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HEALTH, HOPE AND HOME? The possibilities and constraints of voluntary return for African rejected asylum seekers and irregular migrants living with HIV in the Netherlands

January 2009

January 2009

Publisher: International Organization for Migration
ISBN: 978-90-813839-1-2

Authors:

Josh Maiyo

United States International University-Africa

Pierre Celestin Iyamuremye

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IOM International Organization for Migration

IOM

P.O. Box 10796

2501 HT The Hague

The Netherlands

HEALTH, HOPE

AND HOME?

The possibilities and constraints of voluntary return

for African rejected asylum seekers and irregular

migrants living with HIV in the Netherlands

HEALTH, HOPE AND HOME?

The possibilities and constraints of voluntary return

for African rejected asylum seekers and irregular

migrants living with HIV in the Netherlands

IOM is committed to the principle that humane and orderly migration benefits migrants and society. As an

intergovernmental body, IOM acts with its partners in the international community to assist in meeting the

operational challenges of migration; advance understanding of migration issues; and uphold the human dignity

and well-being of migrants.

This research report is published within the framework of the project ‘Return Migration & Health III’. The

research was conducted in the Netherlands, Angola, Cameroon, Ghana, Nigeria and Sierra Leone. The project

was financed by the European Refugee Fund and the Dutch Ministry of Justice, and implemented by IOM in

partnership with STI Aids Netherlands, the Working Group of HIV Consultants (WVAC) and the PharmAccess

Foundation.

Publisher: International Organization for Migration

Mission in the Netherlands

P.O. Box 10796

2501 HT The Hague

The Netherlands

Tel: +31 70 31 81 500

Fax: +31 70 33 85 454

E-mail: missionthehague@iom.int

Internet: www.iom-nederland.nl

ISBN 978-90-813839-1-2

any form by any means electronic, mechanical, photocopying, recording or otherwise without prior written

permission of the publisher.

Opinions expressed in this work are those of the authors and do not necessarily reflect the view of IOM or co-

funders.

HEALTH, HOPE AND HOME?

The possibilities and constraints of voluntary return

for African rejected asylum seekers and irregular

migrants living with HIV in the Netherlands

January 2009

Researchers

Christian Mommers

Hans Eijkhout

with

Pierre Celestin Iyamuremye

Joshua Maiyo

Advisory Board:

Ronald Brands, Iris Shiripinda (Soa Aids Nederland)

Rosanne ten Wolde (WVAC - Werkgroep Verpleegkundigen en Aidsconsulenten)

Dr. Sybil Geelen (PharmAccess Foundation)

This report was made possible thanks to financial contributions from the European

Refugee Fund and the Ministry of Justice of the Netherlands

EXECUTIVE SUMMARY

This report deals with the issue of voluntary return of HIV-positive Africans in the

Netherlands, who have been rejected for asylum or are staying in the country as irregular

migrants. Dutch immigration policy stipulates that any migrant without a legal status is under

the obligation to leave the Netherlands, with voluntary return being the preferred way of

meeting this obligation. In this report, we will examine under which conditions these HIV-

positive migrants may be able to return voluntarily in a manner that allows for a sustainable

situation in the country of origin. We will explore the possibilities of providing assistance to

help create conditions for voluntary return, but also critically discuss constraints that are

likely to be encountered in this return. The results of this exploration, which is primarily

based on interviews with twelve migrants living with HIV in the Netherlands, and

consultations with stakeholders in five African countries, can be summarised as follows:

• For most migrants living with HIV, sustainable return and reintegration requires that,

at a minimum, the following conditions are met:

1) necessary medical treatment (antiretroviral drugs, testing, treatment of

opportunistic infections) is available and the returnee has durable access to

such treatment;

2) the returnee can acquire a sufficient income to cover regular expenses (food,

accommodation, education, etc.) for him/herself and the family and to cover all

costs related to medical treatment (also including transport to hospital, health

insurance fees, etc.);

3) the returnee finds a place within a supportive social network (family, peers,

etc.) and has the ability to cope with possible stigma from society as a whole.

These conditions are seen as very closely interlinked: if one of these does not

materialise, it is likely that other conditions cannot be met either.

• Attitudes towards return are generally very negative, as most migrants living with HIV

do not believe that these conditions can be adequately met, particularly with regard to

access to medical treatment. The certainty that they can access treatment in the

Netherlands is an important motivator not to return. Not all migrants living with HIV

have up-to-date information about the possibilities and constraints in their countries of

origin, nor do they want to have this. Peers in the Netherlands often play an important

role in the mental and physical survival of migrants living with HIV, but they can, in

some cases, also reinforce a taboo on thinking about return.

• Whether the right conditions for voluntary return are in place (or can be created) can

only be assessed by taking into consideration an individual’s specific situation and the

specific context in which he/she would return.

• From the level of the individual returnee, there are only limited means to influence

these conditions. Many conditions are beyond the direct influence of the potential

returnee or others assisting him/her. Acknowledging structural conditions, particularly

in the country of return (including unavailability of certain types of treatment, poverty

and unemployment, widespread stigma and discrimination), is crucial in coming to a

well-informed decision about return.

• When conditions can be influenced at the individual level, the most important

‘instrument’ for doing so is the returnee him/herself. A positive outlook on a future in

the country of origin, motivation and a proactive attitude are essential for achieving

sustainable return and reintegration.

• Assistance by third parties (IOM, civil society actors) in the return process is most

likely to be useful with regard to:

1) information gathering on medical, economic and social conditions in the

countries of origin and provision of referrals;

2) providing resources to assist the development of income generating activities

for the returnee and/or his/her family. A stable economic situation is a

precondition for durable access to medical treatment and can have a very

positive impact on the social support network available to the returnee.

• Providing return assistance may also lead to ethical questions, including:

- Are HIV-positive returnees an added burden on their (often already vulnerable)

communities in their countries of origin?

- Should return assistance be focused specifically on migrants living with HIV

or does this discriminate against other groups (e.g. migrants with other

illnesses)

- Which limits do assistance providers put on their responsibility towards

returnees?

- Does voluntary return by an HIV-positive migrant have a negative impact on

the chances of others who wish to remain in the Netherlands?

- Can returning migrants living with HIV form a public health risk to their

countries of origin?

• Dutch immigration policies are not always conducive to making voluntary return a

viable option for migrants living with HIV:

1) There is an enormous gap between the legal focus on availability of medical

treatment in countries of origin, and the basis for decisions of migrants to

return, which is related to de facto accessibility of this treatment.

2) Returning without any option to come back to the Netherlands deprives

returnees of a medical (and sometimes socio-economic) ‘safety net’. This is a

major deterrent for migrants living with HIV to think about return.

3) The consequences of not having a legal status (e.g. no access to social benefits,

housing, etc.) can force migrants living with HIV in a very basic ‘survival

mode’, which does not allow for reflection on future options, including

voluntary return.

TABLE OF CONTENTS

PART I – BACKGROUND

Chapter 1 – Introduction 9

1.1 HIV-positive and no legal status: what next? 9

1.2 African migrants and HIV 10

1.3 Return Migration and Health III project 13

1.4 Chapter overview 15

Chapter 2 – Methodology 17

2.1 Overview of methodology 17

2.2 Literature review 17

2.3 Consultation with experts in the Netherlands 18

2.4 Target group interviews 18

2.5 Country studies 22

Chapter 3 – HIV and Dutch immigration and return policies 25

3.1 Introduction 25

3.2 Asylum and HIV 25

3.3 Regular immigration and HIV 26

3.4 Consequences of not having a legal status 31

3.5 Dutch return policy and practice 32

3.6 Assisted voluntary return 33

Chapter 4 – Voluntary return and HIV: some theoretical issues 37

4.1 Introduction 37

4.2 What is voluntary return? 37

4.3 Decision-making about voluntary return 40

4.4 HIV-specific considerations 41

PART II – RESULTS

Chapter 5 – Migrants’ perspectives 45

5.1 Introduction 45

5.2 Pre-departure lives and reasons for migrating 46

5.3 Situation in the Netherlands 49

5.4 Expectations of situation in country of origin 53

5.5 Decisions about returning 57

Chapter 6 – Country report: Sierra Leone 61

6.1 Sierra Leoneans in the Netherlands: HIV, immigration and return 61

6.2 Sources of information 61

6.3 Medical issues 62

6.4 Economic issues 63

6.5 Social issues 64

Chapter 7 – Country report: Ghana 67

7.1 Ghanaians in the Netherlands: HIV, immigration and return 67

7.2 Sources of information 67

7.3 Medical issues 68

7.4 Economic issues 69

7.5 Social issues 70

Chapter 8 – Country report: Nigeria 73

8.1 Nigerians in the Netherlands: HIV, immigration and return 73

8.2 Sources of information 73

8.3 Medical issues 74

8.4 Economic issues 75

8.5 Social issues 75

Chapter 9 – Country report: Angola 77

9.1 Angolans in the Netherlands: HIV, immigration and return 77

9.2 Sources of information 77

9.3 Medical issues 78

9.4 Economic issues 79

9.5 Social issues 80

Chapter 10 – Country report: Cameroon 83

10.1 Cameroonians in the Netherlands: HIV, immigration and return 83

10.2 Sources of information 83

10.3 Medical issues 84

10.4 Economic issues 84

10.5 Social issues 85

PART III – CONCLUSIONS

Chapter 11 – Constraints and possibilities of return and reintegration 89

11.1 When might migrants living with HIV choose to return? 89

11.2 Barriers to return 90

11.3 Overcoming barriers: voluntariness, commitment and preparedness 93

11.4 The right combination of circumstances 94

Chapter 12 - Assisting the voluntary return of migrants living with HIV 97

12.1 A ‘road map’ for return 97

12.2 Interventions 100

12.3 The scope and potential of return assistance 102

12.4 Return assistance: risks and ethical questions 103

Chapter 13 – The impact of immigration legislation and policies on the

possibility of return

105

13.1 Legal status and the possibility to return 105

13.2 No way back: return as permanent return 105

13.3 Willingness, proactiveness and legal status 106

13.4 No legal status and no prospect of voluntary return: what next? 106

References 109

LIST OF TABLES, FIGURES AND DISCUSSION TOPICS

Box 1: Persons of African birth living in the Netherlands known to be HIV-positive 11

Box 2: Migrants living with HIV and their legal status 12

Box 3: Partners in the RMH III project 13

Box 4: A hidden agenda? 14

Box 5: Making return a topic for discussion: some reflections 20

Box 6: The Bureau for Medical Advice (BMA) 28

Box 7: The cost of treatment of uninsured migrants living with HIV 31

Box 8: Overview of IOM-assisted returns from the Netherlands (2005-2007) 33

Box 9: Some consequences of being HIV infected and the importance of adherence 40

Box 10: Characteristics of respondents 43

Box 11: Health care as a pull factor for migration? 45

Box 12: Who decides what is best? 83

Box 13: Voluntary return process 91

Box 14: Intervention possibilities 92

LIST OF ABBREVIATIONS

AIDS Acquired Immunodeficiency Syndrome

ARV Antiretroviral

ART Antiretroviral Therapy

AVR Assisted Voluntary Return

BMA Bureau for Medical Advice (Netherlands Ministry of Justice)

DT&V Netherlands Return and Departure Service (Dienst Terugkeer & Vertrek)

ECRE European Council for Refugees and Exiles

EMN European Migration Network

ERF European Refugee Fund

HIV Human Immunodeficiency Virus

HMF HIV Monitoring Foundation

HRT Return and Reintegration Regulation (Herintegratieregeling Terugkeer)

IOM International Organisation for Migration

IND Immigration and Naturalisation Service

MVV Authorisation for Temporary Stay (Machtiging Voorlopig Verblijf)

NGO Non-Governmental Organisation

PEPFAR President’s Emergency Plan for AIDS Relief

REAN Return and Emigration from the Netherlands programme

RMH III Return Migration and Health III project

SSA Sub-Saharan Africa

STI Sexually Transmitted Infection

Vc Dutch Aliens Act 2000 Implementation Guidelines (Vreemdelingencirculaire)

WVAC Working Group of HIV and AIDS Consultants and Nurses (Werkgroep HIV-

Consultants en Verpleegkundigen)

UNAIDS Joint United Nations Programme on HIV/AIDS

UNHCR United Nations High Commissioner for Refugees

Part I: Background

CHAPTER 1 – INTRODUCTION

1.1 HIV-POSITIVE AND NO LEGAL STATUS: WHAT NEXT?

1.1.1 The obligation to leave the Netherlands

This report deals with the issue of ‘voluntary return’1 of African migrants living with HIV in

the Netherlands. A considerable proportion of non-Dutch persons living with HIV in the

Netherlands are migrants2 from Sub-Sahara Africa. Among them are rejected asylum seekers

and irregular migrants, who do not have a legal status that permits them to reside in their host

country. Dutch immigration law states that any migrant without such as status is obliged to

leave the Netherlands, with voluntary return being the preferred way of meeting this

obligation3. While a decision to return is a difficult one for any migrant without a legal status,

the obligation to leave is particularly problematic for those who are living with HIV. In the

eyes of many of them, the difficulties in accessing medical treatment in their countries of

origin makes return equivalent to ‘a death sentence’. This, however, is by no means the only

reason for their negative perception of return, as shall be discussed at length in this report.

Not a lot is known about the way that rejected asylum seekers and irregular migrants living

with HIV deal with return, and which factors influence the decisions they make when

confronted with this issue. With this report, a first – if tentative – attempt is made to explore

this more thoroughly. It does so by drawing on interviews with several migrants living with

HIV in the Netherlands, as well as the results of visits to five African countries that often

receive returnees from the Netherlands4. These efforts were part of the Return Migration and

Health III project (see 1.3), which had the aim of creating a better understanding of:

1 The term ‘voluntary return’ is by no means an uncontroversial one. We will adhere to the use of this wording

for the simple reason that is the terminology used in policy documents to refer to those instances in which

migrants, either with or without external assistance, leave their host country out of their own initiative, rather

than being forcibly removed by the authorities of that country. However, different authors have suggested

alternatives, which they feel might better cover the realities as faced by migrants who are obligated to leave their

host country. These include ‘mandatory return’ and ‘independent return’ (e.g. ECRE 2003). The issue of what

constitutes voluntary return and the role of voluntariness and choice will be discussed in more detail in section

4.2.

2 For the purposes of this report, the term ‘migrant’ means any non-national who has migrated to another country

in order to establish him/herself for a prolonged period or permanently. Although often the term migrant is used

to distinguish those migrating for ‘economic’ reasons from asylum seekers or refugees who have migrated in

order to find protection from persecution or violence, we use the term here to encompass both groups. Where it

is necessary to make a distinction between these groups (for example, when speaking about their legal status in

the Netherlands) we will specify this (e.g. by using the term ‘asylum seeker’ or ‘irregular migrant’).

3 It should be noted that a failure to comply with the obligation to leave the Netherlands can lead to forced

removal from the Netherlands. The issue of forced removal of migrants by the authorities of the host country is

outside the scope of this research, as this does not provide the migrant with a ‘choice’ between different options.

This does not mean, as we shall see, that the threat of forced removal does not have a significant impact on a

migrant’s attitude towards the issue of voluntary return.

4 These countries are: Angola, Cameroon, Ghana, Nigeria and Sierra Leone. The rationale for the choice of these

five countries will be discussed in more detail in section 2.5.2 of this report.

• the current legal and policy frameworks that govern the situation of migrants living

with HIV in the Netherlands;

• the situation faced by HIV-positive migrants in the Netherlands when they are rejected

for asylum or otherwise do not have the right to remain;

• the practical possibilities and impossibilities of voluntary return for these migrants;

• the conditions under which voluntary return, with respect for the migrant’s well-being

and dignity, could be a suitable alternative to irregular stay in the Netherlands; and

• the feasibility of providing assistance in support of the return and reintegration of

migrants living with HIV.

These issues are discussed, first of all, in light of current policies and practices. This provides

us with a starting point to further inform the development of future policies and practices

related to the voluntary return of migrants living with HIV, and to identify issues that require

further exploration in order to improve these policies and practices.

1.1.2 Ethical considerations related to the return of migrants living with HIV

A policy and practice-oriented discussion cannot take place in a moral vacuum. From very

early on in the research process it became clear that the issue of return of migrants living with

HIV provoked strong emotions among both the migrants themselves and the professionals

who worked with them. Our encounters with them inevitably led to discussions of the ethical

dimensions of this issue. Originally, the research was not intended to focus on these ethical

questions. However, as the research progressed, these questions, rather than merely being the

‘by-products’ of the process, began to emerge as fundamental to the problem of return for

persons living with HIV. As such, reflecting on these questions has become an integral part of

this attempt to better understand the issue of return and HIV. It is important to note that this

report will not provide any definitive answers to these questions. This will require further

debate among the various stakeholders concerned. The identification of relevant issues in this

report, however, can provide an impetus for such debate.

1.2 AFRICAN MIGRANTS AND HIV

It is difficult to get a clear picture of the number of Africans living with HIV in the

Netherlands, and even more so to gain an insight into their legal status. In general, it can be

said that Africans form a significant group among persons living with HIV in the Netherlands.

In June 2007 there were more than 13,000 persons known to be living with HIV in the

Netherlands (UNGASS 2007)5. Approximately 17 percent of these were of Sub-Sahara

African origin (this represents almost one third of all persons of non-Dutch origin living with

HIV in the Netherlands). An overview of the number of Africans living with HIV in the

Netherlands is provided in box 1. It should be noted that these statistics are based on country

of birth, rather than the legal status of these persons, and does not distinguish between persons

with Dutch citizenship who were born in other countries, foreigners holding Dutch residency

permits, asylum seekers still in procedure, or irregular migrants. As such, they tell us little

about the proportion of people with precarious legal statuses.

5 This only includes cases that are registered in Dutch hospitals. In May 2008, an Aidsfonds campaign was

launched to address the issue that a significant number of people living with HIV were unaware of their HIV-

positive status. The total number of persons infected is was estimated to be around 18,500 in 2007 (UNGASS

2007).

Box 1: Persons of African birth living in the Netherlands known to be HIV-positive (June

2007)6

Country # Country # Country #

Angola 113 Ghana 243 Nigeria 133

Burkina Faso 13 Gambia 5 Rwanda 127

Burundi 154 Guinea 57 Seychelles 1

Benin 7 Eq. Guinea 2 Sudan 65

Botswana 6 Guinea-Bissau 8 Sierra Leone 126

DR Congo 112 Kenya 71 Senegal 13

CAR 3 Liberia 68 Somalia 101

Chad 2 Madagascar 2 Tanzania 31

Rep. of Congo 93 Mali 4 Togo 40

Côte d’Ivoire 47 Mauritania 11 Uganda 58

Cameroon 162 Malawi 8 South Africa 58

Cape Verde 56 Mozambique 13 Zambia 60

Eritrea 51 Namibia 3 Zimbabwe 35

Ethiopia 185 Niger 5

A small-scale survey, undertaken as part of this research, helps to shed a bit more light on this

issue. Box 2 (next page) provides an overview of the (presumed) legal status of 85 African

migrants living with HIV, as known by health care staff in thirteen hospitals7. More than forty

percent of the included migrants were believed to be in an uncertain situation regarding their

possibility to stay in the Netherlands. Another twenty percent were believed to have had their

claims rejected or never tried to obtain a legal status in the Netherlands, thus facing a legal

obligation to leave the country. While this survey is by no means representative of the entire

population of African migrants living with HIV, it does show that there may be a potentially

large group that is forced to make a ‘choice’ between irregular stay or fulfilling the legal

obligation to leave the Netherlands at some point during their stay.

6 These figures represent the state of the HIV Monitoring Foundation’s database as of June 2007.

7 The survey was undertaken by WVAC (see box 3) between March and August 2007, as part of the research

project presented in this report. The research team would like to thank the members of WVAC for their kind

cooperation. The figures provided are based what health care providers knew of the legal status of their patients.

As this status is sometimes difficult to accurately pin down, both by migrants themselves and by health care

providers, these figures are merely indicative and not verified through other sources.

Box 2: Migrants living with HIV and their legal status (n = 85)

Legal status # % of total

Temporary or permanent right to remain

• asylum status

• regular grounds

• grounds unknown

Sub-total

4.7%

28.2%

1.2%

34.1%

Still in procedure

• asylum procedure

• regular procedure

• type of procedure unknown

Sub-total

22.4%

18.8%

2.4%

43.5%

No right to remain

• asylum application rejected

• application for regular status rejected

• both asylum and regular applications rejected

• no attempt to gain (asylum or regular) status

Sub-total

8.2%

2.4%

3.5%

5.9%

20.0%

Unknown status 2 2.4%

TOTAL 85 100%

Furthermore, the development of HIV treatment initiatives in almost all African countries, in

conjunction with the current focus of Dutch immigration law regarding migrants with medical

conditions, may lead to an increase of migrants living with HIV who face such a situation. In

short, (temporary) residency on medical grounds – which is an important avenue for gaining a

legal status for migrants living with HIV – is primarily dependent on the availability of

appropriate medical treatment in the country of origin of the migrant. As HIV treatment

options in various African countries expand, this may lead to more migrants living with HIV

being legally obliged to leave the Netherlands8. At the same time, many migrants and

professionals working with them have been strongly critical of migrants living with HIV

being told to return. They question whether current developments in the expansion of

treatment programmes in African countries are actually contributing to better access to

treatment. They argue that, in many cases, treatment being available in a particular country

does not mean that the HIV-positive returnee will actually be able to enjoy that treatment.9.

These circumstances all played a part in the development of the Return Migration and Health

III research project. A brief explanation of this project will be provided in section 1.3, as it

forms the organisational background against which the results and conclusions set out in this

report need to be understood.

8 In chapter 3, the Dutch policy regarding residency on medical grounds is discussed extensively.

9 The debate on availability of treatment versus the de facto accessibility of treatment is a major bone of

contention in legal procedures for residency on medical grounds. This debate will be discussed in more detail in

chapter 3.

1.3 RETURN MIGRATION AND HEALTH III PROJECT

The research presented in this report is one of the main results of the two-year Return

Migration and Health III project (RMH III)10, funded by the European Refugee Fund and co-

funded by the Dutch Ministry of Justice. The immediate impetus for the project was formed

by a small number of encounters of the staff of the International Organisation for Migration

(IOM) with migrants living with HIV in the Netherlands, who requested assistance in

returning to their countries of origin11. While IOM had been providing return assistance for

rejected asylum seekers and irregular migrants since the early 1990s, the organisation had

little experience dealing with the specific needs of HIV-positive returnees. Given its desire to

be able to provide return assistance to all those who request it, IOM sought the advice of

organisations in the field of HIV prevention and treatment, in particular Soa Aids Nederland,

to discuss what could be done. IOM and Soa Aids Nederland jointly initiated discussions with

other stakeholders in the field, including the project’s other partners WVAC and

PharmAccess Foundation (a brief description of all four organisations involved in the project

is provided in box 3 below).

Box 3: Partners in the RMH III project

• The International Organisation for Migration (IOM), as the main organisation facilitating

voluntary return from the Netherlands, was the lead agency in this project and carried the

responsibility for its implementation12. In carrying out the project, IOM worked together with

the three non-governmental organisations listed below. These organisations comprised the

project’s Advisory Board, providing advice on methodology, critical feedback on results and

other support throughout the project’s implementation.

• Soa Aids Nederland13 is the national institute for sexually transmitted infection (STI) and

AIDS control in the Netherlands. It works to prevent STIs and improve the quality of STI

control in the Netherlands. Among other things, Soa Aids Nederland houses the national

focal point for ethnic minorities and STIs, who was closely involved in the project. Soa Aids

Nederland participated in the country studies on Ghana and Nigeria.

• The Working Group of HIV and AIDS Consultants and Nurses (WVAC)14 The WVAC is an

association of nurses and consultants dealing with HIV-positive patients in the twenty-five

HIV-treatment locations for adults and five locations for children in the Netherlands. Asides

from being a representative organ of HIV nurses and consultants, the WVAC works on

information dissemination and knowledge development on HIV treatment and care issues.

10 RMH III is a follow-up of earlier projects by the International Organisation for Migration in the Netherlands,

which were concerned, respectively, with voluntary return of migrants with health problems in general (RMH),

and the voluntary return of migrants with psychiatric disorders, including a particular focus on schizophrenia

(RMH II). Publications that resulted from these earlier project include Conze and Muller (2004) and Engelhard

(2004).

11 As shall be discussed in more detail (see section 3.6), IOM in the Netherlands provides assistance to migrants

who wish to return to their countries of origin, , particularly those who are faced with an obligation to leave the

Netherlands, or expect to be faced with the obligation in the near future.. This assistance includes the provision

of an air ticket to the country of origin and, for particular groups, a reintegration grant. IOM’s assistance is

limited to those migrants who return ‘voluntarily’ (also see footnote 1). The organisation is prohibited by its

international mandate from assisting in the forced return of migrants (article 1(1)(d) of the IOM Constitution).

