safe living-conditions and mental stability, social support and acceptance of and trust in the therapist. A lot of the clients are not starting confrontation with the trauma before they get a definitive decision if they can stay.
The counselling offer of Aids-Hilfe Bern: The story of F. G.
F.G. is a 32 years old woman from Ivory Coast. She was the victim of a mass rape during political conflicts in 2007, and experienced sexual and physical violence during escape 2012. In her home town, she had been working as an accountant, she couldn’t finish her studies in engineering because of the traumatic event.
Her entry into Switzerland was in 2012 after escaping via Libya and Italy. She received the HIV diagnosis 2009 in Ivory Coast and began the antiretroviral therapy in 2010 with regular interruptions due to a lack of medication. The main reason for her escape was this medical situation. Due to political conflicts the antiretroviral therapy was most of the time not available. The bad health condition forced her to quit the country.
Manifestation pour le droit des migrant-e-s, Lausanne, 11 juin 2014 (Photos: Gustave Deghilage/Flickr, Public License)
Support in getting residence permit / asylum procedure
When F.G. approached Aids-Hilfe Bern, we first looked into the possibilities of getting a residence permit, and we gave support during the asylum procedure. This meant organizing support from the Red Cross (medical services for illegals) when she was asking for asylum. She entered Switzerland illegally and the Red Cross accompanied her when she was asking for asylum. Giving support during the asylum procedure included the organization of a pro bono lawyer as well as working with the hospital in order to provide the needed medical information for the asylum procedure. In cooperation with the authorities we succeeded in improving F.G.’s living conditions: She could change from a big asylum centre into a small living community so that she could have more privacy and tranquillity.
An important part of the work of Aids-Hilfe Bern is the cooperation with doctors, clinics, and HIV consultations in order to provide information about STI in general and HIV/Aids in particular, living with HIV, treatment, and sexuality. In cooperation with the project “multicolore” of Aids Hilfe Bern we provided translation and attendance in F.G.’s native language.
I was the contact person of F.G. in case of questions or health problems and I was in charge of the communication with the university hospital to obtain information about her health condition and the coordination with doctors. In regular counselling session with F.G. we talked about HIV/Aids, therapy, family planning and future perspectives with the disease. F.G. had many questions about HIV and treatment and the she needed a long time to accept HIV and build up future perspectives. Apart from HIV F.G. was also suffering from tuberculosis and other health problems. She often first talked with me about health issues and I organized the needed treatment together with the hospital.
Another part of my work was to give information about HIV to the authorities on behalf of F.G. The person who was in charge of F.G.’s case during the asylum procedure had little knowledge about HIV and the consequences of the disease in daily life. I had to sensibilize her for the needs of the client.
Psychotherapy
The clients have to be well informed about the therapy and the consequences of confrontation with the trauma in daily life and they need to be ready to start a therapy.
In the case of F.G., we talked about the trauma and the consequences for mental health and daily life and I gave F.G. information about the therapy and therapeutic offers. This included seeking a place in a treatment program. Aids-Hilfe Bern cooperates with the outpatient clinic for victims of torture and war in Bern. The trauma confrontation started one year after asking for asylum.
Psychosocial attendance
Psychosocial attendance includes frequent counselling interviews in order to empower the client, provide financial aid if needed, put F.G in touch with other people concerned, and give support in the matters of accommodation, work and legal questions. The aim was to create stable living conditions for F.G.
At the beginning I had counselling interviews with F.G. every two weeks to build up trust and organize her daily life in Bern and to inform her about the asylum procedure, her rights and duties and Swiss society in general. An important aspect is financial support: A healthy nutrition is very important for HIV positive people and the budget during the asylum procedure is not sufficient for buying healthy food. We also succeeded in getting funds for a swim course for F.G. She was afraid of water due to a traumatic experience on the escape and she could not swim. The confrontation with water was a therapeutic aim.
Advice to professionals who are working with HIV positive and sexually traumatized clients:
Requirements for professionals:
- A good knowledge and expertise of HIV/AIDS and PTSD is the basis for working with this type of client
- Important counselling qualities are empathy, respect, reliability, authenticity, confidentiality
Work principles:
- Building a trustful relationship to the client
- Giving support and providing security
- Avoiding unintentional confrontation with the trauma: Trauma confrontation is only for psychotherapists or trained specialists; the client decides when and with whom she or he wants to talk about the trauma
- Self-management is also essential for the professionals themselves such as supervision and regular exchange with peers
Take home messages:
- HIV positive and sexually traumatized women and men need our help.
- They need support to overcome the trauma and accept and integrate HIV in their life.
- They need acceptance, empathy, patience and stable relationships.
- They need secure living conditions and medical and therapeutic supply.
- They need other people concerned to share their experiences.
- They need trained professionals who are able to face their stories and give support.