12 The role of IOM in voluntary return programmes will be discussed in more detail in chapter 3. For more

information on the activities of IOM in the Netherlands, see www.iom-nederland.nl. For information on IOM’s

worldwide programmes, see www.iom.int.

13 For more information, see www.soaaids.nl.

14 For more information, see www.wvac.nl (in Dutch only).

15 For more information, see www.pharmaccess.org.

• PharmAccess Foundation15 is a Dutch not-for-profit organisation supporting access to HIV

treatment, primarily in Sub-Sahara Africa. To this end, PharmAccess Foundation provides

quality assessments of treatment sites, training and monitoring, and implements various

projects, including workplace programmes.

In these discussions, it was confirmed that there might be a broader need among certain

categories of migrants living with HIV, for assistance in their return, and especially in their

sustainable reintegration in their countries of origin. However, it was also acknowledged that

how such assistance could be implemented, should be explored in more detail before

developing specific activities. The desirability of such an exploration was primarily prompted

by the lack of in-depth information about the experiences of migrants living with HIV who

have to choose between returning and staying in the Netherlands. Additionally, it was noted

that those organisations that worked closely with HIV-positive migrants in the Netherlands,

had little experience and knowledge of the issue of return. This led to the development of the

RMH III project, which was both intended to bridge the knowledge gap between the

‘migration’ and the ‘HIV’ parties at the table, and, ultimately, to move towards a better

understanding of voluntary return as a practical solution to the problem of irregular stay in the

Netherlands by migrants living with HIV. Additionally, the RMH III project incorporated a

pilot, in which return and reintegration assistance – based on the insights gained through the

research – would be made available to a small number of HIV-positive migrants who

considered returning.

Box 4: A hidden agenda?

Throughout the project, there was an inherent tension between the knowledge-building aspect

and the development of interventions for migrants living with HIV. Several interlocutors suggested

that the fact that the provision of return assistance was an integral part of the project, this would

bias the research’s towards the issue how migrants living with HIV could be ‘made’ to return,

rather than answering the fundamental question whether it would actually be feasible and

desirable to actively engage in return assistance for this group. IOM’s position as a major player

in the Dutch government’s return strategy (see sections 3.5 and 3.6) also contributed to concerns

about the objectiveness of the research. After all, would IOM in the Netherlands, as an agency

with a primary focus on facilitating voluntary return, not have a vested interest in suggesting that

return for migrants living with HIV would be desirable? And would it not be in the interest of the

Dutch government (one of the funders of the project) to hear that there were ample opportunities

for migrants living with HIV to return?

In reaction to this, discussions followed in which it was explained that there was no intention to

use the project to significantly increase the number of returnees living with HIV. Rather, its aim

was to look at the possibilities of better assisting those migrants living with HIV who already had

an intention of returning (such as those who had approached IOM in the past) and to inform those

who were weighing up their options. Nevertheless, it should be noted that by the time of the

publication of this report the provision of assistance to migrants living with HIV will have started.

The decision to go ahead with the development of assistance activities, however, is no longer

merely the product of the project’s initial design, but also of a well-considered deliberation that –

in specific circumstances – return assistance to migrants living with HIV may both be desirable

and possible. The rationale behind this deliberation, as well as the limitations it entails, will be

discussed at length throughout this report. Additionally, one of the outcomes of the discussions

with various stakeholders was that more focus was put on raising awareness and facilitating

policy-level dialogue about the situation of migrants living with HIV without a legal status, and

which alternatives – both in the Netherlands and in their countries of origin – should be made

available for them.

1.4 CHAPTER OVERVIEW

In the next chapter, we will first describe the methodological approaches through which we

have gained our results. Chapter 3 describes the legal and policy framework that governs the

situation of migrants living with HIV in the Netherlands. Chapter 4 discusses some of the

basic concepts related to the issue of voluntary return and it provides a frame of reference for

understanding migrants’ decisions to return or to stay.

These general chapters are followed by six chapters in which we present our main findings.

Chapter 5 presents the results of interviews with twelve migrants living with HIV in the

Netherlands. Chapters 6 to 10 outline the results of the visits to five African countries (Sierra

Leone, Ghana, Nigeria, Angola and Cameroon respectively), in which the possibilities and

constraints of reintegration in those countries were explored. Chapter 11 links the findings

from the interviews with those of the country studies. Chapter 12 provides the major

conclusions about the desirability, possibilities and limitations of return, and the specific role

that return assistance can play in this respect. It also includes recommendations for how such

assistance could take shape. Chapter 13, finally, provides a closer look at current Dutch

immigration and residence policies towards migrants living with HIV, and how these impact

on the possibilities of these migrants to find sustainable perspectives for their futures.

CHAPTER 2 – METHODOLOGY

2.1 OVERVIEW OF METHODOLOGY

In gathering information about the possibilities and constraints of the return of migrants living

with HIV, the following instruments have been used:

• a literature review;

• ongoing consultations with experts in the Netherlands;

• interviews with individual migrants living with HIV in the Netherlands; and

• interviews with stakeholders in five African countries.

In this chapter, we will briefly discuss each of these instruments in turn, beginning with the

two that were primarily aimed at gathering information on the broader context of our research

topic: the literature review and expert consultations. Subsequently, we deal with the target

group interviews and the country studies respectively, which form the core of our research, as

they provide more specific insight into the issue of return for African migrants living with

HIV.

2.2 LITERATURE REVIEW

A fairly broad academic and practice-oriented body of literature exists on both the issue of

(voluntary) return of rejected asylum seekers and irregular migrants, and on the issue HIV

among migrant communities in the West. However, there is a significant gap in knowledge

where these two issues meet; no specific research has on the return of migrants living with

HIV from Europe or other Western countries is available. This does not mean that existing

sources cannot help us gain some insight into this topic. The body of work on the issue of

return, for example, provides valuable information on the challenges for migrants who are not

HIV-positive in deciding whether to return and in their actual return and reintegration. Quite a

few of these challenges are no different for migrants living with HIV, although the latter

group is likely to face additional constraints. Additionally, there is an increasing research

focus on the linkages between mobility and HIV, which also provides some insights into the

specific issue of return migration. Finally, there is extensive information available on the lives

and survival of people living with HIV in Africa. This is particularly relevant to our purposes,

since this literature deals with the situation that migrants living with HIV would find

themselves in should they return. These different sources have provided much of the ‘ground

work’ for this research, in terms of:

• being the theoretical background for the development of the target group interviews

and country studies;

• providing a description of the legal and policy frameworks that govern the situation

of migrants living with HIV in the Netherlands;

• being an instrument for verification of, and critical reflection on, the research results.

The literature review is primarily incorporated in the next two chapters, which provide a

description of the policy and legal context governing the situation of migrants living with HIV

in the Netherlands, and a discussion of the theoretical concepts and frameworks used in this

report respectively.

2.3 CONSULTATIONS WITH EXPERTS IN THE NETHERLANDS

Various health care professionals, assistance providers, representatives of migrant

organisations and others, collectively referred to here as ‘experts’, were consulted during the

research process. These experts included representatives of charities providing assistance and

support to migrants living with HIV, representatives of community-based organisations, staff

of municipal health services, a physician and several IOM staff members who had

encountered migrants living with HIV who wanted to return. The consultations were usually

of an informal nature, but they yielded lot of information about perceptions of the issue of

return for migrants living with HIV, about the different organisations that are involved with

this group, and about the practical dilemmas encountered by aid and health care workers.

Perhaps most importantly, these discussions inevitably led to critical questions about the

desirability of return, and the roles that different actors, most notably the Dutch government

and IOM, play herein.

In addition to these ad hoc consultations, the research process provided for structural

discussion through the project’s Advisory Board. The Advisory Board provided a platform for

discussion and reflection not only on the results of the research, but also on the research

process itself. The sessions with the Advisory Board were complemented by a number of one-

on-one meetings between IOM’s researchers and representatives of the three individual NGOs

involved.

Finally, the preliminary results of the research were presented during several conferences, i.e.

the 2nd and 3rd Annual Conferences on Ethnic Minorities and STI/HIV Prevention (5 October

2007 and 3 October 2008), and the 11th National Conference on STIs, HIV and AIDS (30

November 2007)16. The subsequent discussions with civil society actors and migrants also

provided a lot of valuable input for this report.

Like the literature review, the discussions with experts have mainly provided a basis for the

verification and for critical discussion of the results of the target group interviews and the

country assessments.

2.4 TARGET GROUP INTERVIEWS

2.4.1 Main objective

The main objective of the target group interviews was to ensure that our discussion of

voluntary return for migrants living with HIV would incorporate the experiences and

perceptions of these migrants themselves. In other words, it was a means to ensure that we did

not only engage in a discussion about voluntary return of migrants living with HIV, but also

to discuss voluntary return with migrants living with HIV17. The interviews were aimed at

uncovering their opinions, experiences, expectations, hopes and fears related to the issues of

16 These conferences were organised by Soa Aids Nederland. The research team thanks Soa Aids Nederland for

its invitation and the opportunity to speak at these conferences.

17 Although this discussion with migrants was mostly sought to obtain information, the encounters have – in

some cases – also led to further reflection by migrants about their futures; in particular with the information that

extra assistance to rebuild their lives in their countries of origin might become available. As shall be discussed in

chapter eleven, this ‘thinking about ones future’ is an essential part of ensuring a migrant’s well-being, either in

the Netherlands or in his/her country of origin.

living without a legal status and the possibility of return. In chapter five, these results will be

discussed at length.

2.4.2 Selection of respondents

The target group of this research was initially limited to African (rejected) asylum seekers18,

and particularly those from the five countries that would be included in the country studies

(see section 2.5). This limitation in the target group, however, proved to be untenable, for

various reasons.

First of all, a major issue in terms of selection was the practical problem of how to get people

to participate in the interviews. IOM in the Netherlands had not previously been engaged in

issues concerning HIV, and as such had no networks of its own among groups of migrants

living with HIV. As such, it had to rely primarily on the contacts provided by the project’s

NGO partners, who brought the researchers in touch with several organisations dealing

directly with migrants. These were asked to mediate between the researchers and potential

respondents. For this to be possible, in some cases, hesitations about the objectives of the

research, as well as IOM’s role as an organisation implementing governmental return policies,

had to be overcome. Personal meetings with representatives of these organisations helped to

allay their fears to some extent, and a number of organisations eventually helped establish

contacts between the researchers and the migrants.

While being a good method for gaining access to migrants living with HIV, the use of

mediators significantly influenced the composition of the eventual group of respondents. The

mediating organisations were provided with information about the research, and the desired

profiles of respondents. It was left up to them to pass on this information to persons who

might potentially agree to be interviewed. Only when a person agreed to be interviewed the

research team was notified and arrangements were made for the interview. Persons who were

approached by the mediators, but who declined to participate in the interviews, never had any

dealings with the research team. This method provided target group members a high degree of

anonymity, and the research team the assurance that participation in the interviews was

strictly voluntary. This did mean, however, that the mediators formed a filter in the selection

process19. Also, mediators sometimes only had access to specific groups (e.g. West-Africans,

women, etc.), which of course limited their ability to meet the ‘demand’ for certain profiles of

respondents. Adhering strictly to the profiles, due to the sensitive nature of the subject and the

process of selection, would have made it impossible to achieve a reasonably sized pool of

respondents. The choice was therefore made, while still aiming primarily for respondents

from the five selected countries, not to exclude potential interviewees from other Sub-Saharan

African countries20.

18 This initial brief was not due to a methodological or theoretical choice, but inspired by the limitations of one

of the project’s funders, the European Refugee Fund. Its funds can only be used to benefit refugees and asylum

seekers, and not other types of migrants.

19 Choosing, for example, persons whom they knew well – and thus could assess accurately their willingness to

cooperate.

20 For the purposes of this report, we consider Sub-Sahara Africa to comprise all countries on the African

continent, including the island states, with the exception of countries in the Maghreb and North African region

(Morocco, the Western Sahara, Algeria, Tunisia, Libya and Egypt).

A second important factor in the selection process was unclarity about the legal status of

migrants21. This led to the ‘accidental’ arrangement of interviews with migrants who were not

(rejected) asylum seekers, and thus, should have been excluded from the interviewing process

according to the initial criteria. However, the discussions with these persons quickly showed

that in terms of the problems they faced, there was little difference between rejected asylum

seekers and other migrants who were not allowed to remain in the Netherlands, or might be

confronted with this situation in the future. In addition, we came across migrants who did

have a legal status (often on regular grounds and thus excluded from our initial target group)

but who had reflected extensively on the issue of a potential return to their countries of origin.

Their ability to reflect and their insights gained, provided an excellent source for further

discussion of the issue of voluntary return, and thus became an integral part of this study22.

In the end, interviews with twelve migrants living with HIV were carried out, all taking place

between May and September 2007. A profile of these respondents is provided at the start of

chapter 5.

2.4.3 Representativeness and generalisability

As discussed at the start of this report, the exact size and make-up of the group of HIV-

positive migrants living without a legal status in the Netherlands is unknown. As such, there

has been no way of ensuring that the selected respondents constituted a representative sample

of the target group at large. Rather, the interviews provide anecdotal evidence of the

perceptions of certain migrants living with HIV of the issue of voluntary return. The highly

individualised circumstances of our respondents, the unrepresentative sample, and the sample

size make it impossible to claim that our results are in any way representative of the entire

population of migrants living with HIV in the Netherlands. Nevertheless, the interviews are

very useful in identifying possible issues relevant to the problem of return, even if this cannot

be done in an exhaustive way.

2.4.4 The interviews

As noted at the start of this chapter, the main objective of the interviewing process was to get

a clearer picture of the perceptions of migrants living with HIV on the issue of voluntary

return. Uncovering these attitudes and perceptions necessitates getting ‘into the heads’ of our

target group members. Our approach, therefore, was focused on individual experiences, and

less on analysing trends across the target group. The main consideration in choosing the

interview format was the possibility for target group members to get their stories across, and

to leave enough space for further discussion. This resulted in the use of an open interview

structure, in which only broad topics were suggested, but which left a lot of space for the

respondents’ own narratives. Each respondent was asked to discuss his/her:

• attitude regarding the issue of return: was this considered an option or not?

• situation before departing his/her country of origin

• reasons to migrate to the Netherlands;

• current situation in the Netherlands;

21 There is a certain fluidity to the legal status of these migrants, often changing between ‘asylum seeker’,

‘regular migrant’ and ‘irregular migrant’. For example, a person who has been rejected for asylum might be

considered an irregular migrant until he/she applies for a regular residence permit on medical grounds.

22 In many cases, this ability to reflect was not a ‘luxury’ that the interviewed rejected asylum seekers and

undocumented migrants had. As shall be discussed in chapter five, their focus was often so much on daily

survival, that it was very difficult, if not impossible, to ponder the potential implications of return. From a

perspective of discussing the possibilities and impossibilities of return, therefore, the interviews with migrants

who had a temporary or permanent legal status in the Netherlands were often richer in information.

• knowledge about current conditions in his/her country of origin and the channels of

information used;

• expectations in case of (a hypothetical) return.

Each time, the respondents were asked to reflect on at least three aspects: medical, economic

social. The rationale for these three dimensions as a focus for our investigation will be

explained in chapter three. The interviewers were briefed to encourage a free-flowing

conversation, rather than the respondent merely being subjected to a string of questions. This

was done in order to allow the respondents to also ‘lead’ the topics, by focusing on what was

important to them, and by proposing further dimensions of interest. Building trust between the

interviewer and the respondents was an essential part of the process. One of the ways in the

building of trust was stimulated was by employing interviewers who themselves hailed from

Sub-Sahara Africa. This was meant to facilitate communication and understanding. This had

advantages and drawbacks. These, and other considerations during the interviewing process,

are discussed in more detail in the box 5 below. Each interview, with the permission of the

respondent, was tape-recorded and transcribed. All interviewees received a compensation for

their participation to the amount of  30.

Box 5: Making return a topic for discussion: some reflections

Return is not a very accessible topic for most migrants, particularly for those living with HIV.

Since many of the respondents were still focused on gaining a legal status in the Netherlands,

speaking about return required a mental leap that was not always easily made. Even though the

interviews only dealt with the hypothetical situation of return (a ‘what if’-scenario), for some

respondents this may have felt like a ‘weakening’ of their resolve to fight a status in the

Netherlands. This phenomenon is also noted by Engelhard (2004) in his study on refugees and

asylum seekers with medical conditions and the problem of return.

23 The decision to use African interviewers was not taken lightly. An elaborate discussion within the research

team, as well as with the project’s Advisory Board, took place before the interviewers were recruited. The

interviewers, although themselves Africans, were not nationals of any of the five pilot countries of the study nor

were they – as it turned out – of the same nationality as any of the interviewees from other African countries.

Whether the use of interviewers of African origin did actually lead to increased trust between the interviewer and

the interviewee is still a matter of debate. The interviewers themselves remarked on several occasions that

respondents were apprehensive about talking about their HIV-positive status with them for fear that they would

spread rumours within the African community. In some cases, it was suggested that having a non-African as the

interviewer might have helped the respondent to open up more. On the other hand, several interviewees seemed

to have regarded the fact that the interviewers understood ‘African culture’ as a positive factor.

24 It was suggested by some that other organisations, such as the various aid providers and support groups with

which the research team had been in touch, could have undertaken some of the interviewing, in order to avoid

some of the difficulties mentioned here. However, such ‘out-sourcing’ of the interviewing to different groups

was believed to potentially compromise the consistency of the way in which the interviews were undertaken. It

would also have made it more difficult to safeguard objectivity and confidentiality, which were central to the

success of the research process.

25 The interviewers were instructed to briefly explain IOM’s role and the goals of the research project at the start

of each interview. They were also provided with some information materials (leaflets etc.) about IOM in case the

respondent required further information. In order to keep the interview as ‘pure’ as possible, the interviewers

would not discuss the role IOM could play in the respondent’s individual case. For such questions the

respondents were referred to the project coordinator. Nevertheless, in some cases it was necessary for the

interviewers to adjust expectations of the respondents, who sometimes thought IOM would be able to play a

positive role in their struggle for a legal status in the Netherlands. In at least one interviews this may have been

the main motivation of the respondent to agree to the interview. When the interviewer explained that IOM does

not play a part in the decision-making process on admission and residency in the Netherlands, this resulted in the

respondent being very defensive throughout the remainder of the interview.

secret from anyone but those assisting them and – in some cases – a very small circle of friends

or family. As a result, most respondents were not very keen to talk about their situation with an

unknown interviewer and some were afraid that participating in the interviews would lead to

unwanted speculation by members of their communities. Securing the confidentiality and

anonymity of respondents was therefore key to the research process.

Therefore, despite the above mentioned methodological difficulties regarding sampling and

representation of the target group, using ‘gatekeepers’ was deemed necessary to ensure that

participation was strictly voluntary and that the research team would not receive any information

about persons who did not want to participate in the research. When interviews occurred, these

were carried out by researchers who were themselves of African origin, who were able to meet

with respondents in their own communities without attracting too much unwanted attention23.

This limited the chance of unwanted disclosure of the HIV-positive status of the respondents.

Also, the respondents were allowed to choose an interview location, which they thought most

suited their needs and ensured confidentiality. In the end, the interviews took place in a variety

of locations, such as the offices of the assistance providers who acted as gatekeepers, the

homes of interviewees, and IOM’s regional office in Amsterdam.

Finally, the fact the interviewers were employed by IOM, an organisation known by most

respondents to be primarily concerned with return assistance, also had an impact on the

interviewing process. The interviewers were sometimes put in a position where they would not

only have to elicit information from the respondents, but were also expected by these

respondents to provide information on the activities of IOM24. Efforts were made to separate the

role of interviewer from the role of information provider, although this was not always strictly

possible25.

2.5 COUNTRY STUDIES

2.5.1 Objectives and setup of assessments

Together with the target group interviews, the country studies formed the research’s main

source of empirical data. The main objective of the country assessments was to exchange

views with a variety of stakeholders in potential countries of return about the practical

possibilities and difficulties that migrants living with HIV might encounter on return. Five

such country visits took place, each taking approximately one week. In chronological order

these were: Sierra Leone (9-16 July 2007), Ghana (13-18 August 2007), Nigeria (19-25

August 2007), Angola (20-27 September 2007) and Cameroon (29 October-3 November

2007). In each case, one member of the research team met with representatives of

governmental agencies, international organisations, non-governmental organisations, and

support groups of persons living with HIV. Each time, the researcher was accompanied by a

member of staff of the IOM office in the visited country, and, in the case of Ghana and

Nigeria, a representative of Soa Aids Nederland. In each meeting, the interlocutors were

asked to reflect on, and provide their personal opinions of, the possibilities and constraints of

return and reintegration, particularly concerning such issues as:

• the existing (medical, economic and social) opportunities for people living with HIV;

• the gaps in existing services and the reasons for these gaps;

• the potential barriers for returnees to access these services;

• more generally, the barriers to (sustainable) reintegration after return;

• the possibilities (within existing frameworks or through new initiatives) to help

returnees overcome these barriers.

Moreover many of the respondents took great care to keep the fact that they were HIV-positive

It should be noted that way in which these topics were addressed during each country

assessment varied according to the opportunities, practical circumstances and the particular

areas of expertise of our interlocutors. A report of each visit was made. These are each

presented in a separate chapter in this report (see chapters 6-10).

2.5.2 Selection of countries

A selection of five African countries was made based on a range of criteria and data. Two

main concerns were that (1) the selected countries would be common destinations for

returnees from the Netherlands and (2) there were relatively sizeable groups of HIV-positive

migrants originating in these countries staying in the Netherlands. The relevant statistical data

related to these indicators is presented in various places in this report26. In addition to these

criteria, issues relating to the practical implementation of an assessment, such as the presence

of an IOM office and/or of partner organisations, as well as the general security situation and

infrastructure, were taken into consideration.

2.5.3 Scope of the reports of the country visits

Like the interviews with migrants in the Netherlands, the reports of the country visits cover a

wide range of professional and personal perspectives. Given the explorative nature of this

research, these perspectives were used to identify the issues of concern related to the return of

migrants living with HIV as broadly as possible. It was not feasible, nor the intention, to

independently verify all the information provided by our interlocutors in the five countries.

By no means, therefore, should the accounts of the visits – as presented in this report – be

seen as providing a comprehensive or factual reference on the state of medical, economic and

social issues confronting people living with HIV in the five selected countries. Rather, it

provides a synopsis of the various opinions and impressions of persons interviewed.

In addition, the reports provide only a partial picture that is location and time-sensitive. For

example, the visits usually only allowed for meetings with stakeholders working in the

capitals of the five selected countries, thus gaining much more information about the lives of

people living with HIV in these cities than those in rural areas. Also, where medical-technical

information is discussed by those interviewed, it is possible that this information will already

be outdated by the time of the publication of this report27. This is also the reason why, for

example, different drugs are not mentioned specifically28.

26 See, for example, boxes 1, 2, 6 and 8.

27 As such, there were some concerns during the writing up of this report that the different country chapters

would be used by some as reference documents to make a case for or against the return of individual migrants,

despite the inadvisability of such action based on the limitations outlined above. We feel it is crucial to re-

emphasise the general nature of our discussions and the necessity of assessing the possibilities of voluntary

return of individual migrants should be done on a much more specific basis than our report can ever provide

(also see chapters eleven and twelve). It is for this reason that the choice was made not to provide lists of

medications available in the countries, or other very specific medical-technical information. Even when such

lists were provided by governmental officials or other interlocutors, it was impossible within the limited time

available for the visits, to independently verify whether these lists reflected reality in either the country as a

whole or specific locations (this would have necessitated long-term investigation of, for example, availability

and distributions of these medications).

28 It should be noted that this report has no pretence to be a clinical study. Medical issues are therefore only

discussed in laymen’s terms. Medical professionals who are in search of case-specific information on treatment

possibilities in the five countries are advised to consult with hospitals and government agencies there. In case of

voluntary return, IOM mediates between health care professionals in the Netherlands and those in the country of

origin, to ensure that all relevant information related to treatment possibilities is exchanged, and that an

appropriate handover of the patient can take place. For more information on IOM Netherlands’ assistance to

returnees with medical problems, please see www.iom-nederland.nl.

Finally, it should be noted that the reports vary (sometimes significantly so) terms of structure,

length and content. These depend on the number of consultations that feasible within the

duration of each visit, which actors were willing and able to meet with the researcher at that

time, and the professional backgrounds of those actors and the activities implemented by them.

In some cases, those consulted spoke a lot about the general problems that returnees living

with HIV might experience, while others chose to focus on their own activities, and how these

might benefit returnees.

CHAPTER 3 – HIV AND DUTCH IMMIGRATION

AND RETURN POLICIES

3.1 INTRODUCTION

Although there may be different circumstances in which a decision to return is made, this

decision becomes particularly pressing matter when the migrant in question does not receive a

legal status, or is in danger of losing that status. For this reason, in this chapter we will first

provide an overview of legislation and policies related to the status of migrants living with

HIV in the Netherlands. There is a lot that can be said about migration legislation and policy,

and especially about how it is implemented (and contested) in practice. Because jurisprudence

and policies are constantly evolving, it is impossible to go into all details and developments.

We will therefore limit ourselves to a broad overview of the criteria for residency and how

these relate to the position of migrants living with HIV. Following this, we shall discuss the

circumstances that migrants living with HIV are faced with if they do not obtain a legal status.

Finally, we will cover policies and practices in the Netherlands related to the return of

migrants.

3.2 ASYLUM AND HIV

Migrants who do not already have a legal status in the Netherlands have two ‘gateways’ to a

legal status. One is through a so-called regular immigration procedure, which covers all

manner of reasons for (temporary or permanent) residency, including work, education, family

reunification and medical circumstances. The other is by applying for asylum. An asylum

application is a request to the Dutch government to grant protection against persecution or

violence in the applicant’s country of origin29.

The fact that an asylum seeker is HIV-positive usually plays a minor role in the asylum

procedure. Medical circumstances30 can be relevant when these corroborate an asylum

seeker’s claim that he/she has been facing persecution or other treatment that may lead to an

asylum status31, which would usually entail an intentional act. This will generally not be the

case with HIV32. HIV may play a role in determining whether the return of the asylum seeker

could amount to “inhuman or degrading treatment or punishment”. This concept is derived

from article 3 of the European Convention on Human Rights and Fundamental Freedoms,

which protects against such treatment, and prohibits countries to deport persons who may be

subjected to such treatment. In “very exceptional circumstances”, the forced return of a person

living with HIV may amount to inhuman or degrading treatment. These circumstances are

29 Under Dutch law, an asylum status can be granted to a person if (1) he/she is a refugee as defined in the 1951

Refugee Convention; (2) upon return to his/her country of origin, he/she would be subjected to torture or other

inhumane or degrading treatment or punishment; (3) humanitarian circumstances in the country of origin would

make it unreasonable to expect him/her to return to his/her country of origin; and (4) return to his/her country of

origin would be deemed particularly harsh in light of general circumstances there (article 29(1)(a)-(d), Aliens

Act 2000). The law also makes provisions for spouses, children or other dependents of persons deemed to be in

need of protection according to the grounds described here.

30 Asylum policy does not have specific provisions for HIV.

31 See Aliens Act 200 Implementation Guidelines (Vreemdelingencirculaire), section C1/3.2.4.1.

32 Although there may be cases when the person involved became infected, for example, due to rape.

outlined in a key case at the European Court for Human Rights33. In this case, the court

deemed the deportation of D., who was terminally ill and would not be able to get treatment

and support needed to prevent unnecessary suffering, would lead to inhuman or degrading

treatment in his native St. Kitts. The mere fact that the quality of health care was significantly

lower in the country of return, or that return would have led to a shorter life expectancy of D.,

was not found sufficient by the Court to judge that a violation of article 3 would occur. With

this interpretation, the Court has set a very high threshold for a violation of article 3. In those

cases when the forced return of a migrant living with HIV would meet the threshold of a

violation of article 3 of the Convention, the Dutch Aliens Act provides the person with an

asylum status. It is unlikely, though, that many cases will be considered to meet the “very

exceptional circumstances” of the case of D.

Apart from medical conditions being evidence for persecution, or as part of an argument that

forced removal would lead to a violation of article 3 of the European Convention on Human

Rights, there is relatively little leeway in the asylum procedure to consider these conditions. If

the asylum application has been made because the applicant wishes to undergo medical

treatment in the Netherlands, he/she will be referred to the regular immigration procedure,

which also covers (temporary) residency on medical grounds34. The same is true for asylum

applicants who claim they cannot be removed from the Netherlands due to medical

circumstances that make them unable to travel. These instances are covered in more detail

below.

3.3 REGULAR IMMIGRATION AND HIV

3.3.1 Introduction

Regular immigration law covers all non-asylum related grounds for residence, including

family formation and reunification, labour and education. All of these grounds may be

applicable to migrants living with HIV if they meet the circumstances, but they do not have

any specific provisions for HIV as a reason for residency. As such, they will not be discussed

here. Where regular immigration legislation and policy do impact on the issue of HIV is in its

residency status related to medical conditions.

The medical grounds track of Dutch regular immigration policy comprises two separate

permits, one based on ‘medical treatment’ and one based on ‘medical emergency’. However,

since the conditions for these permits are often closely linked, any application for residence

on medical grounds will be assessed against the criteria for both these permits. This means

that cases of applicants, who do not qualify for a permit on the grounds of medical treatment,

are automatically also assessed against the applicability of the grounds of medical emergency.

Before discussing the specific permits for medical cases, it should be noted that a set of

general conditions, which are unrelated to the medical status of the migrant, need to be met to

be eligible for a regular residence permit. These conditions include the migrant having a valid

passport, the migrant not being considered a threat to public order or national security, and the

migrant being in possession of a so-called authorisation for temporary stay (machtiging

voorlopig verblijf or MVV) 35 36. These conditions are already not easily met. Not all migrants

33 European Court of Human Rights, case no. 30240/96.

34 See Aliens Act 200 Implementation Guidelines (Vreemdelingencirculaire), section C1/3.2.4.1.

35 See Aliens Act 2000, article 16(1). Another condition, having a sufficient income, is waived in case of an

application for a regular permit on medical grounds.

applying for a medical residence permit will have a valid passport. Also, when migrants have

entered the country as an asylum seeker, or as an irregular migrant (i.e. they did not hold a

valid residence permit on other grounds before applying for a medical permit), they will not

have the required MVV. Exemption from these obligations is only granted in exceptional

circumstances37.

3.3.2 Residency on grounds of medical treatment

Dutch immigration policy allows migrants to apply for a residency permit on the basis that

they need to undergo medical treatment in the Netherlands. This permit is only awarded if

three conditions are met. These are:

1. the Netherlands is considered the most appropriate country for the treatment;

2. the treatment is deemed medically necessary; and

3. there is a sound financial basis for covering the costs of the treatment.

The first condition, that the Netherlands is considered the most appropriate country, is only

met in exceptional circumstances, and is dependent on a broad range of factors38. For

assessment of the second issue, whether the desired treatment is medically necessary, the

Immigration and Naturalisation Service seeks the opinion of its Bureau for Medical Advice

(BMA). The role of the BMA is highlighted in box 6 on page 28. The third condition implies

that the costs for the desired treatment can be covered by the migrant, and that the Dutch state

should not be made responsible for these costs. This means, generally, that the migrant must

be in possession of a health insurance that covers the costs of the treatment. Registration for

health insurance, however, is usually dependent on having a legal status, resulting in a

somewhat of a Catch 22 situation. This makes gaining a regular status on account of medical

treatment extremely difficult for rejected asylum seekers and other migrants without a legal

status.

3.3.3 Residency on grounds of medical emergency

If an application for residency on grounds of medical treatment is rejected, the application

will be assessed according to the criteria related to medical emergencies. The medical

emergency permit can be obtained if all of the following conditions are met:

36 An MVV is a visa that allows a person to enter the Netherlands on the basis that he/she is deemed to fulfil the

requirements for obtaining a residence permit. The would-be migrant applies for an MVV while still in his/her

country of origin. The application is then assessed on the basis of all the relevant requirements for the procedure

at hand (e.g. family reunification, labour, medical grounds). Only after the migrant is in possession of the MVV,

can he/she travel to the Netherlands. After arrival, the actual residence permit application has to be made.

Nationals of countries in the European Union or European Economic Area, as well as Australia, Canada, Japan,

New Zealand, South Korea and the United States, as well as certain other categories of migrants, are exempt

from the obligation to have an MVV prior to arrival (see www.ind.nl for more information).

37 In case of not having a passport, the migrant will have to show it is impossible for him/her to obtain one from

the authorities of his/her country of origin. In the case of an MVV, the migrant will have to show that he/she is

not able to travel back to his/her country of origin for medical reasons (an MVV is only issued in countries of

origin and cannot be obtained in the Netherlands) or that – due to medical circumstances – it would be

unreasonable to expect the migrant to do so.

38 The Aliens Act implementation guidelines state explicitly that the appropriateness of treatment in the

Netherlands is not a function of the quality of Dutch health care compared to that in the migrant’s country of

origin. Issues that do affect appropriateness include whether the Netherlands’ has specific medical expertise with

regard to the desired treatment, the length of the migrant’s legal residency in the Netherlands, the lack of

availability of the treatment in the migrant’s country of origin, the consequences of not receiving treatment, the

presence of necessary social support in the Netherlands, as well as a number of provisions related to pregnancy.

1. discontinuation of medical treatment will result in a medical emergency;

2. treatment of the illness or condition cannot take place in the country of origin of the

applicant or any other country that the applicant would be allowed to enter;

3. the treatment that prevents a medical emergency from occurring is expected to

continue for a period of more than one year;

The first condition, that discontinuation of treatment will result in a medical emergency,

implies, first of all, that the applicant is already receiving treatment. If this is not the case,

such as with persons who are HIV-positive but who have not (yet) started antiretroviral

therapy, the application for a permit will – in all likelihood – be rejected. In case treatment is

taking place, the issue arises whether discontinuation of that treatment would result in a

medical emergency. The Aliens Act implementation guidelines39 define a medical emergency

as an illness or condition that – within a period of three months – will result in the “death,

invalidity or another form of serious mental or physical damage of the applicant”. The BMA

advises the Immigration Service on the question of whether an illness, if untreated, would

result in a medical emergency.

The fact that discontinuation of treatment will result in a medical emergency in and of itself,

however, is not sufficient to be eligible for a ‘medical emergency’ residency status. This also

depends on whether or not treatment can be continued in the migrant’s country of origin. In

order to assess this, the BMA is asked to advice on whether treatment of the illness or

condition is available in the country of origin. That this condition deals with the availability of

treatment in a general sense, and not the practical possibilities of individual migrants to access

this treatment, is a very important – and for migrants living with HIV often frustrating –

aspect of the medical immigration procedure. Its implications, therefore, deserve more

attention (see paragraph 3.3.4).

The final condition, that treatment is expected to continue for more than one year, is one that

is easily satisfied by migrants living with HIV, since they will have a life-long dependence on

treatment.

39 B8/3.2.

Box 6: The Bureau for Medical Advice (BMA)

The Bureau for Medical Advice (BMA) is a specialised department within the Immigration and

Naturalisation Service, providing support to the decision-making process in medical cases. The

BMA gathers information about medical treatment options in the country of origin. Based on this

information, the BMA reports to the Immigration Service. In brief, the BMA generally provides

information about: (1) the nature of the medical condition of the applicant; (2) the nature and

expected length of the treatment the applicant is receiving; (3) the availability of necessary

treatment in the applicant’s country of origin40; (4) the possibility of a medical emergency occurring

if treatment is discontinued; and (5) the ability of the applicant to travel.

Medical advice in HIV cases41

In 2006, BMA provided advice in 198 instances where the applicant had been diagnosed as HIV-

positive. This constituted the biggest group (12 percent) of all cases in which a physical medical

condition was the subject of the advice42. Of the 198 cases, 168 (or 85 percent) dealt with persons

from Sub-Sahara Africa43. The table below provides an overview of the countries of origin that

were the subject of these 168 cases. Note that the six countries on which the BMA had to advise

most frequently are the five pilot countries covered in this report plus the Democratic Republic of

Congo.

Country # Country # Country #

Ghana 23 Uganda 6 Niger 3

Cameroon 21 Burundi 5 Ivory Coast 2

Nigeria 18 Rep. of Congo 5 Tanzania 2

DR Congo 11 Sudan 5 Zimbabwe 2

Angola 10 Somalia 5 Cape Verde 1

Sierra Leone 10 Rwanda 4 Eq. Guinea 1

Ethiopia 9 Togo 4 Guinea-Bissau 1

Guinea 6 Zambia 4 Kenya 1

Liberia 6 Eritrea 3

Treatment availability

BMA statistics covering 2006 show that in 38 cases (or 23%) of Africans living with HIV,

appropriate treatment was deemed to be available in the country of origin. In 125 cases (74%)

treatment was deemed not to be available or no information was available on treatment options44.

There are, however, significant differences between individual countries. In cases of Ghanaians,

for example, the BMA deemed treatment to be available in 13 out of 23 cases (57%). For

Cameroon this was 2 out of 21 (10%). In none of the cases of Nigerians, Angolans and Sierra

Leoneans, the BMA found treatment to be available45.

40 The Aliens Act implementation guidelines make provisions for instances in which there is no adequate or

reliable information about treatment in a certain country: “If, on account of a uncertain situation in the country

of origin, BMA is not able to advise on the availability of treatment possibilities in said country, it will be

assumed treatment possibilities are not available.” (B8/6).

41 The information presented here draws on statistics provided to the research team by the BMA. The research

thanks the BMA for its kind cooperation.

42 Overall, however, physical afflictions account for only a minority of the BMA’s assessments. Of the 3,664

reports it produced, 2,050 deal with psychiatric afflictions (57 per cent) and only 1.614 with physical afflictions.

Overall, cases in which HIV/AIDS was the main issue of concern constitute 5.4 percent of the advice reports.

43 It is unclear how many individuals are concerned here, as in any individual case more than one BMA

assessment might be necessary.

44 In the remaining four cases, the availability of treatment was deemed not to be relevant (presumably because

the applicant was not receiving treatment in the Netherlands).

45 The BMA found treatment availability not relevant in one case from Sierra Leone and in one case from

Angola.

3.3.4 Availability versus accessibility of treatment

A major bone of contention in many cases in which being HIV-positive is the basis for a

claim to residency, is whether appropriate treatment is available in the country of origin. The

Aliens Act implementation guidelines make a clear distinction between the objective

availability and the de facto accessibility of treatment. Objective availability should be

understood here as the existence of certain forms of treatment in the country of origin. This is

what the assessment of treatment options in countries of origin is based on. The

implementation guidelines explicitly state that circumstances regarding the de facto

accessibility of this treatment by an individual migrant will not be taken into consideration.

These circumstances include:

- the inferior quality of medical care in the country of origin, compared to that in the

Netherlands;

- the applicant’s financial difficulties in accessing the appropriate treatment (i.e. the

affordability of treatment based on the applicant’s individual circumstances);

- the fact that the applicant may have to travel considerable distances to access the

appropriate treatment;

- issues that may affect the applicant’s ability to receive treatment that are considered

‘asylum-related’, such as discrimination or persecution. The implementation

guidelines put these ‘asylum-related’ issues beyond the scope of the regular procedure;

- long waiting lists for the appropriate treatment;

- the fact that a medical escort is necessary during the travel home. The implementation

guidelines state that arranging this escort is the responsibility of the applicant. It

specifically points towards the facilitating role that IOM can play in the travel back to

the country of origin (see 3.6.1). Should the applicant be forcibly removed from the

Netherlands, the Dutch authorities will assume responsibility for the necessary

medical arrangements en route.

Special consideration is reserved in the guidelines for preventing gaps in treatment from

occurring, should the applicant return to his/her country of origin. The implementation

guidelines consider this to be a matter of availability rather than accessibility of treatment, and

therefore of procedural relevance. However, the responsibility for preventing such gaps in

treatment is put on the applicant. For example, the applicant should make arrangements for

carrying a sufficient stock of medication46.

3.3.5 Status

If a status on medical grounds (either based on ‘treatment’ or ‘medical emergency’) is

awarded, the migrant will receive a temporary residence permit, which – in principle – needs

to be renewed (and thus is reassessed) after a maximum of one year. As such, the migrant may

face uncertainty over the right to stay in the Netherlands each time his/her permit needs to be

renewed. This is the case for several of our migrants we interviewed (see chapter five). The

holder of such a permit on medical grounds is entitled to welfare benefits and housing47.

However, he/she does not have the right to work.

46 See B8/4 of the implementation guidelines. Should interruptions in treatment be unavoidable if the applicant

would return, the implementation guidelines state that an individual decision (incorporating the applicant’s

responsibility and the duration and regularity of these interruptions) needs to be made. If interruptions are found

to occur for the duration of one month or longer, this will lead to the conclusion that treatment is not (sufficiently)

available.

47 In some cases, this may also be an asylum seekers’ centre.

3.4 CONSEQUENCES OF NOT HAVING A LEGAL STATUS

3.4.1. Obligation to leave the Netherlands

In the previous section we have discussed some of the grounds on which migrants living with

HIV could be granted a legal status in the Netherlands. It shows that it is not self-evident that

a migrant living with HIV will be able to obtain a legal status. This is particularly true for

those who are not yet receiving treatment. In any case, the right to remain in the Netherlands

will be very dependent on an individual’s (medical) circumstances and the treatment options

in his/her country of origin.

If a legal status is not granted, or the migrant has never applied to regularise his/her status,

he/she will be under the obligation to leave the Netherlands of his/her own accord. Generally,

the migrant will have four weeks to leave the country48. Once the deadline for independent

departure has passed, the authorities are empowered to forcibly remove the migrant. If

necessary, the migrant can be detained, provided that there is a reasonable prospect of the

removal actually being effected. The Dutch policy related to return will be discussed in more

detail in section 3.5.

3.4.2. Exclusion from public services and amenities

In 1998, the Koppelingswet (Linkage Act) was enacted, which linked the legal status of

migrants to their entitlements to public services and amenities. The Aliens Act 2000, enacted

in 2001, reiterates this connection by stating: “[t]he alien who does not have legal residence

cannot claim amenities, services or benefits administered by a governmental body” (article

10(1)). This means that migrants without a legal status are not entitled to such amenities as

welfare benefits, rental subsidies or public housing, study grants or public health insurance.

Also, the right to work is connected to a legal status, and migrants without a legal status are

thus not allowed to work. The exclusion from entitlements, however, is not absolute:

“An exception […] can be made when this [exclusion] relates to education, to the

provision of medically necessary care, to the prevention of dangers to public health, or to

legal assistance to the alien.” (article 10(2) of the Aliens Act 2000; emphasis added).

This means that even when a migrant does not have health insurance, which is generally

impossible to register for without a legal status, he/she should receive ‘medically necessary

care’. In a policy note on irregular migrants the Minister of Alien Affairs and Integration

notes that:

“…out of humanitarian considerations, irregular migrants retain the right to humane

treatment. This means that basic rights to education and health care will not be curtailed

out of the Government’s wish to combat irregular migration.” (Illegalennota (Illegal

Aliens Policy Note) of 23 April 2004).

What is ‘medically necessary’ is generally up to the health care provider to assess. However,

the policy note states that “[i]f a situation occurs that is life- threatening or which entails the

risk of permanent physical damage, medical assistance will always be provided” (ibid.). In

general, treatment of HIV is always considered to be medically necessary.

48 However, in specific cases the obligation to depart is immediate. This is the case, for example, when a migrant

does not have, and has not tried to obtain, a legal status; when he/she is not in possession of a valid MVV; or

when he/she has been declared a so-called ‘undesirable alien’.

It is important to note that this does not mean that treatment of HIV, or any other medically

necessary care, is free. In principle, uninsured migrants are expected to pay for treatment

themselves. However, since costs may be very high (also see box 7), this is usually not

possible. In order to compensate health care providers and institutions for the cost they incur

when providing treatment to uninsured migrants, the Ministry of Health instituted two

measures. Firstly, there is a special fund (often referred to as the Koppelingsfonds) which

compensates first line care providers (e.g. general practitioners, obstetricians and pharmacists)

for ‘excess costs’ for medically necessary care that has remained unpaid. Secondly, hospitals

and other care institutions can make a provision within their budgets for patients who cannot

pay their fees. The amount that can be set aside for this has to be agreed with health

insurance companies on an annual basis49.

Box 7: The cost of treatment of uninsured migrants living with HIV

For hospitals, the treatment of undocumented migrants living with HIV can lead to considerable

costs. Below are a few illustrative examples, which were provided by a nurse in one of the

hospitals designated as an HIV treatment site.

• A woman was uninsured for ten months. She was never admitted to hospital, but only

had consultations with physicians and underwent tests. Total costs:  3,112.70

• In March 2007 a woman was tested HIV-positive. She was pregnant and was admitted to

hospital for her delivery. She stayed in the hospital for three or four days. Total costs:

 6,697.99

• A man came for several check-ups and was admitted for six weeks in 2007. Total costs:

 9,257.22

• An uninsured patient had to stay in the hospital for six months in 2006. He was supposed

to be transferred to a nursing home after his initial admission, but this was not possible

due to his lack of insurance. Total costs:  20,851.20

It should be noted that these figures only include hospital costs, and not the actual cost of the

antiretroviral medication. The nurse who provided this information, also remarked:

“These are just a few from our group of uninsured patients. There are people who only come for

check-ups and tests, but often these people come to us too late or – due to circumstances – are

unable to follow their therapy well. Because of this, medical problems occur and they have to be

admitted. In some cases they will have to stay for a long time, because they cannot go to another

institution on account of their insurance problems.” (e-mail communication between nurse and

researcher, 26 May 2008).

While the system in place grants all persons living with HIV, regardless of their legal status,

access to treatment, this does not mean that all who are in need of treatment receive it. As

several consulted experts noted, migrants without a legal status may be afraid to go to the

hospital for fear of being identified by the authorities. Also, a significant proportion of

persons living with HIV may not be aware of the fact that they are infected. Finally, it is

important to note that the access to treatment is only one factor determining migrants’ mental

and physical well-being, as we shall see in chapter five.

3.5 DUTCH RETURN POLICY AND PRACTICE

The exclusion of migrants without a legal status from certain public services and amenities is

part of a broader policy to discourage irregular immigration. Stricter immigration legislation

49 For more information, see the website of Stichting Koppeling, www.stichingkoppeling.nl.

(both for regular migration and asylum cases), as well as measures to make the Netherlands

less attractive as a country for immigration and irregular stay have been a major part of the

development of the Dutch migration policy in the last decades. In recent years, this has been

complemented by a strong focus on the return of migrants without a legal status. A central

premise of the Dutch policy towards return that it is the primary responsibility of the migrant

him/herself to comply with the obligation to leave the Netherlands (see, for example, the

Terugkeernota (Return Policy Note) 2003). When the migrant does not have the means to

comply with this obligation, he/she can request assistance under the Return and Emigration of

Aliens from the Netherlands (REAN) programme, which is implemented by IOM50. More

details on the REAN programme are provided in section 3.6.

While the voluntary departure of rejected asylum seekers or other migrants without a legal

status is regarded as the preferred solution, failure to comply with the obligation to leave the

Netherlands may eventually lead to forced removal. In 2007, a special service within the

Ministry of Justice, the Departure and Repatriation Service (DT&V) was set up to take

responsibility for effecting return, whether voluntary or forced51. While only the possibilities

and constraints of return on a voluntary basis are of concern in this report, it is important to

bear in mind that (the threat of) forced removal has an important impact on the decision of

migrants to return of their own volition.

3.6 ASSISTED VOLUNTARY RETURN

3.6.1. Return assistance provided by IOM

As mentioned above, there is a strong policy preference for migrants without a legal status

leaving the Netherlands voluntarily. To facilitate this, assisted voluntary return (AVR)

activities have been set up, of which the most important one is the REAN programme, carried

out by IOM52. This programme provides for basic assistance to migrants who seek to return to

their countries of origin, and – in some cases – who resettle in third countries53. In the

Netherlands, IOM operates a nationwide network of Project Officers, who provide the main

ports of call for migrants who want information about return. The assistance generally

provided covers information about the return programme, obtaining travel documents, and

circumstances in the migrant’s country of origin. For those who meet the criteria of the REAN

programme54, an air ticket and financial assistance for travel from the airport of arrival to the

place of residence of the returnee. Where possible and necessary, IOM officers in the

50 The group that makes use of the REAN programme is very diverse. It primarily covers rejected asylum seekers

and other migrants who are no long allowed to stay in the Netherlands. This does not mean that ‘pure’ voluntary

return cannot and does not take place under the REAN programme. There are many known instances of migrants

returning home while still having the right to remain in the Netherlands, and giving up this right in doing so.

51 Previously, the responsibility for overseeing the removal of migrants without a legal status was carried by a

department within the Immigration and Naturalisation Service.

52 IOM is an intergovernmental organisation that was set up in 1951 to assist governments in managing

international migration. Currently, it has 125 member states. The organisation operated under a variety of names

from its inception in 1951. In 1989, it was renamed the International Organisation for Migration, and its current

mandate was adopted. While the organisation was initially concerned primarily with resettling and repatriating

refugees in the aftermath of the Second World War, its activities have expanded significantly to cover almost all

aspects of international migration. In European countries, IOM is best known in its role as implementer of return

assistance programmes. This is also true for the Netherlands, where IOM implements the REAN programme.

53 The group of migrants who resettle to a third country only constitutes a small minority of those assisted under

the REAN programme. In most cases, migrants without a legal status do not have the possibility to legally travel

to any other country then their country of origin.

54 see www.iom-nederland.nl.

countries of origin can provide arrival assistance, which usually covers reception at the airport

and referrals to relevant services. The REAN programme also generally provides for a small

cash incentive. The REAN programme is open to all migrants, regardless of their legal status

and whether they are economic migrants or asylum seekers, although the extent of assistance

that can be provided may differ according their legal status.

Annually, IOM assists the return of between approximately 1,500 and 3,500 persons from the

Netherlands to their countries of origin, as can be seen in the table in box 8.

Box 8: Overview of IOM-assisted returns to Sub-Sahara African countries from the

Netherlands (2005-2007)55

2005 2006 2007

Angola 407 431 145

Burkina Faso 1 1 1

Burundi 2 2 14

Benin 13 17 7

DR Congo 0 0 7

Chad 1 1 0

Rep. of Congo 12 6 2

Côte d’Ivoire 0 0 1

Cameroon 17 16 5

Cape Verde 3 2 1

Eritrea 6 1 3

Ethiopia 21 11 7

Ghana 117 79 54

Gambia 1 2 0

Guinea 31 9 4

Guinea-Buissau 2 1 0

Kenya 3 6 2

Liberia 5 7 2

Mali 1 1 1

Mauritania 2 0 0

Niger 27 21 9

Nigeria 119 93 52

Rwanda 2 0 1

Soa Tome & Principe 0 2 0

Sudan 88 50 8

Sierra Leone 30 19 11

Senegal 1 1 2

Somalia 10 12 8

Tanzania 11 12 5

Togo 10 15 2

Uganda 4 7 2

South Africa 3 0 2

Zambia 0 0 2

Zimbabwe 0 0 2

Sub-Sahara Africa

total

950 825 362

Other regions total

2,513 2,024 1,197

GRAND TOTAL

3,463 2,849 1,559

55 Sources: IOM Netherlands annual report 2007, available at www.iom-nederland.nl.

In addition to the REAN programme, there is a special Return and Reintegration Regulation56

(Herintegratieregeling Terugkeer or HRT) for (rejected) asylum seekers. The HRT regulation

gives extra financial assistance for reintegration in the country of origin of certain categories

of (failed) asylum seekers. The REAN programme and HRT regulation form the core of the

assisted voluntary return activities of IOM in the Netherlands. This is complemented by

special projects aimed at providing additional assistance to specific, often particularly

vulnerable, groups. An example of this that is particularly relevant for this report is the extra

assistance provided to returnees with medical conditions. This extra assistance covers special

facilities to make travel back to the country possible (if necessary) and referrals to treatment

sites in the country of origin.

IOM is prohibited by its mandate from assisting in the forced removal or migrants57, which is

the exclusive responsibility of the Dutch government. Nevertheless, IOM has frequently been

criticised by civil society organisations and migrants for its close association with the Dutch

government, which is the major funder of IOM’s activities in the Netherlands. This, they

argue, blurs the line between what is voluntary and what is forced return. In addition to this

debate about the link between assisted voluntary return activities and forced return, the issue

of voluntariness itself is a contentious issue, which will receive more attention in section 4.2.

3.6.2. Other actors providing return assistance

Return has become an increasingly mainstream issue in the migration debate in the

Netherlands. This is particularly clear from the large number of organisations that have

become involved in assisting voluntary return. A 2005 overview of return-related projects by

IOM, governmental agencies and non-governmental organisations, illustrates the proliferation

of the issue. It identified no fewer than sixteen projects related to the voluntary return of

migrants (primarily rejected asylum seekers), while acknowledging that the study possibly did

not encompass all activities in this area (Odé 2005). Although a similar study has not been

undertaken recently, arguably the field of organisations providing return-related assistance has

become even broader. Certainly, the topic has become more central to the agenda’s of many

organisations traditionally involved providing assistance to migrants in their legal procedures

to stay in the Netherlands, or in their integration in their host country.

The activities these various organisations engage in range from counselling and preparation

for return in the Netherlands, to training and material support in the reintegration process after

the migrant’s arrival in the country of origin. The actual travel back to the country of origin is

usually arranged under the REAN programme. At the time of the research, there were no

activities specifically aimed at the return of migrants living with HIV.

3.6.3. Do migrants living with HIV return voluntarily?

The sections above have attempted to provide a sketch of the context in which HIV-positive

migrants without a legal status find themselves. This context is characterised by the primacy

of the migrant’s own responsibility to comply with the obligation to leave the Netherlands, the

discouragement of further irregular stay by excluding migrants from certain public services

and amenities, the proliferation of return assistance activities, and, ultimately, the threat of

expulsion by the Dutch government.

56 see www.iom-nederland.nl.

57 Constitution of IOM, article 1(1)(d).

But does this context mean that migrants living with HIV are inclined to return to their

countries of origin voluntarily? The available evidence suggests that this is not the case. As

already mentioned in the first chapter, IOM has encountered very few instances in which

people that were living with HIV turned to the agency to facilitate their return58. The

reluctance to leave the Netherlands also shows from the interviews with migrant living with

HIV, as presented in chapter five. Indeed, many of them have said they would prefer to stay in

the Netherlands without a legal status and without access to many public services, rather than

face the uncertainties of life in their countries of origin. The idea that most migrants living

with HIV are unlikely, under current conditions, to return to their countries of origin

voluntarily is confirmed by many of Dutch assistance providers, who regularly deal with

persons without a legal status59.

But does this mean that return will always be an undesirable option for migrants living with

HIV, even if certain interventions would be possible to make this return more feasible? Before

going into the results of our investigation of this issue among migrants and in the five selected

countries, we will first discuss some of the basic concepts related to voluntary return (in

particular the issue of ‘voluntariness’) and set out a brief theoretical framework for

understanding the decision-making process of migrants when confronted with the choice

between irregular stay in their host country or return to their countries of origin.

58 Although it should be noted there is nothing prohibiting migrants from returning voluntarily without making

use of IOM’s assistance.

59 In addition, some have suggested that the Dutch government may be reluctant to forcibly remove migrants

living with HIV, who have not departed voluntarily. In an e-mail to the research team, a solicitor with several

years of experience representing migrants living with HIV wrote: “As of yet, I have not encountered any client

infected with the HIV virus who has chosen to return to his country of birth voluntarily. Also, so far, I have not

encountered anyone who has been deported to his country of birth against his will, after having exhausted his

legal remedies.” (e-mail communication, 29 August 2007).

CHAPTER 4 – VOLUNTARY RETURN AND HIV:

SOME THEORETICAL ISSUES

4.1 INTRODUCTION

As suggested in the first chapter of this report, exploring the possibilities of return specifically

for migrants living with HIV takes us into relatively uncharted territory. This does not mean,

however, that we are painting on a blank canvas. Increasingly, academic and practice-based

literature is dealing with the issue of the return of rejected asylum seekers and irregular

migrants from Europe (see, for example, Koser 2001, Black et al 2004, Van Wijk 2008). A

specific area of interest within this literature is the issue of (sustainable) post-return

reintegration (e.g. Black and Gent 2004, Ghanem 2003), which is of particular importance to

the target group of this report.

While HIV has not been much of a topic in the debate on return migration, a small body of

literature has developed on migrants with health problems generally and the consequences for

their possible (voluntary) return (see, for example, Van Krieken 2001, Engelhard 2004). Part

of this literature has been developed from activities that have preceded the Return Migration

and Health III project60.

Other studies that are important for our purposes are those related to the lives of HIV-positive

persons in their countries of origin, and in this particularly, in Africa. This literature covers a

broad spectrum of topics, including the availability and accessibility of HIV treatment (see,

for example, Hardon et al 2006). This literature does not tend to focus on persons living with

HIV who return to their countries after having stayed abroad for prolonged periods of time,

but on those who have always remained there. Nevertheless, such studies help provide a

background to our study, given our focus on the possibilities and constraints migrants living

with HIV re-establishing themselves in their countries or origin (and thus finding themselves

in a similar situation to those who ‘stayed behind’).

The literature discussed above will be used to outline some issues, which will frame our

subsequent discussion of return for migrants living with HIV. First of all, we will consider in

a bit more detail the issue of what constitutes ‘voluntary return’. Secondly, we will provide a

basic framework for understanding how and when a migrant might decide to return

voluntarily. Thirdly, we will try to identify some factors that might specifically impact on this

decision when the migrant in question is living with HIV.

4.2 WHAT IS VOLUNTARY RETURN?

4.2.1 Voluntariness

‘Voluntary return’ is a much used term in migration policy. Voluntary return implies that it

can be distinguished from non-voluntary or forced return. It is this distinction that usually

often cause for debate. We will attempt to provide a brief overview of this debate, and what

this means for the use of the term ‘voluntary return’ in this report.

60 See footnote 9.

Returning to one’s own country is a fundamental human right61. However, it is not usually the

right to return that makes voluntary return a tricky issue, but the fact that return to one’s

country of origin can be also be a legal obligation. When this obligation is enforced by the

government of the host country, by physically removing the migrant from its territory, this is a

clear case of non-voluntary return. However, this still leaves a broad spectrum of return that is

not forced, in which different levels of voluntariness can be identified.

The most clear form of voluntary return is “when migrants decide at any time during their

sojourn to return home at their own volition and cost” with the migrant having “a clear and

open choice…either to return to his or her country of origin or to stay permanently and

integrate into the host society” (Morrison 2000, quoted in Black et al 2004: 4-5). In practice, a

much more common situation which is “when persons are at the end of their temporary

protected status, rejected for asylum, or unable to stay, and choose to return at their own

volition” (IOM 2008a). This, as Morrison argues, confronts the migrant with “a choice

between returning to the country of origin now in a voluntary fashion (perhaps with financial

or other incentives) or staying risking forcible return later” (quoted in Black et al 2004: 4-5)62.

Apart from the legal situation, definitions of voluntariness can also be related to other

circumstances in which the choice to return is made. IOM, for example, has argued that the

migrant’s choice between the different (if limited) options should be “based on adequate,

available, accurate, and objective information” (IOM 2008a). Practically, the extent to which

such information is available will depend on the resources of both the migrant and the

organisation facilitating the return, the situation in the country of origin, how long before

departure the information is sought, and a host of other circumstances.

When a migrant requests assistance to return, it is often very difficult to accurately assess the

relevant individual circumstances leading to this request, and whether on what kind of

information this has been based. In some cases, the motivation to return might lie in

circumstances in the country of origin (an improved situation, family issues). In other cases,

the pressure to leave the host country (for example, because forced removal is impending)

may lead to the desire to leave voluntarily63. However, even though not a legal option, many

migrants make the choice to stay in the Netherlands without a legal status, at the risk that they

will be forcibly removed if found out.

Given the broad possibilities for interpreting voluntary return, it is important to clarify how

we use the term here. For the simple reason that it connects best to the way it is used in

policy and practice, when we refer to it as a decision to return based on a conscious

choice between staying or returning, regardless of the legal consequences that this

choice entails for the migrant involved. A ´conscious choice´ suggests that the migrant

has information about the different options and their consequences, and that he/she is able

61 This is laid down, for example, in the Universal Declaration of Human Rights, which states that “the right to

leave any country, including one’s own, and to return to one’s country” (article 13(2), emphasis added).

62 To some, this does no longer constitute voluntary return, since there is no legal option to stay. The European

Council for Refugees and Exiles, for example, has suggested that when a person chooses return because he/she

has no legal option to stay in the host country, the term ‘mandatory return’ would be more appropriate (ECRE

2003). Nevertheless, also for these situations, voluntary return has remained the dominant operational term.

63 In a report on the return of Afghan rejected asylum seekers from Denmark/Norway, the fact that the returnees

considered deportation to be ‘undignified’ was an important motivator to return voluntarily.

to fully understand this information and has a realistic view of the consequences of

choosing either of the options64.

4.2.2 Going ‘home’

Another conceptual issue related to voluntary return is what it means to return. Discussions of

return often revolve around the themes like ‘going home’ or ‘going back’. However, it is

questionable whether anything as clear as ‘home’ or a place to go ‘back’ to exists for migrants.

Our respondents, for example, arrived in the Netherlands between one and six years before

the interviews took place. In some cases, they have stayed in other countries than their home

country before coming to the Netherlands. This time-lapse has several possible consequences.

First of all, the situation in the country of origin, in all its aspects, might have changed

significantly since the migrant left. This is particularly relevant for those who have been out

of their countries for long periods of time. In other cases, conflicts might have started,

intensified or stopped, resulting in a very different political and economic situation. On a

more personal level, the very fact that the migrant has been away from his or her family,

friends and community members, who may have stayed behind, can have an impact on the

extent to which the country of origin can still be considered ‘home’ by the migrant. This is

particularly true when taking into consideration the changes in the migrants him/herself, due

to new experiences in the Netherlands, and of course due to having found out he/she is HIV-

positive. For this reason, it is questionable whether migrants can actually come ‘home’. This

discrepancy between a remembered or even imagined situation in the country of origin and

the reality once a migrant returns is often referred to as the ‘myth of return’ (see, for example,

Al-Rasheed 1994, Zetter 1999).

Apart from this discrepancy, there is a practical difference between returning ‘home’ (often

seen as the migrant’s prior place of residence) and returning to the country of origin. While

there may be a legal obligation to return to the country of origin, there is no obligation for the

migrant to settle in his hometown or village. In fact, some returnees may prefer, for a whole

range of reasons, to settle elsewhere in the country of origin. This may be related to family

circumstances, for example, or economic opportunities. When we talk about returning in this

report, therefore, we relate this to returning to the country of which the migrant has the

nationality, which may or may not entail returning to his/her former place of residence or

social network within that country.

4.2.3 Sustainability of return

A distinction should also be made between merely returning, or returning indefinitely (or at

least for a prolonged period). While in this report we focus on long-term, sustainable return,

this does not mean that this is always the objective of the returnee. Migrants may return to

their countries of origin purely to comply with the obligation to leave the host country,

without any intention to settle there. Indeed, they may migrate again very quickly after their

arrival (either back to the original host country or another country) or may use their time ‘at

home’ to make preparations for future migration.

Apart from implying a long-term stay in the country of origin, what constitutes a ‘sustainable

return’ for migrants can differ according to their own specific circumstances (Black and Gent

2004, Van Houte and De Koning 2008). In chapter five, the twelve interviewed migrants

64 This is not always self-evident. For example, IOM in the Netherlands has repeatedly dealt with migrants who

requested return assistance, but who were coping with psychological or psychiatric disorders. In these cases, a

minimum requirement for providing assistance is that the migrant’s doctor or counsellor declares the person

involved to be capable of making sound judgements.

provide a number of conditions under which they would be able to not only survive in the

countries of origin, but also to have a long-term future. Our discussion of sustainability,

therefore, focuses on the long-term needs of migrants, should they return. While these needs

may differ, we will focus primarily on those issues that are common to all the interviewees.

As we shall see, the focus on long-term solutions adds an important level of complexity to the

already intricate issue of return.

4.3 DECISION-MAKING ABOUT VOLUNTARY RETURN

If voluntary return is conceived of as a conscious decision of the migrant, it is also necessary

to provide a basic framework for understanding of how such a decision would be made. It is

important to note that the decision to return or stay in the host country is an extremely

complex one, as well as very personal. The description below is therefore by now means

meant as an all-encompassing conceptualisation of this decision-making process. Rather, it

provides a broad theoretical framework that covers certain elements generally considered to

be part of this process. The main aim of this framework is to explain how our discussions with

migrants and other stakeholders have been structured.

Several studies have been undertaken to map the motivations of migrants to return home or to

stay in the host country. Most of these studies employ a push and pull factor approach. In the

host country, ‘push’ factors constitute negative reasons to leave. These factors vary in nature,

and can be, inter alia, of a legal, political, social, economic or personal nature (see, for

example, Black et al 2004: 12). The legal obligation to leave is an example of a potential push

factor (although it may not be experienced as such by everyone), but they can also be lack of

possibilities to work or the inability to integrate in the host country socially. ‘Pull’ factors,

conversely, are circumstances which form positive reasons to return to country of origin, such

as the presence of family members at home or the end of a conflict. Van Wijk (IOM 2008)

also uses the terms ‘stay’ and ‘deter’ factors to describe those elements that make the host

country attractive to the migrant and the country of origin unattractive.

Very generally speaking, the pull and push and stay and deter factors in the host country and

the country of origin are weighed against each other by the potential returnee. It is important

to recognise that the eventual decision to stay or go is not a matter of rational ‘bookkeeping’;

a tallying of the plusses and minuses of each alternative. Rather, the decision to stay or to

return is one that is intensely personal, and emotionally and socially charged. Also, it is not

necessarily the de facto situation in either the host country or the country of origin that forms

the basis for the decision to stay or go. It can also be the way that these situations are

subjectively perceived or experienced by the person in question form the basis of his/her

attitude towards return. In our study, we mainly consider this subjective perspective. We will

attempt to deconstruct this subjective perspective in chapter 5 by focusing on (1) the

migrants’ experiences in their countries of origin before migrating and the reasons for leaving

their countries of origin; (2) their experiences in the host country and; (3) the migrants’

expectations of the current situation in their countries of origin. Finally, we look the

subsequent attitudes towards the issue of return of the migrants and their actual decisions to

return or to stay in the Netherlands.

4.4 HIV-SPECIFIC CONSIDERATIONS

While the discussion above provides us with a broad framework for understanding decision-

making about return, it tells us very little about the specific factors relevant to migrants living

with HIV who are confronted with the question of return.

The first, and perhaps the most obvious, factor to consider is the medical aspect of living with

HIV. When it comes to treatment of HIV, three related issues can be identified: availability,

accessibility and adherence (Hardon et al 2006). The former two have already been discussed

in the context of the Dutch criteria for residency on medical grounds. Availability, in brief,

refers to whether treatment exists in a certain place. Accessibility, on the other hand, is more

individually determined, and includes the affordability for an individual, as well as other

geographical, social and economic factors that determine whether or not the individual can

actually make use of the available treatment. Adherence, finally, refers to the ability of

individuals, once they have accessed treatment, to take this treatment consistently and

continuously. Since HIV is treatable but not curable, a migrant living with HIV, who returns

to his/her country of origin, will have a life-long dependency on treatment. Therefore, the

durability of availability, access and adherence is an important overarching concern.

These medical issues are closely related to the other two factors that emerge from the

literature: economic circumstances and social circumstances. As we shall see, being HIV-

positive can have a significant impact on an individual’s ability to earn a livelihood and meet

his/her needs and those of his/her dependents. Alternatively, economic circumstances

determine an individual’s ability to access treatment and adhere to treatment. The same goes

for social circumstances. On the one hand, HIV can have an enormous impact on the social

life of an infected person, of which plenty of examples will be covered by our respondents.

On the other hand, social relations are important to the mental and physical well being of a

person living with HIV, and may also determine his/her ability to earn a livelihood.

Before going into these issues from the perspectives of migrants living with HIV themselves

in more detail, box 9 provides a short overview of some aspects of HIV, which are relevant to

understanding the concerns and issues raised by our respondents in the Netherlands and the

five pilot countries.

Box 9: Some consequences of being HIV infected and the importance of treatment

adherence65

It would go much too far to go into the intricacies of HIV and the effects it has on infected

persons. However, it is important that some aspects of HIV are covered, albeit very briefly. We

limit ourselves to a very basic summary of some issues that will come back during the discussion

of the interviews with migrants living with HIV and the country assessments. This summary is

primarily aimed at migration practitioners and policy-makers who may be unfamiliar with HIV.

HIV – The Human Immunodeficiency Virus (HIV) is a virus which attacks the immune system.

The ability of the immune system to resist infections gradually reduces, though the period in

which the system breaks down can vary significantly in individual cases (median time in adults is

around 8 -10 years. If the immune system is in an advanced state of breakdown, the HIV infection

may advance to AIDS (Acquired Immuno Deficiency Syndrome).

65 The research team would like to thank Dr Sybil Geelen of PharmAccess Foundation for her input on the report

generally, and this overview particularly.

Opportunistic infections – because of their weakened immune system, people with an

advanced stage of HIV infection are vulnerable to infections that would not normally affect a

healthy person. These infections are called ‘opportunistic infections’. For people living with HIV,

many opportunistic infections cause serious health problems and often threaten the life of the

infected person.

Treatment and monitoring – there is currently no cure for HIV, but it is treatable. Treatment is

done through antiretroviral therapy (ART), consisting of a combination of medicines which aim to

stop the replication of the virus. As a result of this, the immune system has the chance to recover.

For the decision to start treatment the clinical condition of the HIV infected person is important but

also his/her ‘CD4 cell’ number. CD4-cells are an important sub-group of immune cells. When they

are too low, a person will need to start therapy to prevent further illness. To determine the

effectiveness of therapy, clinical recovery and recovery of CD4 cells are relevant, but also the

‘viral load’. With a viral load test it can be determined if the HIV is optimally suppressed. Viral load

tests are complicated and expensive, and availability in resource-limited areas is often limited to a

few specialised centres.

HIV resistance and adherence – During any kind of antiretroviral treatment it is possible that the

HIV virus becomes resistant. This means that the treatment is less or no longer effective in

fighting HIV. The most important way to limit the danger of developing resistant HIV strains is to

take medication consistently and continuously. Gaps in treatment significantly increase the

chances of HIV becoming resistant to the combination of medicines that is taken. Adherence to

treatment is therefore essential, particularly in situations were alternative drugs, and more

complicated combinations, are less available, as is the case in many resource-limited settings

Nutrition – Different combinations may require different ways of taking medication. Some need to

be taken with food, in order to assure the optimal effectiveness, others should be used on an

empty stomach. Also, HIV infected persons generally benefit from a healthy diet.

Psychological issues – Being HIV-positive usually has a strong psychological impact. Stress,

anxiety, fear of stigmatisation, fatalism and depression may all be experienced by the infected

person. Several experts note that the relationship between HIV and psychological issues is

cyclical: HIV can have an effect on the psychological wellbeing of a person, while at the same

time the psychological wellbeing of the person is an important factor in successfully treating HIV.

Stress, for example, might speed up the spread of HIV, while a positive attitude might make it

easier to stick to a treatment regime.

Further information about HIV and its consequences can be found, for example, on the website of

the Dutch HIV Association (www.hivnet.org), and The Body, a resource website on HIV and AIDS

(www.thebody.com).

Part II: Results

CHAPTER 5 – MIGRANTS’ PERSPECTIVES

5.1 INTRODUCTION

In this chapter, we will present the results of the interviews with migrants living with HIV in

the Netherlands. Between May and September 2007, twelve interviews were held. The

respondents represented a wide variety of nationalities and legal categories. An overview of

the characteristics of the respondents is provided in box 10. For the sake of anonymity, the

names of the respondents have been changed.

Box 10: characteristics of respondents

Name* Gender

(M/F)

Country of

origin

Age Years

Neth.

Receiving

medication?

Legal status

Helen F Sierra Leone Mid-30s 5 Yes Awaiting decisions on

asylum and regular permit

(medical)

Virginia F Uganda Early 20s 3 Yes Regular status (medical)

Carolyn F Zambia Early 20s 2 No Rejected for regular permit

(medical grounds), intends

to re-apply

Sylvia F Southern

Africa**

Early 30s 2 Yes Awaiting decision on

asylum application

Diane F Zimbabwe Late 30s 4 No Regular status (labour)

Elizabeth F Zimbabwe Mid-20s 6 No Initially as a student.

Currently awaiting decision

on asylum application

Margaret F Nigeria Mid-30s 3 Yes None, intends to apply for

regular permit (medical

grounds)

Michael M Nigeria Late 30s 1 No Awaiting decision on

regular permit (medical

grounds)

Frederick M Nigeria Late 40s 4 Yes Regular status (medical

grounds)

Kenneth M Ghana Mid-40s 5 Yes Renewal of regular status

(medical) rejected. Awaiting

decision on appeal

Simon M Cameroon Early 30s 3 No Asylum status

Philip M Cameroon Late 30s 6 Yes Rejected for asylum, now

has regular permit (medical

grounds)

* All names have been changed to protect the anonymity of the respondents

** To safeguard anonymity, if fewer than 10 persons living with HIV from the country of birth of the

respondent are in the Netherlands (cf. HIV Monitoring Foundation, June 2007), the nationality of the

respondent is withheld.

As suggested in the previous chapter, the factors that lead to a migrant’s decision to return or

to stay are highly dependent on the interplay between various factors, which in turn are highly

specific to the individual’s situation. It is impossible to exhaustively discuss all these factors

and circumstances for each of our twelve respondents. Instead, a summary of the narratives of

the respondents is provided, which covers five specific dimensions:

1. the experiences of the migrants while still in their countries of origin and their reasons

for migrating to the Netherlands (5.2)

2. their experiences in the Netherlands (5.3)

3. their current perceptions of conditions in their countries of origin (5.4)

4. their deliberations about staying or returning (5.5)

In line with our framework set out in chapter 4, the discussion of these issues will broadly

focus on medical, economic and social circumstances, while also leaving space for other

issues of concern.

5.2 PRE-DEPARTURE LIVES AND REASONS FOR MIGRATING

5.2.1 Access to medical services

With the exception of Sylvia, who lived in South Africa and in her own country origin for a

few years after discovering she had HIV, all of the respondents say that they did not know

they were living with HIV while still in their countries of origin. Some explain that they were

already experiencing some medical problems, which could possibly have been related to HIV.

Most of them had not had an HIV-test, however66. For this reason, most respondents do not

have first-hand experience trying to access or receiving HIV treatment in their countries of

origin. Some did have experiences with family members and/or friends who were (thought to

have been) HIV-positive. These experiences are without exception negative. Kenneth from

Ghana believes that two of his brothers were HIV-positive and that both of them died due to

lack of treatment. Virginia from Uganda explains that when she was young, her father brought

her to a hospital were he worked. There she encountered people living with HIV:

“And I say: ‘why are they looking like that? Why are they skinny?’. [My father] tells me:

‘they are positive.’ I said: ‘do they get medicine?’. He said: ‘some.’ So he tried to explain

to me. I was young then, but it [stuck] in my mind.… Still my heart [hurts for] those

hundreds of people I saw in the queue, and some were lying on the ground. That picture

never gets out of my mind.”

Michael went to get tested while still in Nigeria, but found the experience disconcerting:

“The hospital was not organised… They told me to come and take the results. When I

came back, they found that there were some results are missing, [my file] is not complete.

When you ask, they say they don’t know about it – you should go to another office. If

you go there, they say: we don’t know about it; you go to the other office. It is the same

problem for many people there. You will be annoyed. I went there for my second blood

test, but I didn’t get it. I met the doctor; he told me: ‘you have to do some questionnaire, I

will tell them to look for it.’ But I didn’t see it.”

66 Apart from Sylvia, Michael is the only respondent who said to have had an HIV test in his country of origin.

Sylvia is the only respondent with moderately positive experiences. She was included

in antiretroviral trials when she was living in South Africa. However, after she went

back to here country of origin, the logistics of accessing medication caused significant

problems, and Sylvia stopped her treatment.

Unsurprisingly, given the fact that most respondents were not, or did not know that they were,

HIV-positive, medical issues did not play any significant role in the decision to migrate to the

Netherlands. The pull exerted by the quality and accessibility of the Dutch health care system

(which, as explained, also provides medically necessary care to all migrants, regardless of

their legal status) is sometimes cited as one the reasons to restrict the number of persons

eligible for a regular status on medical grounds. Some argue, that this would curtail so-called

‘medical tourism’, migration flows particularly driven by the search for higher quality health

care (see, for example, NRC 2000). In the case of our respondents, there is no evidence for

that ‘medical tourism’ was an issue. Even in the case of Sylvia, who knew she was HIV-

positive before coming to the Netherlands, the accessibility of treatment only seems to have

played a very limited part in her decision. She had previously been able to access treatment in

South Africa and in the UK, where she also lived. In each case, she decided to leave the host

country anyway, choosing to abandon this treatment when she did.

Box 11: Health care as a pull factor for migration?

Restrictions on residency on medical grounds are sometimes related to a fear of Western policy-

makers and the general public that more lenient measures would encourage ‘medical tourism’67.

Insofar as this is a motivation behind health-related immigration policies, it would be important to

explore in more detail whether this fear is realistic. While there is an increasing body of literature

on the links between migration and health, this tends to focus on the health care implications of

migration, such as the health of migrants or the access of migrants to health care facilities once

they are in the host country. However, some of the literature concerned with access to health

care for irregular migrants and failed asylum seekers in Western countries has also addressed

the question whether migrants are actually motivated to go to those countries because they

provide them with high quality health care. This literature suggests that this is not the case. Fallek

(1997: 980) asserts that in the United States, “health care is not a pull factor, nor will the halt of

health care push immigrants away.” In the context of European countries, this view is supported

by Romero-Ortuño’s later study of the policies of six EU member states. He suggests that

“’generous’ measures” for providing health care for undocumented migrants will “not have any

‘disastrous’ consequences”, such as providing a pull factor for potential immigrants (Romero-

Ortuño 2004: 268).

The studies mentioned above are concerned with access to health care in general, and not with

HIV treatment specifically. However, they indicate that fears of ‘medical tourism’ are not generally

supported by evidence. Further research would be required to ascertain whether this is similarly

true for HIV treatment.

5.2.2 Economic opportunities

In terms of their economic situation, the conditions of our respondents before their departure

to the Netherlands vary considerably. Some interviewees (Michael, Frederick) were running

there own businesses, while others had steady employment (Simon) or were studying (Sylvia).

67 When the revision of the Dutch aliens’ legislation was discussed in parliament in 2000, it was indeed

suggested that one concern was that ‘medical tourism’ should be curtailed (Document of the Parliament (Tweede

Kamer) 1999-2000, 26732, no. 14). A similar development has occurred in the United Kingdom, where “the

declared purpose of the 2004 Charging Regulations was to crack down on ‘health tourism’” (Yates et al 2007:

299).

There are, however, few – if any – of our respondents that could be considered affluent

citizens in their home countries. In many cases, the respondents had low-income (subsistence

level) jobs, or none at all. Virginia from Uganda, for example, was living in a camp for

internally displaced persons, after fleeing violence in the north of the country. Margaret

depended on her family for housing and food. Quite a few respondents had enjoyed little

formal education.

On the whole, it proved complicated to get a clear picture of the economic circumstances of

the respondents while they were still in their countries of origin. The interviewers noted a

certain reluctance of some respondents to explain why they chose to leave their countries. The

negative connotations of the term ‘economic migrant’ in the Netherlands may have had

something to do with this. Nevertheless, economic reasons for going to the Netherlands seem

to have played quite an important role in the decision of most of our respondents.

That the search for ‘a better life’ was quoted as an important motivation to migrate is

unsurprising given the economic situation of most respondents in their countries of origin.

Whether or not this was intended to be long-term migration or only temporary is not always

clear. Some seem to have had particular ‘projects’ in mind: goals they wanted to achieve

before going back, such as completing a study or saving up a certain amount of money. In the

case of Frederick, for example, there seems to have been no intention of staying in the

Netherlands for a prolonged period, as he regularly travelled between Nigeria and the

Netherlands for business. He more or less became ‘stuck’ in the Netherlands after being

diagnosed with HIV. This is also true for other respondents, for whom finding out they were

HIV-positive has completely disrupted any previous plans for their futures they had.

5.2.3 Social issues

In terms of social relations, the situations are very different again. Some respondents did not

have family members to rely on when they were still in their countries of origin. Virginia, for

example, lost both her parents. Others did (and still do) have parents, siblings and even

children in their countries of origin. Since the respondents usually did not know for certain

that they were infected before they left their countries of origin, they have had no face-to-face

reactions to them being HIV-positive from their families or friends. Sylvia, the only person to

have been with her family while knowing (and telling them) that she was living with HIV,

found them to be supportive. Similarly, most respondents do not have first-hand experience of

how it is to live in their home societies as a person with HIV.

Social relations are generally considered to have a strong impact on a decision to migrate. The

decision to migrate is seldom a decision that an individual migrant makes without significant

influence from his/her direct social network. Furthermore, the lack of a social network (e.g.

the disintegration of family ties in a civil war situation) may be a reason to migrate. More

specifically, the destination itself may be influenced by existing social networks in a specific

country. If family members, acquaintances or a large community of compatriots live in a

certain country, this may provide a potential migrant with more opportunities than if he/she

would migrate to a country with which he/she does not have any social connections (see, for

example, Koser and Pinkerton 2002).

Within our group of respondents, however, there is only limited evidence that social relations

have been a major reason for migrating, although there are some exceptions. Some

respondents suggest that they had very little social support in their countries of origin. It is

most likely that the impact of this on their livelihoods played a central role in the decision to

migrate. Likewise, the decision to come to the Netherlands only seems to be connected to pre-

existing social relations in relatively few cases. Carolyn, for example, came to the

Netherlands because members of her family were there. As mentioned, Frederick came to the

Netherlands for business. In some other cases, a completely different kind of relation

contributed to the ‘selection’ of the Netherlands as their destination. In the cases of Helen and

Virginia, a ‘travel agent’ (i.e. a trafficker) chose the destination, with the respondents

themselves not having a say in this.

It should be noted, that deconstructing the role of social relations in this matter is a very

complex matter. Given the primary focus on issues related to HIV in the interviews, as well as

the limited time available, the impact of social relations on the interviewees’ migration

decisions can only be addressed here very superficially.

5.2.4 Security

Another major issue in the pre-migration lives of a few of our respondents is that of insecurity.

Simon and Philip, both from Cameroon, experienced “political problems”, which made their

lives untenable in their country of origin. Virginia spent a number of years in an internally

displaced camp, was raped, and experienced problems with the authorities of Uganda. Helen’s

tells that the conflict in Sierra Leone prompted her to leave. It is important to emphasise that

our focus on issues related to HIV does not detract from the importance of experiences. In the

cases of some of our respondents, factors like political security, that are completely unrelated

to the issue of HIV, are just as relevant, if not more, in migrants’ attitudes towards return.

5.3 SITUATION IN THE NETHERLANDS

5.3.1 The impact of legal status

When dealing with the respondents’ situations in the Netherlands, the issue of legal status

cannot be ignored. As already discussed in chapter three, the legal status of migrants (or lack

of it) has an enormous impact on the way these migrants can live their lives in the Netherlands.

Our respondents, as listed in box 10, represent almost the full spectrum of legal possibilities.

Michael is an irregular migrant. Several of our respondents are in possession of the coveted

(temporary) medical emergency permit, while others are still awaiting a decision on their

application. Our list of respondents also includes those who have a legal status that is not

based on their HIV-positive status. Simon, for example, has been granted an asylum status

based on his political problems in his country of origin, while Diane has a residence permit

for work purposes68. Neither of them received antiretroviral treatment at the time of their

interviews, but – contrary to those applying for a permit on medical grounds – this did not

have an impact on their eligibility for a legal status.

It is worth noting that Michael is the only person who is not at least in a procedure to obtain a

legal status. At the time of the interview, he said that he would start his antiretroviral

treatment in one month, and would then immediately re-apply for a permit on medical

grounds. The need for a legal status is emphasised by all our respondents. For those who do

not have such a status, obtaining it, and thus avoiding the legal obligation to return, is their

most important immediate goal. Holding on to their status is a major concern for those who

have it69. Even for those who may have some intention of returning to their countries of origin,

68 Because this latter permit has no connection to the applicant’s HIV-positive status, it has not been discussed in

chapter 3.

69 Recall that the regular permit on grounds of a medical emergency is reassessed on an annual basis.

a legal status is a prized possession, as it provides a ‘safety net’ of some sorts. Furthermore,

for as long as they are living in the Netherlands (and many intend to stay there indefinitely),

life without a legal status is regarded as unacceptable. As we shall discuss below, the

possibilities for HIV-positive migrants to sustain themselves without documents are generally

smaller (often considerably so) than for their counterparts who are not HIV-infected. It is

therefore unsurprising that obtaining a legal status is such a central concern to them.

5.3.2 Access to treatment and coping with HIV

Those respondents who were receiving treatment reported very few problems in accessing

health care services. They all said they went to hospital regularly and obtained their

medication. All those who were not yet receiving treatment went for regular check-ups and

were in touch with HIV counsellors in hospitals.

Few respondents talked specifically about their health situation, although some explained that

they experienced physical limitations due to either HIV or the side effects of the medication.

These limitations, as we shall discuss below, mainly impact on their ability to earn a

livelihood. Perhaps more poignantly, however, a number of respondents chose to emphasise

their psychological, rather than their physical well-being. First of all, many respondents said

they experienced a lot of stress on account of the uncertainty over their legal status. Secondly,

they spoke of the mental impact of having to come to grips with the fact that they were HIV-

positive. This is particularly true for those who had only recently become aware of their status.

Margaret, for example, had found out she was living with HIV only a few months before the

interview took place. At the time of the interview, she was still focused almost wholly on

dealing with her new situation:

“I don’t want to accept that I have HIV. I don’t want to talk about it – I don’t even know

why I am doing this interview. Because I can’t adjust, don’t want to believe I have…to

live on drugs. Already life as it is… then you have to live on drugs – going to the hospital

every time to get drugs, to live on drugs. I am not normal anymore…”

Others experienced similar feelings, but suggested that the counselling they received in the

Netherlands helped them to develop a positive outlook again. Frederick from Nigeria, for

example, wanted to go home to die as soon as he heard he was HIV-positive: “my conclusion

by HIV [was] that if you have it, you are going to die.” “But”, he continues, “the doctor said

that…if you have HIV that doesn’t mean you are dying. You can still have a normal life.” At

first, Frederick did not believe this: “I insisted that I wanted to go back… They had to put

someone at my door to be sure that I don’t go and run away.” Eventually Frederick was

convinced to continue his treatment and to apply for a residence permit on medical grounds.

When the interview took place, Frederick had been on treatment for several years, and was in

possession of a residence permit. Furthermore, he became an active member of a support

group for Africans living with HIV, helping others to accept their situation and look towards

the future again.

Helen from Sierra Leone, who was awaiting a decision on her asylum application, told a

similar story:

“I didn’t believe [I would survive] until I asked almost three or five nurses if I was going

to die. They all said I was not going to die. They gave me courage. The social workers

came to educate me, to tell me about the problem, how people can still have life.”

This positive outlook, as Diane from Zimbabwe explained, is crucial for both the mental and

the physical well-being of persons living with HIV. She experienced herself how the stress

about being HIV-positive had a severe impact on her health:

“If you accept things the way they are… Initially, you know, I was really drained…I lost

weight and everything because I was so worried and because I wasn’t eating at all – I

couldn’t. But with time, talking to other people, my family’s support and everything, it

changed. I started to work and everything.”

This importance of social support in gaining a positive attitude towards life generally, and

living with HIV particularly, is emphasised by others as well, and we will come back to this

later on.

5.3.3 Economic opportunities

Only a few of the respondents had a status that allowed them to work legally. Diane’s permit

based on her work contract is a notable exception. Simon, who had an asylum status, also had

the possibility to work legally, but he had not found a job yet. Those with a residence permit

based on a ‘medical emergency’ did not have the right to work, sometimes to the frustration

of the respondents. Philip, for example, felt well and wanted to work. Like the other

respondents with a residence permit on medical grounds, he was on social welfare benefits to

sustain himself. Helen and Simon were staying in an asylum seekers’ centre, and received a

small stipend.

For those who did not have either a job or received state support, the situation was precarious.

Many relied on the support of local charities that helped them financially70. This assistance

just about helps them keep their heads above water. Michael, for example, explained: “I am

struggling… Every month I go to [this charity] to collect 375 euro… So that is how I am

managing.” Margaret was relying on some friends, as well as the same charity to get by. She

said this was not enough to meet her basic needs, but that it “is better than nothing”. Before

finding out that she was HIV-positive, Margaret had fewer problems getting by without a

legal status. She sustained herself by doing informal jobs here and there. By the time of the

interview, this was no longer possible for her, since her health often did not allow her to work:

“You know, I don’t have strength. Maybe some times…when I walk for too much…

when I walk for one hour, two hours, it’s like I want to faint… I don’t know if it’s just

because of the medication, at least it was like that in the beginning. It depends on my

body, sometimes I get weak, I get dizzy… The drugs are really affecting me.”

This situation was reiterated by others. Although some were still able to find some (unofficial)

jobs to do now and then, they found it increasingly difficult to muster the energy needed for

living outside the legal framework of Dutch society. It is thus clear that living with HIV has

made it even hard to survive and even harder to realise whichever goals they wanted to

achieve by coming to the Netherlands. Most respondents spent the little income they had,

from whichever source it came, on surviving. On account of the costs of treatment, many of

70 These are the same charities that helped identify potential respondents. As such, the fact that a large proportion

of the respondents receive assistance from such charities may not be representative. In fact, there are indications

that our respondents are part of the ‘lucky few’. Philip, for example, suggested that there are many migrants

living with HIV who do not have any kind of assistance and are afraid to seek it. This, according to him, leads

many of them – men and women – to resort to prostitution.

the respondents were accruing debts71. Philip, for example, had to use part of his social

welfare benefits to pay back his debts to his pharmacy.

Of all the interviewees, only Elizabeth reported sending money back home. However, since

this was not a specific topic for discussion in the interviews, it is unclear whether this makes

her an exception. Nevertheless, given the financial situations of our respondents, if

remittances were being sent, these were likely to be very limited72.

5.3.4 Social issues

The importance of social networks was emphasised by almost all respondents. These

networks provided access to opportunities to sometimes earn some money, but more

importantly, they provided the social support that helped many of the respondents cope with

their situation. Diane and Elizabeth, for example, were both members of a support group for

women living with HIV. Diane said that “talking with other people…actually helps me a lot”.

Elizabeth supported this view: “I think, the main thing is that you realise you are not the only

one. It can happen to anyone and so that’s why now I am more accepting than I was before.”

She added: “For me, I get so much support from these people – they are like my good

friends.”

The support groups provides an opportunity to talk about living with HIV, that none of the

respondents thought possible with other Africans who are not HIV-positive, as Kenneth

explained:

“The problem is that you cannot tell people about your problem… So it is [inside] you…

the only place where we can express our problems is in this [support group], where you

know that all who are coming there have the same problem as you… to go to your own

community I don’t think is easy for anyone. You know our people, especially African

people. [If] they hear that [you are HIV positive], even the cup you are drinking from,

nobody will touch it. So it is something you should really keep to yourself.”

This stigma led some other respondents to close themselves off completely from other

Africans, mainly out of fear that their HIV-positive status would become known. Michael

explained:

“Nobody has ever known that I have something like that. I don't let it out for them to

know, because I am scared for it. If you let them know, you would be another caste. They

would be commenting to you, you understand?”

For this reason, they tended to keep the fact that they were living with HIV hidden from

others, in particular other Africans. When they did disclose their status, this was usually to

others who are living with HIV. The fear of being sidelined by the community has led some

respondents to almost withdraw from social life altogether. Philip, for example, said he tried

to avoid contact with others as much as possible. He suggested that if someone knew about

his HIV-positive status, soon the whole community would know. Therefore, he preferred not

to interact with other Africans.

71 Recall that treatment is not free, although it will be provided even if the person in question cannot pay for it

(see chapter 3).

72 Remittances have become a very important topic in migration studies. Not only is it regarded as a powerful

instrument for the development of the families of migrants and more generally their home countries, it is also

increasingly seen as a means to create ‘social capital’ that would enable migrants to return and reintegrate more

easily.

5.4 EXPECTATIONS OF SITUATION IN COUNTRY OF ORIGIN

5.4.1 Shaping expectations

Discussing the respondents’ expectations of which situations they would encounter if they

went back, proved to be a difficult exercise. As already suggested, many of the respondents

were focused almost exclusively on the immediate task of surviving, and on sorting out their

legal status. Talking about return, even if only hypothetically, did not fit in well with these

concerns. Also, since many of the respondents did not see return as a viable option (see 5.5),

they saw no need to discuss what their lives would look like if they returned.

Nevertheless, all of the interviews yielded some information on what the respondents

expected the situation in their countries of origin to be. From the interviews several factors

emerged that helped shape these expectations. These included the pre-departure experiences

of the respondents, their level of knowledge about recent developments in their countries of

origin since their departure, and the influence of their social networks. The experiences of the

migrants while still in their countries of origin have already been discussed (see 5.2). These

experience often had quite a negative influence on how they saw their prospects should they

return. As Helen from Sierra Leone said, as soon as she found out she was living with HIV “I

just took my brain back home. I saw the situation, how people die of HIV.”

Memories of pre-departure experiences did not form the only basis for the respondents’

expectations. After all, they had left their countries of origin between one and six years prior

to the interviews. The information they had received about developments since their departure

also played a role. The extent to which the respondents had sought or received information

about the circumstances in their countries of origin, however, varies. Simon, who drew mostly

on his experiences before coming to the Netherlands three years earlier, acknowledged that

“maybe things have changed.” He had not tried to found out whether this was actually the

case though, since he feared persecution in Cameroon and would not return to his country of

origin regardless of the medical, economic and social circumstances. This does not mean that

all respondents who rejected the idea of return did not have an interest in the state of, for

example, antiretroviral treatment in their countries of origin. For them, however, obtaining

such information was important for securing or prolonging their residence permit on medical

grounds, and not as part of any plan to return.

There were some, however, who followed developments closely with an eye on a possible

return, such as Sylvia and Virginia. In her interviewed, Virginia cited a number of reports,

newspaper articles and statements by officials. She had little confidence in these sources

though. According to her they provided a biased picture of the success of HIV prevention and

treatment in her native Uganda, just to satisfy donors.

Negative perceptions of return also seemed to be reinforced by the social networks of which

the respondents were part. While this was not explicitly stated by the respondents themselves,

several of the consulted experts suggested that there was considerable pressure on migrants to

maintain the image that return would be impossible no matter what. The tendency to frame

return as negatively as possible has also been noted by Engelhard in his study on return for

migrants with health problems. He quotes a health care worker who suggests:

“The problem is that asylum seekers picture the possibilities of return vis-à-vis

themselves and their environments negatively, in order to reinforce the necessity of a

residence permit (in terms of ‘return equals death’)” (Engelhard 2004: 84-85).

This does not mean that these negative perceptions of the situation in countries of origin are

necessarily inaccurate. It does, however, suggest that they can be part of some kind of

collective coping strategy. The reinforcement of certain images of countries of origin is also

illustrated by the interviews with Frederick and Kenneth, who were part of the same support

group. In his narrative Frederick quoted the prices of medication in the Netherlands and

projected this directly to the situation in Nigeria. During the interview, Frederick produced

several boxes of medicines and showed the prices:  404.00,  222.22,  561.88. He explained:

“And this I have to consume every month. So what kind of work would I do [in Nigeria],

so I can earn such an amount of money to be able to buy this medication every month? If

you stop for one reason that you can’t continue for a few days, it becomes a problem… In

my country I don’t know many people who can earn 1,000 euros permanently in a month.

And if I don’t earn this money, how can I buy this medication [and get] the intensive

treatment you get from the [Dutch] hospital also?”

Strikingly, given the distinct differences between the situations in their two countries,

Kenneth from Ghana did exactly the same in his interview.

By contrast, while not mentioned by any of the respondents, there may also be pressure on

migrants from within their communities to return. An illustrative case was provided when the

research team came across a Ghanaian man in the Netherlands who wanted to know more

about the possibilities of IOM to provide return assistance to a Ghanaian woman in his care,

who was living with HIV. According to this man, the woman (who was not present) was

seriously ill, and she was adamant that she wanted to go back home because this would be

much better for her. When pushed on this issue by a representative of a support organisation

for Africans living with HIV, who hosted the researcher and the Ghanaian man, the latter

repeatedly complained of the burden he faced taking care of this woman, whose situation did

not allow him to work73. This raised serious concerns about whether it was indeed the

woman’s desire to return, or rather her caregiver’s74.

While anecdotal, both the case of Frederick and Kenneth, and the situation described above,

suggest that if the issue of how migrants see the possibilities for return in their countries of

origin is to be better understood, a focus on the mutual influence of migrants may be very

insightful. Unfortunately, given the nature of our data, we have to limit ourselves to noting it

as an issue that would require further research.

5.4.2 Medical situation

None of the respondents believed that accessing treatment in their countries of origin would

be unproblematic. In fact, they listed a large number of concerns in relation to getting

antiretroviral treatment and other medical care. The first issue was that of availability. Some

believed that for them, no appropriate treatment existed where they would return. Margaret,

73 Coincidentally, the woman was allegedly doing fine when she was still receiving treatment from the local

hospital, but she had discontinued this treatment on the advice of a member of her community, who had

suggested she should bring her medication back to the hospital and limit herself to praying for her recovery.

74 This is one of the reasons why IOM Netherlands never assists in the return of the migrant if he/she has not

personally requested this.

for example, suggested that in her hometown “there is no government hospital there, maybe

just a [primary health] clinic.” More often, however, respondents focused on the accessibility

of treatment, rather than its existence. Affordability of medical care and drugs was a primary

concern for almost all respondents. Simon stated that “you have to buy [medication]. There is

no free medication. If you have money, you pay medication. That is how Cameroon is, as I

know.” Kenneth was just one of many who confirmed the idea that medication was only

accessible to those who were relatively well off: “Even to go for a check up, control in Ghana

costs a lot of money. When you hear you have this problem there, then you are waiting [to]

die… Only those with a little money they can use it…” Helen from Sierra Leone had a similar

view: “If you are not rich, you are only waiting to die.”

Even with a decent income, some respondents said, they would still not be able to solve the

problem of accessing treatment, because the provision of treatment could be unreliable.

Michael explained:

“[The medication they have] is not the medication they use to cure. It is incomplete.

Because the time I went to hospital, there were many people. This is the hospital they say

that the government is sponsoring and drugs and everything. But the problem is that all

these drugs, if they get it, they will sell it at the back. You understand? So, for the masses

to come and collect it, they cannot. Sometimes some of them who would come, they will

give them [something]. Like somebody who used to take three types of medication, when

he will come they give him one and say that the other two are not there, that they don’t

have it. And you know that when you start the medication you are supposed to take it

regularly, every day the same time. The problem is complete medication. It is not easy”

Diane from Zimbabwe agreed: “Some of the medication is not there. You might have the

money, but you won’t find the medication… it has to be sourced out from…neighbouring

countries or here [the Netherlands].” According to the respondents, unreliability was also

connected to the quality of health care. Frederick explained:

“If you stop for one reason that you can’t continue for a few days, it becomes a

problem… And if you get resistance of these things, then it becomes more difficult for

the doctor to handle… When I started medication I didn’t start with this one. They have

to take blood to see which one works well, which one does not. Even with advanced

technology they cannot get it [right] in one time… Let’s assume I [can] buy medication

in my country. What about other factors like a good professional doctor?”

These are just some of the examples of the issues raised by respondents with regards to their

medical situation, should they return. These concerns about availability, accessibility (in

particular affordability), reliability and the quality of health care are common to all interviews.

5.4.2 Economic situation

All respondents agreed that an income was not only necessary to meet basic needs, but – as

already suggested –could also be a piece of solving the puzzle regarding access to treatment.

However, expectations of being able to earn enough money to sustain oneself and to cover all

costs related to treatment, were generally low. Elizabeth suggested:

“Well, if I have to go back it would be terrible because at the moment, even for someone

who has a normal job, even to take care of themselves it’s difficult. And for me, maybe

by that time I will be taking my medication, so I don’t think I will be able to even pay for

my medication and expenses, because I won’t have a job by then. So it will be very

difficult when I go back..”

Elizabeth’s concern is particularly noteworthy because she was – in contrast to some of the

other respondents – highly educated. According to Carolyn from Zambia, was no guarantee

for a positive economic outlook. She explained that in her country: “even those who are

educated – they have gone to university – it is difficult for them to find a job. […] you see

people who are educated, they have papers, and [they’re] not working.” Sylvia suggested that

even if one is able to get a job, this may not be enough. One of Sylvia’s wishes was to become

a teacher, but she thought this would not be a viable option in her country of origin:

“It’s a romantic idea to do a teaching career. You know, you don’t earn much money as a

teacher and…if I get medical aid, because I am HIV-positive, I have to pay much more

into my medical aid than anybody else – and that’s a big chunk of my salary.

Perhaps…housing is not so much of an issue if I live in a rural area – I won’t have to pay

a big bond.”

However, Sylvia also explained that accessing treatment would be a lot more difficult in rural

areas, thus negating any economic benefits of living there.

5.4.3 Social situation

Having a support network provides both an emotional safety net as a practical one, as Diane

explained: “I have two kids to look after... In case I get sick, who’s going to look after them?

Because they need to go to school and things like that.” Whether or not the respondents

expected to have a social support network in their countries of origin was dependent on very

personal circumstances. Virginia from Uganda lost both her parents and lived alone in a camp

for displaced persons, while Helen lived alone in Sierra Leone until she was brought to the

Netherlands. Others had relatives, but did not expect to be able to rely on them, such as

Carolyn from Zambia:

“All my family [on my mother’s side] are dead… My brother is very very sick and my

father… I have my father in Africa but he cannot take care of me. He is married, so he is

just with his wife and they have their children there. So if I go back today to Africa, I will

be stressed with many things…”

Another major issue for the respondents was the whether their family members and friends

would accept them. Only a handful of respondents had actually told relatives and friends that

they were HIV-positive. Sylvia found that her family and friends accepted her situation when

she was living with HIV in her country of origin before coming to the Netherlands. Diane,

although she had not been back, had found her family to be “very supportive”. Most others,

however, felt that it would be impossible for their families and friends to deal with the fact

that they were living with HIV. In Michael’s case, only his older brother knew about his HIV-

positive status, and he was afraid to tell other members of his family. Margaret also did not

want to inform her mother that she was living with HIV: “she would even die before me”.

Frederick suggested that his family would outright reject him if they knew he had HIV:

“Here in Europe now, HIV people, you hardly know them – did you know I am HIV

positive? But where I come from in Nigeria, you can know, because there is no

medication… all people know [when someone is HIV positive]. Maybe your family,

they’ll even disown you. If your family disowns you, they’ll even make you want to kill

yourself…it’s like you don’t even have family there, what kind of life are you living? So

is it not better just to stay here? [Your family] cannot live with the shame, the disgrace,

nobody wants to live with you. Your family, they disown you, they chase you out of the

house, you don’t have friends anymore…though it’s not good here, there, it’s just, it’s not

a place to live. When you have this kind of sickness, it’s not a place to live at all.”

The stigmatisation and discrimination, Frederick suggested, would also affect his ability to

earn an income. He had a trading business in Nigeria, but would have great difficulties to

work with his old partners, who “when they find out about my AIDS, might be keeping their

distance.” As such, the reactions and support of family and friends, as well as the way in

which society deals with people living with HIV in their countries of origin, were important

deliberations for our respondents.

5.5 DECISIONS ABOUT RETURNING

5.5.1 To return or to stay?

When dealing with the issue of deciding about return, two separate groups can be identified

among our respondents: those who had no intention to return, and those who might consider

it, given the right conditions.

Among those who dismissed the possibility of returning out of hand were Frederick, Kenneth

and Helen. For Frederick, this had, to some extent, to do with the stage of his life he is in. He

did not want to make any plans for his long-term future:

“I am already in my future. I’ll be fifty. A man of fifty should not be interested in his

future. So I am living my future. I have kids. I am not looking for children anymore, I am

not looking for a wife. What I am thinking is just to stay alive for a while. I don’t know

how many more years I have to live with this illness. I am living my future now.”

Just “staying alive” was his main consideration, and this was possible because of the

medication that he received in the Netherlands. Although he did not consider his situation

ideal, he had a legal status which gave him peace of mind: “Otherwise I am not so

comfortable; all my family [is] back there and I am staying here. But as it is now, because I

have a permit, I can always go visit them and come back within one month.”

Helen found it difficult to lead her life as she wanted in the Netherlands. Nevertheless,

because of the availability of treatment, she wanted to stay in her host country at all costs:

“I want to be active. I want to be busy. I want to do something which will distract my

brain from thinking… Of course in my country, I’ll be more active than here. But the

problem is that most people say if you go home you’ll have medication. All these things

are not true… If I should go back to my country it would be destroying my life. [Being in

the Netherlands] is an opportunity God gave me. I see it as a chance to live. The last thing

I’ll do is go back to my country like now, because I need medications and I can get them

here. I have no reasons to go back now.”

Helen did not know whether she would be allowed to stay in the Netherlands, but was clear

that she would prefer living as an irregular migrant over returning: “before…I was living out

of procedure. I was on the street, but [the charities] took care of me.” Like Frederick, Helen

did not have a long-term focus. Her immediate concern was gaining a legal status, and she

found it almost impossible to look beyond that: “I don’t really want to think about the future.

My life is short. I can’t make plans. I wait for what the future brings. I don’t have plans

whatsoever, no. I just sit down and wait.”

Margaret from Nigeria, who had recently started her antiretroviral therapy was also focused

on the here and now:

“For now, I just want to concentrate. I started with the medication and am getting better.

The medication is really breaking me down right now. I just don’t know, for now I just

want to see if they will help me … Maybe [also] just look for something so I can be

supporting myself, helping myself, pay my bills, pay my rent.”

For her, return was out of the question: “if I [have to] go back, maybe I’ll just kill myself”.

Kenneth also believed return could never be an option for him. Like the previous respondents,

Kenneth saw major problems in accessing medication if he would be back. However, for him

this was not the main consideration for not wanting to go back. Rather, it is the way society

in his homeland Ghana deals with people living with HIV that is his major concern:

“Brother, I’ll never dream about going back. Because I know my country and even [if

you can] get medicine, you are not comfortable in you own society, even in your own

family. People don’t think you are a human being – they think you are something else.”

As suggested, there are also those who said they could not return for reasons unconnected to

their HIV-positive status. Both Simon and Philip had fled Cameroon for political reasons,

and had no intention of returning even in the hypothetical situation that all issues related to

treatment, and economic and social reintegration could be resolved.

The second group of respondents would prefer to stay in the Netherlands, but could envisage

circumstances in which they would consider returning. For some this was related to whether

or not they would be able to get a legal status. Carolyn, from Zambia, for example, was not

very satisfied with her life in the Netherlands: “Here, I don’t have a status, I don’t have

anything, I don’t feel good.” At the same time, her outlook on the situation in her country of

origin was bleak:

“You know, if I go back to Africa, the situation is very very bad. […] I prefer to stay

because of the medication. With the other things, I can go back. But me, I don’t want to

die – really, when I go to Africa I can die.”

Nevertheless, Carolyn could see herself returning if she would be unable to secure a

residence permit: “If I don’t get the status, then I’ll go back.” Elizabeth similarly framed her

future around getting a legal status: “If everything goes well [I will] start thinking about

getting a job and just continue being active and helping out people who are in need.” Her

ability to earn some money to help her family was a motivator for staying in the Netherlands:

“I think it’s their wish that I stay here, because I also help them out by sending some money.”

To do this, Elizabeth needs a legal status. Without this, return would be a serious

consideration for her: “if it doesn’t work out then, yes, I will probably be in Zimbabwe.”

Even some of the respondents who did have a legal status were tentatively thinking about

return. However, they see themselves confronted with lots of doubts. Diane said:

“I would love to go home, but the thing is, I am scared. If I go home, suppose I start to

need medication – how am I going to go about it? [Treatment] is the most worrying issue,

if things are really sorted out with medication… My kids, they are also worried how I am

going to get things to get well. The neighbouring countries, am I going to be able to go

there to seek medical [assistance]? Am I going to be on [public] medical aid, or do I need

access to some private medical plan? All these things…”

In some respects, Diane was in an advantageous position. First of all, she was not yet receiving

medication and thus not yet dependent on a ‘Dutch’ treatment regimen for which continuation

might have been difficult in Zimbabwe Also, because she still had a residence permit, she

would have the possibility to travel back temporarily75 to ‘test the water’, as she suggested:

“I’d rather if I start with medication [in Zimbabwe], see how I go about, how I react to the

medication and things like that. If I respond very well to the medication they give me, then I

have no problem.” Despite these advantages, Diane did not think that permanent return was a

particularly viable option at this time. She worried about the continuity of access to medication

and the possibilities of importing additional medication from neighbouring countries or the

Netherlands. She particularly related this to the political situation in her country of origin. For

her, the right time to return had not yet come. In fact, for the short-term future, Diane did not

see any positive change: “I think that is going to take so many years, it is not something which

is going to happen drastically just like that. [It] is going to take a good number of years.”

The uncertainties identified by the respondents make return, to a certain extent, a leap of faith.

Particularly for those who did not have the possibility to return temporarily to see first hand

what the situation in their countries of origin was like, this was a scary prospect. As Frederick

noted, once returned, there were no back-up options: “If anything goes wrong you have to

learn how to survive, it is your own responsibility, not the responsibility of anybody else.”

5.5.2 The role of assistance

While a broad spectrum of problems related to a possible return were identified, several

respondents discussed the role that assistance programmes could help to solve some of them.

For Michael, for example, having some money to re-start his business would be helpful.

However, this would have to be accompanied by a guarantee that he could to access

medication: “if [medication] will be arranged for life, it will be OK.”

Sylvia suggested that she could benefit from temporary guarantees for medication that would

“sustain me […] until I adapt to the government programme.” This to her would involve:

“First of all finding out, if I was to go back, [if] a regimen that we know for sure I am not

going to be resistant to [is] available there. And then giving it to me for a few years until I

can actually get into a [government] programme.”

Also, she said that it would be essential “to go back with a skill that you know would be

sellable back home”, which in her case could involve a scholarship to study. Virginia also

suggested that if there was assistance to return, this would have to give her “medical security”.

To her, this security could only be found by developing her own independence:

“Because we cannot ask to finance us all the way until our death now. Let them take, for

example, me – I would like to go to school. [If] someone supports me to go to school, I’ll

do social work, maybe counselling and humanitarian. Then I get employed in an

organisation, where I can have the guarantee that I earn a living every year. Giving me an

education is giving me a support that at some point I’ll be ready to stand on my own. It’s

not that we migrants or asylum seekers need to be given money until the end of time. But

75 It should be noted that those who want to travel back temporarily cannot make use of the REAN programme.

One of the conditions for return under the REAN programme is that the returnee relinquishes all claims to a legal

status in the Netherlands. However, this does not stop migrants from making their own travel arrangements.

we don’t have a…foundation. [Assistance has to have] a long-term effect on me. Because

most help they give you in the Western world, what they give you back in Africa is short

term – it is for the moment. But we don’t want to look in the moment - we have to

survive… Don’t give me a push for three months and leave me there.”

Another area of concern is that of information. As already discussed, the extent to which

respondents were informed about the situation in their countries of origin varied. The level of

information was primarily connected to the desire of the respondents to return to their

countries of origin. Those respondents who talked about different official sources of

information usually had little confidence in the veracity of these sources. Some of them

suggest they would want to go back temporarily and see for themselves how the situation is.

They had little confidence in reports and other sources, which, as one of the respondents

suggested, only give you “hearsay” and not eye witness accounts. According to Virginia,

there could be a role for assistance providers to help gather reliable information: “Let them

investigate [if] there is medicine in Africa. Let them send people who have got a heart to give

[the] right information.”

5.5.3 The ‘activists’

In addition to suggesting areas in which assistance could be useful for themselves, a number

of respondents suggested that, if they went back to their countries of origin, they could have

an active role in improving the lives of other people living with HIV there. Both Sylvia and

Virginia wanted to draw on their experiences, and their positive attitudes to help raise

awareness among others in their countries. Philip, although he could not go back due to his

fears of the current regime in Cameroon, suggested making some of his land available for

women and children living with HIV: “If I go back I will focus on these women and children,

because the way they live is so bad; it is extremely bad.” He would let them use his land to

sustain themselves, but would also offer skills training and opportunities for children to go to

school. This, he said, “will show people that […] these people are normal people. They can

work, they can live, you can do everything with them normally.”

It is worth noting that this ‘activism’ was also part of the lives of quite a few respondents who

were exclusively focused on continuing their lives in the Netherlands. In their cases, they

were active members of support groups for migrants living with HIV in the Netherlands.

Unfortunately, given the wide range of topics covered in the interviews, the possibilities of an

‘activist’ approach to return could only be discussed fleetingly. Further research would need

to be done to explore the practical possibilities for this.

5.5.4 Perspectives from countries of origin

In this chapter, we have provided a description of the way in which our respondents regard

return, and which issues are relevant to them in making decisions about staying in the

Netherlands or returning to their countries of origin. In the next five chapters, we will explore

these issues further, but this time from the perspective of those who work and live in some

common countries of return. We will start this exploration with the case of Sierra Leone,

followed by Ghana, Nigeria, Angola76 and Cameroon respectively.

76 As already explained in chapter two, it was not always possible to ‘fit’ the nationalities of the respondents with

the five countries selected for a visit. In the case of Angola, no respondents from that country were included due

to a lack of contacts with persons living with HIV and/or their willingness to participate in the research.

CHAPTER 6 – COUNTRY REPORT: SIERRA LEONE

(9-16 July 2007)

6.1 SIERRA LEONEANS IN THE NETHERLANDS: HIV, IMMIGRATION AND

RETURN

The HIV Monitoring Foundation reports that in June 2007, there were 126 persons of Sierra

Leonean birth registered as being HIV-positive, making it the seventh-largest group among

Africans. In the survey of 85 migrants living with HIV (see box 2 on page 4), Sierra Leoneans

formed the largest group behind Cameroonians (11 persons).

With 113 asylum applications between August 2006 and July 2007, Sierra Leone constituted

the fourth-biggest African country of origin for asylum seekers in the Netherlands (behind

Somalia, Nigeria and Burundi). Comparatively, numbers of persons returning to Sierra Leone

are low. Between 2004 and 2006, IOM annually assisted approximately twenty persons to

return to their country of origin.

6.2 SOURCES OF INFORMATION

During this country visit, representatives of the following organisations were consulted:

• IOM mission in Freetown

• the National HIV/AIDS Secretariat

• the United Nations Population Fund (UNFPA)

• the World Food Programme (WFP)

• the United Nations High Commissioner for Refugees (WFP)

• government-run urban hospital

• an association of people living with HIV

• a faith-based NGO working for women and girls living with HIV

• a faith-based organisation providing home-based care for people living with HIV

• a local micro credit NGO

• an NGO that provides home-based care, and social and palliative care to people

living with HIV

• an NGO providing micro credit and training for small scale entrepreneurs

• an association of women living with HIV

• an NGO clinic

• a government-run hospital in a district capital

• a hospital run by a faith-based organisation in a district capital

Below is a summary of the various discussions held with these interlocutors, and their

opinions and perspectives on the issue of return to Sierra Leone of people living with HIV.

Opinions expressed by these interviewees do not necessarily reflect the policies and views of

their respective organisations77.

77 At this point, it is worth recalling the limitations of the scope of the country reports, as outlined in 2.5.3.

6.3 MEDICAL ISSUES

At the time of the visit, ART services were said to be provided in all of the twelve district

government hospitals. In all, 43 community health care centres where some form of treatment

was available were open around the country. A representative of one NGO, however,

suggested that while treatment was relatively well organised in the capital Freetown and in

hospitals in the district capitals, access to treatment and care, as well as laboratory facilities,

remained problematic in rural areas. He suggested that because of the cost of transport and

distances that would need to be covered, returnees living with HIV might be forced to settle

near a treatment site (i.e. in urban areas) to ensure they would have access to ARVs.

At the time of our visit, according to a government official, 1,416 persons living with HIV

were receiving treatment, constituting about 25 to 30 percent of all persons believed to be in

need of treatment78.

All medication (both first and second line) was reported to be provided free of charge. In

addition, HIV testing, pre- and post-testing counselling and CD4 counts were also free. One

physician expressed his concerns about the sustainability of this free treatment programme,

however. He explained that the entire system was primarily based on international funding

from the World Bank and the Global Fund, which, should it be withdrawn, would cause a

collapse of the HIV treatment system, since no back up with national funds was in place.

It is also important to note that while most interlocutors agreed that there is a free treatment

programme, they also noted that this programme does not cover everything. Blood, liver, stool

and other tests, X-rays and treatment of opportunistic infections were likely to be charged to

the patient.

In addition to the costs associated with the treatment of opportunistic infections, other factors

which negatively affect adherence were identified. One main issue was that of food

availability, as a representative of a women’s NGO explained. She explained that food can be

a serious problem for those who did not have a steady income. Food consumption is an

important part of effective therapy, and those who do continue treatment ‘on an empty

stomach’ are likely to encounter more serious side effects, she explained. However, not all

persons living with HIV can afford to buy more food and may decide to stop treatment

because of this. For this reason, returnees need to be self-sufficient in their nutritional needs.

It was argued by some that for those working in agriculture, this might be easier than those

who are undertaking other activities at a subsistence level. However, working in agriculture

by default would also mean settling farther away from treatment sites.

Even if nutrition is not a problem and treatment is continued successfully, this can lead to

problems if the patient is not informed well. An HIV counsellor in a government hospital

discussed cases of people who, as a result of ART, were feeling better, and therefore decided

they did not need treatment anymore. The representative of the women’s NGO therefore

urged that returnees should be properly educated regarding their health status and be given

good and reliable info on the situation in Sierra Leone prior to coming back. The call for

78 PlusNews reported that in September 2006, the number of people receiving treatment was 1,253 out of a total

of approximately 4,500 believed to be in need of treatment (see www.plusnews.org). While this is a far cry from

universal access, it is noteworthy that the number of persons reported to receive treatment, as a percentage of the

total number believed to be in need of ART, was far higher than in any of the other countries included in this

report.

active pre-departure and post-arrival counselling on drug adherence was reiterated by a doctor

at a hospital run by a faith-based charity.

Finally, as far as medical issues are concerned, the representative of an NGO clinic called for

attention to the mental health issues of people living with HIV, who, according to him, were

prone to depression and other mental health problems.

6.4 ECONOMIC ISSUES

Those respondents that discussed the economic situation in Sierra Leone invariably described

it as bad. Unemployment, both in rural and urban areas was said to be high. According to a

representative of an NGO involved in providing economic support through micro credit and

education, the Sierra Leonean economy is characterised by high inflation, resulting in a rising

cost of living. Many people, he explained, are dependent on small retail activities to create

some income. Gaining a decent income in this way is difficult as many people are selling the

same things for the same price.

The respondents agreed that education and skills are essential for a returnee to survive

economically. Carpentry, mechanics, tailoring, computer literacy and agricultural skills were

said to be continuously in demand. In rural areas, an NGO representative said, the

combination of agricultural activities and selling produce in markets seems to be working well

for people. In most cases, some respondents suggested, it would be necessary to supply

returnees with a start-up capital to enable them to set up their own business. Without a proper

preparation of such a business and some money (e.g. taken from the host country) to make it

work, it would be very difficult to make a living. A well thought out business plan, therefore,

was seen as a precondition for economic reintegration.

There are organisations that provide micro credit to those interested. Returnees are free to

apply, but must meet the requirements just like anyone else. Credit is usually provided to

groups rather than individuals and the amounts are small.

There was consensus among our interlocutors that people living with HIV are in a more

difficult position economically than the general population. If a person’s HIV-positive status

becomes known, finding and keeping a job will be difficult. An NGO director explained that a

law to protect persons living with HIV had been passed, but she also said that it would take

some time before it could be fully implemented.

Antiretroviral treatment is making it possible for Sierra Leoneans living with HIV to keep on

working for longer periods than before, said a representative of a non-governmental clinic.

However, he explained, if they do get ill, it takes them longer to recover than an HIV-negative

person, thus running the risk that their employer will replace them with a healthy person.

Stigma and discrimination might not only lead to unfair dismissal from work. It was also

identified as being the cause of people living with HIV being evicted from their houses, and

of problems in getting houses allocated.

Food insecurity was seen as a problem for those who do not manage to get a sufficient income.

While the World Food Programme, through partner organisations, was providing nutritional

support to some groups, this was only limited. Furthermore, due to lack of funds, a WFP

spokesperson said, the agency was scaling down its food support programme in Sierra Leone.

Economic circumstances also impact on the type of medical assistance persons living with

HIV can obtain. As a representative of a government hospital explained, those returnees who

are relatively well off may prefer to pay for treatment in a private clinic. Others will be

dependent on the services offered by public hospitals and health centres.

6.5 SOCIAL ISSUES

Stigma and discrimination were seen by almost all respondents as major impediments to

successful return and reintegration of persons living with HIV. While it was reported that the

Sierra Leonean government and others actors were developing information campaigns to

tackle this issue, the overall impression was that these, so far, had had little result. Among the

direct effects of discrimination on persons living with HIV mentioned by the various

interlocutors were loss of employment and eviction of persons living with HIV from their

homes (see above). According to a physician in one of the government hospitals, depression,

caused by the stigma and discrimination encountered, was a common occurrence among

people living with HIV in Sierra Leone. The way persons living with HIV cope with this

stigma and discrimination, a representative of a faith-based organisation suggested, is very

dependent on their own attitude towards their situation. For a returnee living with HIV, it

would be extremely important to be aware of the stigma he/she would be subjected too, and

should be prepared for this by developing a good coping strategy. The involvement of support

groups of people living with HIV, as well as that of family, a representative of an association

of persons living with HIV explained, should be an integral aspect of such a coping strategy.

These people have been living in Sierra Leone and have acquired survival strategies. They can

share these with the returnees.

The importance of having a social network for returnees living with HIV was emphasised by

almost all interlocutors. In particular, they stressed the traditional role of the extended family

in Sierra Leone. Having the support of this extended family after return, especially if the

returnee would fall ill, was found to be absolutely crucial. However, different respondents

suggested that the support by the extended family would have its limitations. First of all, they

argued, by taking care of a person living with HIV, the extended family itself would also

become the target of stigma and discrimination, which would make them more reluctant to

take up a role as caregiver. Also, as one NGO representative suggested, extended families

may be hesitant to take a person living with HIV into their care, as they might not be well

informed about the modes of transmission of HIV, and fear becoming infected themselves.

This informant, therefore, called for particular attention to educating and counselling the

potential caregivers of the returnee. The limitations of care and support by the extended

family, according to both an NGO director and staff members of a government hospital,

become most apparent when the returnee becomes more ill.

Apart from the misconceptions and misgivings about HIV, other factors that impact on the

care and support by the extended family were identified. A UN official stated that the

traditional extended family system had become weakened due to the large-scale displacement

caused by Sierra Leone’s civil war. An NGO representative agreed that an important reason

why persons living with HIV might not want to return to Sierra Leone, is that their family

members have left the country. Various interlocutors told that there was a distinct difference

between rural and urban areas, as far as the survival of the extended family system was

concerned. The system, which had dissolved to a considerable extent in the larger towns and

cities, according to one UN official. In the rural areas, most respondents agree, the extended

family system is still relatively strong, while also from an economic point of view there might

be advantages to living in rural areas. However, several interviewees noted that stigma and

discrimination were also (much) stronger there, compared to urban areas, where persons

living with HIV could be relatively anonymous. As one person explained, in rural areas HIV

is still considered either a ‘white man’s disease’ – which reflects negatively on a returnee

from Europe – or as a punishment for behaving promiscuously while ‘in the big city’.

Finally, the existence of support was related to the duration of the absence of the returnee, and

the success or failure of the returnee to maintain good relations with the extended family

while abroad. Sending money, and thus helping relatives, was considered an important means

to maintain positive relationships. In these cases, the extended family would probably be more

amenable to taking care of the returnee in his/her time of need. Coming back empty-handed,

on the other hand, would put the returnee in danger of being isolated by his/her relatives.

In the absence of (or in addition to) family support, there are some organisations that provide

home-based care to people living with HIV, but by their own admittance, the level of service

provision is not adequate throughout the country.

Another thing that was repeatedly stressed by informants in Sierra Leone was the fact that

returnees should be very aware of the situation that they would find themselves in. As a

country in the process of reconstruction, Sierra Leone still faces many difficulties, they argued.

This might be a big shock for Sierra Leoneans who have been away for a long time,

particularly if they have become used to the ‘European way of life’. It was emphasised that

those thinking about return should have realistic (i.e. not too ambitious) expectations of the

situation they would find. As one interlocutor suggested, all returnees were welcome and were

free to use programmes and facilities, as long as they met the criteria for eligibility. However,

the demand for assistance in all areas is very high, and returnees should not expect to be

treated any differently from the rest of the population. Most importantly, therefore, potential

returnees should have a realistic and clear view, as well as a plan, of what they would do

when returning to Sierra Leone, so that it would be easier to re-adapt to the situation there.

CHAPTER 7 – COUNTRY REPORT: GHANA

(13-18 August 2007)

7.1 GHANAIANS IN THE NETHERLANDS: HIV, IMMIGRATION AND RETURN

In June 2007, the HIV Monitoring Foundation reported that there were 243 persons of

Ghanaian birth known to be living with HIV in the Netherlands. This makes Ghanaians the

biggest group of HIV-positive Sub-Sahara Africans in the Netherlands.

Ghanaians form a considerable part of Dutch immigrant society. A report by the Ministry of

Interior (Choenni 2001) put the number of persons of Ghanaian origin legally residing in the

Netherlands at more than 15,000 in 2000. As a country of origin of asylum seekers, Ghana is

relatively insignificant in the Netherlands. Between August 2006 and July 2007 only 16

asylum applications of Ghanaians were received. A major gateway to the Netherlands for

Ghanaians seems to be irregular migration. The estimates of the number of Ghanaians living

in the Netherlands irregularly vary from several thousands to as many as 25,00079.

The large Ghanaian society in the Netherlands is also reflected in the voluntary returns from

the Netherlands to Ghana. Between 2004 and 2006 an average of approximately 100

Ghanaians per year arranged their voluntary return through IOM80. This group constitutes

primarily of persons irregularly residing in the Netherlands. In 2006, over eighty percent of

Ghanaian returnees had never applied for asylum.

7.2 SOURCES OF INFORMATION

During this country visit, representatives of the following organisations were consulted:

• IOM mission in Accra (Migration & Health and Technical Cooperation departments)

• UNAIDS

• an NGO which supports associations of people living with HIV

• USAID

• the National AIDS Control Programme

• the World Health Organisation

• an international NGO concerned with HIV prevention and treatment

• a network of associations of people living with HIV

• the Dutch embassy in Ghana

• a local NGO providing HIV prevention, counselling and referral through support

groups of people living with HIV

• a rural hospital

• an association providing home-based care and support for people living with HIV

• a national NGO network dealing with HIV

• an international health care NGO

79 Article in Volkskrant, 5 January 2000.

80 See IOM annual reports 2007 and 2006, www.iom-nederland.nl.

Below is a summary of the various discussions with these interlocutors, and their opinions

and perspectives on the issue of return to Ghana of people living with HIV. Opinions

expressed by these interviewees do not necessarily reflect the policies and views of their

respective organisations.

7.3 MEDICAL ISSUES

Respondents consistently provided a figure of around 70,000 persons in Ghana in need of

antiretroviral treatment ARVs. Of these, only about 6,000 (approximately 9 percent) were

believed to be accessing treatment.

At the time of the visit, a government official reported that 42 treatment and ARV distribution

sites were operational around the country. At the same time, a push was being made to expand

this number. First line and second line treatment regimens were reported to exist. In addition,

several private clinics – including some run by NGOs – were operational. The range of

treatment provided was said to differ significantly; particularly in rural areas this was

considered problematic. Given the fact that treatment was centralised in some locations, it was

suggested that treatment sites may not always be able to cope with demand, particularly if

they cater to a large geographical area.

Several of our interlocutors expressed doubts over whether the treatment available in Ghana

would be suitable for returnees who had already been receiving medication in the Netherlands.

They noted that HIV treatment in Ghana had only started a few years earlier, and qualitatively,

therefore there would be a significant gap with the treatment regime in the Netherlands. The

longer and more complicated the treatment in the Netherlands, the less likely it would be for

returnees to be able to find adequate alternatives in Ghana.

Representatives of an association of people living with HIV, as well as an informant from an

NGO mentioned that in the past there had been problems with the supply of ARVs, when

some hospitals had run out of stock. However, since a public protest in 2005, this had no

longer been the case.

The availability of qualified health care staff was recognised to be a problem. Ghanaians, it

was argued, have a high mobility rate and many health care professionals have gone to seek

employment in the West.

On the issue of cost of treatment, again respondents were very consistent. According to them,

ARVs were available for a nominal fee of GH¢ 5 per month (equivalent to about USD 5).

Although this seems like a relatively small sum, respondents indicated that even paying this

amount could be a problem for the poorest segments of Ghanaian society. Some aid workers

noted that those who were not able to pay for their medication were not necessarily turned

away. They could sometimes receive medication ‘on credit’ but would inevitably run up high

debts. The nominal fee did not include treatment of opportunistic infections, CD4 and viral

load countries.

There is a National Health Insurance Scheme, which covers the treatment of opportunistic

infections. One respondent noted that around one third of all Ghanaians were now registered

with the Scheme.

A frequently mentioned barrier to treatment adherence was that of transport costs. Despite the

scaling up of treatment sites, various interlocutors suggested, persons from more remote areas

would still have to travel considerable distances to reach a treatment site. Also, persons who

started treatment before the scaling-up operations might prefer to continue to travel to the

treatment site where they have received treatment for some time, because of the relationship

they had with health care workers, the presence of more qualified staff, or better quality of

treatment at the more established sites. Finally, several respondents suggested that people

often did not seek treatment in the nearest location, as the chances of running into an

acquaintance – and thereby being identified as a person living with HIV – were bigger. The

fear of stigmatisation from their immediate surroundings leads them to travel larger distances

than objectively necessary. Because of this, they might also incur extra costs for overnight

stays.

One clinician interviewed expressed concerns about the public health consequences of return

of persons living with HIV/AIDS from the Netherlands. Returnees, he argued, might have

been receiving treatment in the Netherlands for some time. The standard of this treatment,

generally, will be more advanced than that in Ghana. If patients on treatment in the

Netherlands have developed resistancies or mutated strains of the virus, it would be

impossible for Ghanaian clinics to treat these appropriately. Also, if the returnees who have

developed resistancies would infect others, these resistancies or mutated strains would be

introduced in the Ghanaian situation, which is not prepared for dealing with this. The clinician,

therefore, urged for more research done on the implications of return of HIV-positive persons

who had received treatment in countries with advanced treatment regimes to countries were

treatment regimes are basic.

7.4 ECONOMIC ISSUES

Poverty and lack of employment opportunities were reported to be higher in rural areas than

in urban areas. However, in rural areas there may be more financial support schemes (through

NGOs) available than in urban areas.

Several activities for helping people to set up small businesses or to provide skills training

exist in Ghana. Representatives of NGOs running these activities noted that these are open to

returnees, but that they will have to meet eligibility criteria just as others who did not leave

Ghana. Opinions varied about whether having stayed abroad would provide an advantage in

reintegration. Some had the impression that skills acquired in the west and experience with

western cultures would give returnees some ‘market value’. However, having an established

network was also considered important. Returning migrants might miss this network and

would need to invest heavily in their social relations to regain it.

Setting up a business would be very difficult if others would know the person is living with

HIV. For example, as one person suggested, if a returnee would set up a shop it would

become known that he/she is HIV-positive, the shop keeper was likely to lose all his/her

customers.

One interlocutor noted that while difficulties for people living with HIV to find employment

remain, both in the private and the governmental sector this situation seems to be changing

slowly. Some large corporations have developed work place policies for people living with

HIV. Representatives of a network of people living with HIV noted that the government is

working with other stakeholders to encourage businesses to employ people living with HIV.

When applying for a job, there is no obligation for a person living with HIV to disclose

his/her illness to the prospective employer, and few people do so.

Several respondents noted that a legal framework against the discrimination of workers living

with HIV was in place in Ghana. They noted that it is illegal for employers to dismiss workers

because of their HIV-positive status. It was unclear whether there were effective remedies

against unfair dismissal. Most suggested that workers prefer not to disclose their status

because of the fear of stigmatisation. For returnees seeking employment, it would be

extremely difficult to get a job if employer would know or suspect that the candidate was

HIV-positive.

Several respondents reported cases of people living with HIV being evicted from their houses

when their landlords found out they were HIV-positive. At least one NGO in Accra suggested

they were able to provide temporary accommodation for those who returned.

7.5 SOCIAL ISSUES

Returning to a family network may be complicated by the stigma of people living with HIV.

Associations and support groups for people living with HIV were considered well placed to

help returnees to reconnect with their families. Their members had to deal with the issue of

disclosure themselves, and were very willing to provide advice and counsel others in dealing

with this.

There is an extensive network of local associations for people living with HIV, which are also

connected at the national level. The activities of these associations vary and may include

meetings or support groups, counselling and sometimes the provision of nutritional support. A

network of these associations also engages in a political lobby to improve circumstances for

people living with HIV.

A common issue identified by respondents was that of the perception of returnees from

Europe and North America. In popular opinion, Ghanaians living abroad are rich, without

exceptions. This idea is reinforced by the big houses that Ghanaian expatriates build for their

families or for themselves when they return. A returnee without money, therefore, would be

seen someone who was hiding his/her wealth from others, or as a failure. Particularly the

latter might make their environments suspect that there was something wrong with the

returnee.

Stigmatisation and discrimination of people living with HIV was said to be high. Several

respondents noted the negative effects of this on social relations, economic opportunities and

access to medical treatment. While there were intensive public campaigns to reduce stigma

and raise awareness, the effects were thought to be only slowly showing.

While at lower levels, some people were publicly disclosing their status, this was not the case

at higher levels. As a consequence, there were few public figures who are leading by example

in the fight against stigma and discrimination. A representative of an association of people

living with HIV noted that persons who were affluent had no need to come out and talk

openly about his/her status, because he/she was able to survive anyway. People who are less

well off, it was argued, need certain public facilities and are therefore forced to stand up for

their rights.

Self-stigmatisation was seen as an important problem for people living with HIV. This causes

them to retreat from social activities and become socially and economically isolated. It is also

associated with mental health problems.

CHAPTER 8 – COUNTRY REPORT: NIGERIA

(19-25 August 2007)

8.1 NIGERIANS IN THE NETHERLANDS: HIV, IMMIGRATION AND RETURN

Nigerian-born persons account for the fifth-largest group among Africans known to be living

with HIV in the Netherlands. In June 2007, 133 cases of Nigerians being infected with HIV

were registered in Dutch hospitals81.

In 2005, the Ministry of Justice reported there were 7.615 Nigerians residing in the

Netherlands (Van Heelsum and Hessels 2006). In recent years, Nigeria has become one of the

biggest African countries of origin of asylum seekers in the Netherlands, with 205 asylum

applications between August 2006 and July 2007. Somalia is the only Sub-Saharan African

country to have produced more asylum seekers in the same period. No accurate estimate of

the number of Nigerians residing irregularly in the Netherlands is available.

Between 2004 and 2006, IOM Netherlands facilitated approximately 95 voluntary returns to

Nigeria each year, making Nigeria the third-largest African destination of voluntary returnees,

behind Angola and Ghana82.

8.2 SOURCES OF INFORMATION

During this country visit, representatives of the following organisations were consulted:

• IOM mission in Nigeria (Abuja and Lagos offices)

• UNAIDS

• the National Agency for the Control of Aids

• a women’s rights NGO

• an NGO focused on women and HIV

• an advocacy organisation for people living with HIV

• an association of people living with HIV

• an association of women living with HIV

• a government hospital

• three international health care NGOs

• an NGO dealing with human rights and health

• a religious-based NGO for people living with HIV

Below is a summary of the various discussions with these interlocutors, and their opinions

and perspectives on the issue of return to Nigeria of people living with HIV83. Opinions

expressed by these interviewees do not necessarily reflect the policies and views of their

respective organisations.

81 According to the HIV Monitoring Foundation database.

82 See IOM annual reports 2006 and 2007, www.iom-nederland.nl.

83 As this visit was shorter, and involved travel to both Lagos and Abuja, less time was available for

consultations than for most of the other countries. This is also reflected in the length of this report.

8.3 MEDICAL ISSUES

A government respondent stated that a full range of HIV treatment services was available in

Nigeria, which had been expanded to every state, including free treatment, testing and

monitoring. However, several interviewees noted that a difference should be made between

the treatment facilities offered under a PEPFAR84-funded scheme. When discussing treatment

possibilities, it was not always clear if these related to this scheme or to other programmes. A

government respondent stated that a full range of HIV treatment services was available in

Nigeria, which had been expanded to every state, including free treatment, testing and

monitoring. A respondent from UNAIDS added that there was no lack of medication, and that

both first and second line drugs were available. He did, however, suggest that in some places

it was difficult to find the right combination of ARVs and laboratory facilities needed by

people living with HIV. All in all, about 160,000 people out of a total of 500,000 were said to

be receiving treatment. A state government physician also explained that outside the Pepfar

programme, the Nigerian government set up 51 federal government hospitals providing first

line medication. Laboratory facilities, however, were said not always to be available, and

sometimes people would need to pay for these facilities. A government official added that

although conditions in rural areas were more complex than in urban areas, it should still be

possible for returnees to settle there.

Others paint a far bleaker picture of treatment possibilities. A women’s rights NGO

spokesperson suggested that, in her experience, only the hospitals that were running under the

PEPFAR programme had sufficient drugs and laboratory facilities. Other hospitals, she

argued, did not always have ARVs available, and their services were not always free. Another

NGO representative also explained that the PEPFAR programme was only being run in

selected states.

Most respondents felt that in rural areas problems would be much bigger, with insufficient

staff, medication and transport to the treatment sites being available. One respondent

expressed doubts about whether it would be practically possible for a returnee living with

HIV to settle in a rural area, since this would offer considerable logistical problems.

Furthermore, the sustainability of the HIV response in Nigeria was called into question, as it

was said to be built primarily on international funds.

Treatment in general was said to be free. However, several respondents noted that in some

treatment locations, patients were obligated to pay for their medication. The free treatment

does not include the treatment of opportunistic infections, for which patients need to pay.

Even when treatment is officially provided for free, in some places people are still asked to

pay.

In general, paying for health care costs can be a big problem for many people, a representative

of a PLHIV association explained, as people living with HIV are not eligible the National

Health Insurance Scheme. According to him, people living with HIV are excluded from this

Scheme since they are considered to suffer from a ‘terminal’ illness.

84 PEPFAR, the President’s Emergency Plan for AIDS Relief, provides funding from the US government for the

prevention and treatment of HIV. See www.pepfar.gov for details.

Lack of nutrition was identified as a major impediment to adherence of HIV treatment. As

also mentioned in 8.2.2, some patients go as far as to sell their medication for food.

8.4 ECONOMIC ISSUES

In general, respondents explained that poverty is a major problem. For persons living with

HIV this sometimes leads to desperate measures. Some register at treatment sites so that they

can sell the medication they receive, and use the money to buy food for themselves and their

families.

Having an education, as well as bringing some start-up capital from the host countries are

important for returnees to survive, several respondents noted. Having a good idea of what to

expect on return, and being prepared were considered as essential. One NGO representative

particularly noted the role that corruption plays in Nigerian economics. According to him, a

well-established network (connections) is therefore necessary to find work.

For returnees living with HIV, there was one of the major issue of concern arising from the

interviews. Several respondents noted that in order to get employment in, for example, banks

and other big companies, that candidates may be subjected to HIV testing. A representative of

a human rights NGO also noted with concern that a there had been a proposal to subject

students to a mandatory HIV test. It was also suggested that people living with HIV were

sometimes facing eviction from their homes, due to discrimination by their landlords.

8.5 SOCIAL ISSUES

Most respondents listed family support as an important factor in successfully returning for

persons living with HIV. Stigma was considered a major impediment to getting this support

from the (extended) family. The fear of the unknown is still great. Although the extended

family system was said to be still functioning well in rural areas, these are also the areas

considered to have the highest level of discrimination due to lack of education. Coming back

empty-handed would also negatively impact on the relationship with family members and the

support that could be expected from them.

Several respondents noted that while there were social support groups active in Nigeria, their

activities were mostly concentrated near larger cities. In the rural areas, it would be very

difficult to find social support groups.

A human rights NGO spokeswoman suggested that compulsory HIV testing was not just

restricted to the economic area. She knew cases in which couples who wanted to get married

in an (Anglican) church were also required to do an HIV test.

Some respondents said that re-adapting to the way of life in Nigeria should not be taken

lightly, and that returnees would have to have strong personalities to do this. One official

particularly stressed that the expectations of returnees should be realistic. In the end, he said,

they will return to much the same situation that they tried to leave behind. They should not

expect extra assistance because of being a person living with HIV or as a returnee (“the

country owes them nothing”). He suggested that it would not be fair of returnees from the

West to expect this extra assistance, as many people who never left Nigeria were also waiting

for this support. A hospital staff member reiterated this and stated that returnees might not

receive much sympathy, because “they should not have gone to Europe in the first place.”

The representative of an association of people living with HIV also reiterated that adapting to

Nigeria might be one of the biggest hurdles returnees would have to face. In his opinion,

returnees should not only be aware that fewer health services would be available, but that

generally everything would require much more effort than they would be used to in Europe.

CHAPTER 9 – COUNTRY REPORT: ANGOLA

(20 – 27 September 2007)

9.1 ANGOLANS IN THE NETHERLANDS: HIV, IMMIGRATION AND RETURN

Of the five countries included in this report, Angolans account for the lowest number of

known persons living with HIV in the Netherlands, with 113 cases in June 200785.This makes

them the eighth-largest group of Sub-Saharan Africans.

In January 2004, some 12.000 Angolans resided in the Netherlands (Van Heelsum and

Hessels 2006). In terms of asylum applications in the Netherlands, Angola has traditionally

been an important country of origin. Between 2003 and 2005, approximately 250 asylum

applications were lodged by Angolans every year. Recently, however, this influx has sharply

declined. Between July 2006 and June 2007, only 27 new requests for asylum were made by

Angolans (IND 2007).

In 2002, a 27-year long civil war came to an end, which led to a high number of Angolan

(rejected) asylum seekers returning voluntarily. Between 2004 and 2006, more than 400

Angolans used the REAN programme each year, making them by far the biggest caseload of

IOM in the Netherlands. In 2007, this number started to drop significantly (120 returns), but

given the overall decline in return in that year, Angolans have remained a relatively prominent

group in terms of voluntary return86.

9.2 SOURCES OF INFORMATION

During this country visit, the representatives of the following organisations were consulted:

• IOM mission in Luanda

• UNAIDS

• UNICEF

• UNHCR

• UN High Commissioner for Human Rights

• Ministry of Health

• Instituto Nacional de Luta Contra a SIDA

• an advocacy organisation for the rights of people living with HIV

• a network of associations of people living with HIV

• a women’s advocacy group

Below is a summary of the various discussions with these interlocutors, and their opinions

and perspectives on the issue of return to Angola of people living with HIV. Opinions

expressed by these interviewees do not necessarily reflect the policies and views of their

respective organisations.

85 According to HIV Monitoring Foundation database.

86 See IOM annual reports 2006 and 2007, www.iom-nederland.nl.

9.3 MEDICAL ISSUES

Before discussing the specific treatment of HIV in Angola, some attention to the general

health care situation is in order. Many of the respondents expressed their concern about the

availability and quality of general health care. During the 27-year conflict in Angola, much of

the health care system was destroyed, they reported. One government official estimated that

approximately seventy percent of the health care infrastructure had not survived the conflict.

Although efforts were underway to rebuild this infrastructure, this official suggested, only

about thirty percent of the population countrywide had access to health care facilities.

Whatever the accuracy of these estimates, it must be noted that all respondents were in

agreement that most of these health care services were concentrated in the capital Luanda,

with far fewer facilities outside the city. Most of what was available elsewhere would most

likely be concentrated in provincial capitals.

It was noted that ART was a very new venture in Angola. At the time of the interview,

treatment was primarily located in the capital Luanda, mainly in the Hospital Esperanca,

which was opened in 2005. A government official explained that it was the government’s

priority to start scaling up the availability of treatment to the various provincial capitals; the

target was to increase this number to 15.000 in 2008. At the time of the visit there were 34

treatment sites with about 7.000 individuals receiving treatment. All interlocutors emphasised

that there was a large gap between treatment possibilities in Luanda and in other parts of the

country, particularly those areas not near a provincial capital.

The focus of the expansion of the governmental treatment programme, it was suggested, was

on first line treatment, with the government doing a study to see how it could move into

providing second line treatment. This second line treatment was not available at the time of

the field research, although one respondent reported that there were small-scale private sector

attempts to introduce this.

A UN official noted that despite the rapid expansion of treatment, many people were still

trying to go to other countries, such as Namibia, South Africa and Brazil, to get medication

there. A medical Junta Nacional existed that could approve people getting the necessary

medication in from abroad. However, representatives from HIV advocacy groups argued that

since the governmental HIV treatment programme had started, the Junta Nacional had

effectively stopped providing such authorisation.

In addition to the limited possibilities for antiretroviral treatment, testing was considered by

many to be a problem. Only CD4 counts were reported to be available. Other types of testing

were usually not feasible as the appropriate equipment was often broken, there were only few

people qualified to operate this equipment or there the reagens necessary for the testing was

not available. This problem was seen by some as indicative of the quality of health services

and health care professionals in Angola generally.

Despite ARVs being available free of charge, accessibility was also reported to be hampered

by the fact that demand for ART far outstripped the capacity, particularly in the capital

Luanda. One interlocutor noted that around 11.000 people were registered at the Hospital

Esperanca. The cost of treatment of opportunistic infections was said to depend on hospital,

although some locations provided services free of cost. For exams and tests a nominal fee was

usually charged in public hospitals. Treatment in private hospitals was widely seen as

unaffordable for people without a high income. (some people have health insurances that

cover it)

With regard to particular groups, a spokesperson of a women’s network told that a programme

for the prevention of mother to child transmission (PMTCT) was being rolled out, but that

access was still limited. UNICEF reported that treatment for children was difficult as there

were few paediatric clinicians. In Luanda, two interviewees suggested, there were

approximately 1.000 HIV-positive children and only two qualified doctors to deal with them,

leading to long waiting lists.

9.4 ECONOMIC ISSUES

Despite a booming economy, unemployment rates were reportedly high. One respondent

suggested that this could be particularly problematic for people coming from abroad. They

could be marginalised because they spoke other languages, and because there is already a

fierce competition for jobs. Having a good personal network is important. Without such a

network, finding employment could be very difficult.

For people with HIV, this may be even more difficult. Several respondents suggested that

employers may ask for HIV-tests. When people are found to be HIV-positive, they may be

fired. A advocacy group had recorded several instances of this happening. Getting legal aid in

these cases could be problematic. Lawyers are overwhelmingly located in Luanda and there

are only a few non-governmental groups providing legal counselling.

In the light of the difficulties of finding employment for people living with HIV, a

representative of a women’s network suggested the possibility of setting up cooperatives.

These might provide more security for people living with HIV, including those returning from

abroad.

While Luanda was widely acknowledged to hold more opportunities, both economically and

in terms of treatment, for returnees, it was also found to be a very expensive place to live. A

governmental official noted that some form of credit scheme might be beneficial to returnees,

as borrowing money from banks is very difficult due to very high interest rates. This makes it

difficult for returnees to build their own house. The women’s network representative noted

that there were no places where people with HIV could turn to when they were rejected by

their families.

It should be noted that while discussions with our respondents concerned returnees from

Europe, this is an issue of relatively minor concern in the grand scheme of Angolan return

migration. Following the end of the war, more than 400.000 refugees have repatriated from

neighbouring countries such as DRC, Namibia and Zambia. This puts an enormous strain on

the countries capacity to assist in the reintegration of these persons, and possibilities for this

are limited.

Nevertheless, the spokesperson of the returnees’ association mentioned that there were several

Dutch and NGOs and international organisations providing support for (European) returnees.

However, he suggested that their lack of coordination may have limited their effectiveness.

The association itself tried to mediate for employment of returnees, but these efforts were

hampered by the lack of stable financial support from donors. The preparation of return in the

Netherlands also seems to be fragmented. Finally, the political will of the government to

allow returnees enough time to properly prepare was debated. The possibility of economic

reintegration, according to him, was intimately tied to this preparation. Organisations

supporting returnees do not always focus on why a person left Angola in the first place.

Motivation is an important aspect of the process. This is problematic for those for whom

return is not really a free choice. As such, experiences have been very mixed. Some have been

very happy to be back with their families and friends, while others have been disappointed.

Reintegration can also be provided by IOM, which has a special reintegration department.

Whether assistance can be given, however, depends on the entitlements to support under

schemes of the Dutch or other European governments. In many cases reintegration assistance

involves setting up small businesses.

One respondent noted that skills that are offered in preparation for return should be useful in

the Angolan context. In some cases, having stayed abroad might be considered an advantage.

Returnees from the Netherlands may have extra skills, since they have experienced a different

system. This experience can be used, for example in administrative functions.

9.5 SOCIAL ISSUES

Opinions about the level of stigma and discrimination were divided. Some saw the

prominence of government sensitisation programmes as evidence that being HIV-positive was

more and more acceptable. Others suggested that discrimination was not much of an issue for

completely opposite reasons: in the current climate almost no one dared to disclose their

status, so people did not know that others were HIV-positive. Still others rejected the idea that

discrimination was not widespread outright. These interviewees talked about cases in which

families had rejected members who were living with HIV, banks who refused to give loans to

HIV-positive clients, and (as mentioned) people who had lost their job for this reason.

Additionally, mention was made of discrimination of people with HIV by health care staff,

who, as one person suggested, may have the attitude that “treatment of a ‘dying’ person is not

worth the effort anyway.”

One interviewee suggested that the stigma of being a failure, merely due to the fact that one

has returned, should also be taken into consideration. It would be important for returnees to be

self-sufficient to expel this myth of failure. They would need the appropriate skills and

equipment for this. The problem would be even worse when one comes back empty-handed

and with HIV. This person could then very easily be considered a burden on his/her

community. Several respondents noted that coming back would be particularly difficult for

women living with HIV. One person wondered who would take care of them and their

children when they fell ill, given that these women were traditionally the care providers in

their families.

A UN official told that in some cases there were tensions between returnees and those who

stayed in Angola. For example, those who stayed behind might think that people who had left

the country were linked to the rebel group UNITA. In cases when returnees received

assistance, this could lead to jealousy by those who had not moved. For this reason most

reintegration programs focused on assistance to both – the receiving community and the

returnees. It should be noted, however, that these examples were given in the context of

repatriated refugees from neighbouring countries to rural areas in Angola, while most

returnees from the Netherlands and other European countries seem to congregate in Luanda,

where they lead a more anonymous existence.

CHAPTER 10 – COUNTRY REPORT: CAMEROON

(29 October – 3 November 2007)

10.1 CAMEROONIANS IN THE NETHERLANDS: HIV, IMMIGRATION AND

RETURN

Of the five countries included in this report, only Ghanaians account for more known cases of

HIV than Cameroonians. In 2007, 162 Cameroonians were registered in hospitals as being

HIV-positive87. This disproportionately high number was the main reason for the selection of

Cameroon as the final pilot country.

This relatively high number of persons living with HIV contrasts sharply with statistics on

asylum. Between August and July 2007, only 34 new asylum requests from Cameroonians

were received in the Netherlands. No fewer than ten other African countries produced more

asylum seekers in the same period.

This low number of asylum applications is also reflected in the number of voluntary returnees.

Between 2004 and 2006, approximately fifteen Cameroonians returned home voluntarily

using the REAN programme each year. In 2007, this number had reduced to only 5 cases88.

10.2 SOURCES OF INFORMATION

During this country visit, the representatives of the following organisations were consulted:

• IOM mission in Cameroon

• the National Aids Control Committee

• UNAIDS

• two hospitals

• a human rights NGO for people living with HIV

• a women´s health NGO

• an NGO providing general health care services

• a network of support groups of people living with HIV

• three associations of people living with HIV (one with general membership, one for

women, and one for youth)

• an NGO focused on reproductive health

• a church-based medical centre

• an NGO providing assistance to HIV-positive children and AIDS orphans

Below is a summary of the various discussions with these interlocutors, and their opinions

and perspectives on the issue of return to Angola of people living with HIV. Opinions

expressed by these interviewees do not necessarily reflect the policies and views of their

respective organisations.

87 According to HIV Monitoring Foundation database.

88 See IOM annual reports 2006 and 2007, www.iom-nederland.nl.

10.3 MEDICAL ISSUES

At the time of the research, two major developments had taken place very recently. First of all,

on the 1st of May 2007, a programme for free distribution of first line antiretroviral drugs was

put in place. This programme was financed by the Global Fund. Distribution was taking place

through certain approved treatment centres (CTAs) and smaller medical facilities called

UPECs (unite de prise en charge). Accessing first line medication was considered to be easier

in and around urban centres than in rural areas, where people would have to cover long

distances to get to CTAs or UPECs. These would mostly be located in at district capitals in

rural areas. One respondent noted that the areas furthest away from distribution sites were also

often those were the standard of living was lowest, leading to problems in covering

transportation costs to get treatment. Additionally, second line antiretroviral drugs had

become available in September 2007, less than two months before the visit, but only to a very

limited extent. Where they were available, these cost FCFA 7,000 (equivalent to about USD

14) per month, and were not subsidised. Also, resistance tests which should preceded

changing to second line medication were said to be very costly.

The costs of laboratory tests were covered by the government to the amount of FCFA 3.000

(about USD 6). However, other tests such as CD4 counts costs FCFA 10.000 apiece and these

costs would have to be borne by the patient. Test related to opportunistic infections were

provided free of charge, one official explained. He also noted, however, that the actual

treatment of these infections could be very costly.

A representative of the National AIDS Control Committee (NACC) noted that the

sustainability of Cameroon’s HIV treatment programme should not be taken for granted, as it

depended heavily on external sources of funding (in addition to the Global Fund, the World

Bank and the Clinton Foundation were mentioned as contributors). Also, he suggested that

funding brought in by NGOs also played an important part.

Members of associations of people living with HIV mentioned that community-based care for

persons living with HIV were not yet well developed. This was due to lack of experience by

those who were responsible for developing this. Were available, communities were not

always aware of the possibilities.

10.4 ECONOMIC ISSUES

Associations of people living with HIV were considered to be important actors in helping

with income generation. All of the associations encountered implemented some small-scale

economic activities for their members. Some associations of people living with HIV were able

to connect awareness raising activities to income generation. Those who would go out to give

talks on HIV issues would receive some remuneration for this. The NACC was said to

provide financial support to these associations for their income generating activities. At the

time of the visit, the NACC representative said that 117 associations were receiving this

support.

Several NGOs were also found to be providing micro credits or other financial support for

small-scale economic activities. Also, some women’s groups were reported to have set up

‘solidarity funds’, which could be used to help out those in need with paying school

registration fees or medical bills.

One respondent noted that specific assistance from the host country to returnees in relation to

income generation would be necessary to help them meet their basic nutrition and

accommodation needs. He mentioned that rural areas might provide more opportunities to be

self-sufficient at least in terms of nutrition, as returnees could engage in agriculture there, at

least if they would be physically fit enough for this.

In terms of employment, the rights-based NGO reported that in the past, some companies had

subjected their employees to unwanted medical tests. Those who were found to be HIV-

positive were confronted with dismissal or were refused promotion. The spokesperson of this

NGO noted, however, that such things were becoming less common.

10.5 SOCIAL ISSUES

Despite activities to sensitise people on the issue of HIV, stigma and discrimination was

considered to be widespread. This, staff members of a hospital suggested, can lead to persons

living with HIV refusing community workers to visit them, for fear of their status becoming

known by their neighbours. This also forces some to avoid nearby health centres, and to travel

large distances to other places. Particularly for women, it was said, disclosing their HIV-

positive status was a difficult issue, as this might lead to being abandoned by their spouses or

families.

In addition to HIV-related problems, an NGO representative noted, social difficulties could

arise from the economic expectations of returnees’ families. They would expect much

financial support from the person coming back from abroad, rather than the family having to

support the returnee. He worried about families’ reactions if returnees, particularly those who

are in ill health, became to dependent on them.

The importance of connecting to associations of persons living with HIV was emphasised by

almost all respondents. This would greatly benefit returnees, they argued, not only because of

the support in income generation they can provide, but also for psychological support. As

already mentioned, there are large numbers of such associations active in Cameroon.

Part III: Conclusions

CHAPTER 11 – CONSTRAINTS AND POSSIBILITIES

OF RETURN AND REINTEGRATION

11.1 WHEN MIGHT MIGRANTS LIVING WITH HIV CHOOSE TO RETURN?

In the previous six chapters we have presented the discussions we have had with migrants

living with HIV in the Netherlands and with a range of interlocutors in five African countries.

These have helped identify a broad range of issues concerning the desirability of voluntary

return as an alternative to irregular stay in the Netherlands, and the potential problems to

actually realise such an alternative.

From our target group interviews it is clear that some of our respondents consider return

simply unthinkable. It is important to acknowledge that under current conditions, it is very

likely that the majority of HIV-positive migrants without a legal status would opt to stay in

the Netherlands, even if this means living in an irregular situation. As discussed in chapter

five, they find the situations in their countries of origin much too uncertain, particularly in

terms of access to treatment, while in the Netherlands this is guaranteed. Also, some might

not see return as an option for completely different reasons. Regardless of the circumstances

in the country of origin, they may value opportunities in the Netherlands too much to consider

return. Examples of this could be the fact that they are able to send money back to their

relatives, the possibility to enjoy high quality education, or the simple fact that they have

become accustomed to life in the Netherlands.

In contrast, some respondents have indicated that they would like to return home, if only the

conditions were right. They are motivated by a desire to be with their families, to continue

their lives in ways that they are not able in the Netherlands, or to help improve the lives of

others living with HIV in their countries of origin. The conditions that would have to be met

for them to seriously consider returning generally encompass, at a minimum:

• sustainable access to suitable medical treatment;

• an adequate income to meet both ‘regular’ costs of living and costs of medical

treatment; and

• successful reintegrating in social networks.

While these minimum conditions for voluntary return will probably be shared by many

migrants living with HIV, this does not mean they will be shared by all. Some, for example

might see the fact that they would have guaranteed access medication for only a limited time,

with a reasonable prospect that treatment programmes in their countries would develop in the

mean time, as sufficient. Others, on the other hand, would only find a life-long guarantee of

medication acceptable. Also, as we have seen, there may be additional conditions that would

need to be met, of which a political security, as perceived by the migrant, can be a particularly

relevant one. Finally, it is imaginable that in exceptional cases, the ‘minimum conditions’ for

return might actually be lower than the ones we have described here89.

89 IOM’s experience with persons with medical problems who return to their countries of origin, reveals a broad

range of – sometimes unexpected – considerations. In 2008, a migrant living with HIV requested assistance from

IOM to explore the possibilities for return. He knew that returning to his country of origin, with a considerably

less advanced medical system, would in all likelihood shorten his life expectancy. However, he asserted, he was

The appeal of voluntary return as an alternative solution to staying in the Netherlands is not

only determined by the conditions in the country of origin. Negative push factors in the

Netherlands may also play a role. Some respondents noted that they life in the Netherlands

was difficult for them. Particularly in the case of those who did not have a secure legal status

the struggle for daily survival had detrimental effects on their well-being (also see, for

example, Shiripinda and Van Eerdewijk 2008). This also led some experts to argue that

migrants who find themselves ‘in the gutter’ in the Netherlands might benefit from returning

to their countries of origin, provided that their basic medical, economic and social needs could

be met. The voluntary return of migrants living with HIV being prompted by negative

circumstances in the Netherlands, rather than by positive circumstances in the countries of

origin, however, raises some difficult questions. First of all, it is debatable whether these

migrants, who would return because it is ‘the lesser of two evils’ would have the right mindset

to make their return a success (this is discussed in more detail in 11.3). Also, it raises

questions about the relationships between assistance providers and migrants, and the extent to

which this relationship influences the decision of a migrant, particularly when he/she is

vulnerable. This discussion is briefly described in box 12.

Box 12: Who decides what is best?

Discussions about return put health care workers and other assistance providers in a difficult

position. While all consulted experts agreed that the decision to return should be one that should

be made by the migrant themselves, they struggled with the extent to which they should try to

motivate the migrant to think about return as an option. They realised that their advice and

opinions as a confidant and assistance provider could be a powerful influence on the decision-

making process, leading to the question: at what point is the assistance provider deciding for the

migrant what is best for him/her? These discussions also touched upon the professional

framework of these assistance providers and the extent to which it was their responsibility to play

a role in this process of thinking about return. Some health care professionals, for example, saw

their role as being limited to providing medical care, while others found it necessary to help their

patients find a solution that was best for their overall health, which could also mean making

interventions on social, economic or legal issues.

11.2 BARRIERS TO RETURN

In the previous six chapters, it has become clear that meeting the conditions that would lead to

migrants living HIV to opt for return encounters significant barriers. Below, we briefly

summarise the main medical, economic and social barriers, as well as some of the suggestions

made by migrants and experts how to deal with these barriers.

11.2.1 Medical issues

Availability of treatment

The most obvious concern of both our respondents and our discussants in the five African

countries is the availability of suitable treatment. Based on our research, it is impossible to

make sweeping statements about the extent to which HIV treatment will be available to

returnees living with HIV. In all five countries some forms of treatment were in available and

willing to exchange quantity of life for what he saw as a better quality of life – being with family, in a familiar

environment, without the worry about legal procedures, etc.

Another illustrative case is that of a woman who suffered from cancer, and was expected to die shortly. She

returned to her country of origin in order to be with her family and die in dignity.

the distribution of antiretroviral drugs was being expanded, often quite rapidly. It goes

without saying, however, that the level of care and treatment significantly differed from that

which migrants living with HIV are able to get in western countries like the Netherlands.

Only specific medication were available, with people living with HIV usually relying on

limited combinations of first and second line drug combinations. Whether this treatment

would be sufficient for the individual returnee, therefore, is very much dependent on his/her

personal situation. In general, our contact persons in the countries of origin considered that

the more complicated the treatment received in the Netherlands was, the less likely it would

be that appropriate treatment and follow-up would be available. Not all treatment sites could

provide the same quality of care, with hospitals in urban areas usually considered to be better

equipped and staffed than rural treatment sites.

While the availability of treatment is a concern for those who are not yet on antiretroviral

drugs in the Netherlands, the issue is likely to become more complicated for those who are

already on treatment before returning. Ensuring that no gaps in treatment occur in the post-

return period is considered crucial. In some cases it was reported that supplies of even the

most common types of medication were interrupted. It was also noted that the way that the

HIV response in the different countries was financed might lead to continuity problems in the

long run. With the exception of Angola, where the government provided the bulk of the

resources for its HIV response, treatment programmes in other countries tended to rely

heavily on international funds. While these funds seem to have some staying power, the

sustainability of HIV treatment will remain somewhat precarious until governments are able

to take full financial responsibility for their own programmes.

Accessibility and affordability of treatment

Even when adequate HIV treatment is available, there are several factors which affect the

individual accessibility of this treatment. One important factor, which was a major concern for

the interviewees in the Netherlands, is affordability. When comparing the views of our

respondents in the Netherlands with the situation that was presented in the countries of origin,

the question arises whether all target group members had a realistic idea of the cost of

treatment. Better information about this issue might help these migrants consider their options

better. However, even if prices were lower than some respondents suggested, the affordability

of HIV treatment and monitoring may still provide significant problems in individual cases.

This is determined by more than just the price of medication, so even in those cases that there

is a free ARV distribution programme in place, other costs should be expected to occur. One

of these costs is related to the treatment of opportunistic infections. This treatment was often

not included in programmes that offered ARVs for free or at a reduced price. The cost of

treatment of opportunistic infections was said to be quite considerable, especially in settings

were there was no health insurance scheme. In those countries were health insurance schemes

did exist and covered treatment of opportunistic infections and were open to persons living

with HIV, fees had to be paid to make use of these schemes. In addition to these costs directly

related to health care, people with HIV may be forced to travel considerable distances, leading

to significant travel expenses. It is unsurprising, therefore, that many of the migrants and the

experts that we consulted with considered economic reintegration as a major success factor in

making return possible.

11.2.2 Economic issues

Conditions for economic reintegration

Economic reintegration was not only considered a necessary precondition for gaining

sustainable access to treatment, but an important issue in its own right. Food, accommodation

and education are basic needs that are not limited to the concerns of returnees living with HIV;

they are the concerns of all returnees, and of the vast majority of the citizens of the countries

of origin we have visited. It is important to note here that all of these five countries have high

levels of poverty and unemployment.

According to our informants in the countries of origin, successful economic reintegration

depends on a number of factors. The first one is preparation. As many of our respondents

suggested, economic reintegration is not easy because of the general economic situation. At

the very least, therefore, a returnee should have a good plan for attaining economic self-

sufficiency. He/she should be aware of the steps to take, which assistance programmes might

be available and what kind of start-up capital would be necessary. Secondly, the importance

of having sellable skills and/or training was emphasised. Especially in the post-conflict

countries, having practical skills was seen as a necessity. Small-scale retail (e.g. selling

products in the market), on the other hand, was seen as a difficult route to follow. Competition

in that area was considered high and the possibilities for generating income viewed as low. It

should be noted that most people in the five, regardless of whether they had migrated, only

earned an income at a basic subsistence level (or below). It was emphasised that living with

HIV places quite a considerable financial burden on the returnee. Therefore, if economic

reintegration would amount to merely gaining a subsistence level income, this was unlikely to

be sufficient for the returnee living with HIV to meet both his/her basic food, accommodation

or education needs and pay for medical costs.

It was suggested that in most countries the possibilities of getting employed or keeping a job

would likely to be seriously diminished if it were known the returnee was HIV-positive.

Stigma and discrimination of people living with HIV was also said to lead to the failure of

businesses run by persons known to be HIV-positive.

Access to reintegration services and programmes: just a face in the crowd

Several services and programmes that could potentially facilitate the reintegration of returnees

living with HIV were available in the five countries. With the exception of some IOM

activities in those countries, however, these services and programmes were generally not

specific to returnees, but were offered to a broad population. It was seen as important,

therefore, to reiterate that returnees need to have realistic expectations of the services

available to them. In all countries, and particularly in Angola and Sierra Leone, which are

recovering from devastating conflicts, the number of persons in need of assistance, whether

economic, medical or otherwise, is huge. Rather than receiving special attention because of

his/her situation, the returnee will probably become ‘one of the crowd’. This seems like an

obvious statement, but is extremely important in creating the right expectations of the post-

return situation. The attention that is lavished on the issue of return (and by proxy on

returnees) in the Netherlands and other European states might easily lead one to believe that a

large apparatus just to help returnees reintegrate in their countries of origin is in place. In

reality, however, returnee-specific programmes are usually small in scope, scattered and

temporary. Where larger-scale activities for returnees were in place (e.g. in Sierra Leone and

Angola) these were aimed at the large numbers of refugees returning from exile in

neighbouring countries, and the displaced that were scattered around these. In these countries,

the issue of returnees coming from western countries, was therefore a comparatively very

minor one.

11.2.3 Social issues

Social support networks

The importance of social support networks for successful return was emphasised by virtually

all persons interviewed and consulted. The availability of a social support network is

dependent on a lot of factors. In some cases, this network might not exist at all, since family

members and others are not in the country of origin, or the migrant has lost track of them.

This is particularly relevant for countries like Sierra Leone and Angola, where conflicts have

led to a lot of people being displaced. Even if there is a support network in the country of

origin, the extent to which a returnee can rely on it varies. Several respondents in the

countries of origin noted that returnees should expect a quid pro quo attitude; if they had

(financially) supported their network while being abroad, they could expect to be ‘rewarded’

for this by their family and friends, who would support them in their time of need. However,

if the returnee would come back empty-handed, the willingness of families and friends to

provide support could be diminished. In such cases, it was possible that the returnee would be

seen as an added burden, especially because of carrying an illness that would reflect

negatively on the family or circle of friends.

In all countries, associations of people living with HIV and mutual support networks were

present. These support groups provided an important coping strategy for people living with

HIV, and potential returnees were urged to connect with a local association. Some of these

associations were also possible to provide a small measure of material support (e.g. food

distribution) or provide the opportunity for skills training.

Stigma and discrimination

The issue of stigma and discrimination was an enduring theme in all interviews and

consultations. Stigma and discrimination were found to work at three main levels: (1) self-

stigma of the returnee, (2) stigma and discrimination by the returnee’s immediate social

network (family and friends); and (3) stigma and discrimination in wider society. The issue of

stigma and discrimination may be one of the biggest barriers to successful return and

reintegration, and the importance of acknowledging this cannot be emphasised enough. As

already discussed, discrimination was found to have a very negative impact on the ability of

the returnee to earn a livelihood. This also goes for finding accommodation. In addition,

people living with HIV were also sometimes found to be the targets of discrimination by

health workers, affecting their enjoyment of medical treatment. While in several countries

some formal legal protection system against such discrimination was in place, it is

questionable whether those experiencing discrimination actually have recourse to legal

remedies. However, this, it was suggested, would only be a relevant issue only when the HIV-

positive status of the returnee was known. In most of the countries visited, persons living with

HIV preferred not to disclose their status to anyone but their closest relatives. Our

interlocutors stressed that returnees needed to think hard about whether they would want to

disclose their status when back in their country of origin, and should realise the consequences

of doing so.

11.3 OVERCOMING BARRIERS: VOLUNTARINESS, COMMITMENT AND

PREPAREDNESS

Above we have discussed several specific issues that need to be taken into consideration when

migrants living with HIV consider returning. In the remainder of this chapter, we will discuss

some more general preconditions for overcoming barriers to sustainable return and

reintegration. The first of these is psychological in nature. It was noted by several

interviewees that overcoming barriers to return would require a very firm commitment to

rebuilding a life in the country of origin. A positive, forward-looking attitude was considered

crucial to have a chance of making return work. It should be noted that in our conception of

what might constitute voluntary return (see 4.2.1), the existence of such a commitment is by

no means self-evident. While we consider a migrant choosing to return due to a lack of viable

alternatives in the Netherlands as one who is returning voluntarily, such a situation is unlikely

to produce the sort of commitment to return that our respondents allude to. Rather, in order to

have a chance of sustainable return, the interviewees suggested, the migrant needs to have a

large measure of mental readiness, as well as being proactive in practically preparing for

return.

As we have shown in chapter five, amongst our respondents, this state of mind was not a

common thing. Quite a few of them firmly believed that return would never be possible for

them, and as such did not have any interest in preparing for it, mentally or practically.

Additionally, there was a group that, even if they would have wanted to, were unable to

prepare for return. This was the group of respondents that was only living in the ‘here and

now’ – they were exclusively focused on accepting the fact that they were HIV-positive, on

obtaining a legal status, and/or on meeting their immediate needs. In other words, they were

surviving rather than working towards a future. Until this group has found some measure of

stability, it is highly unlikely they would be able to develop the forward-looking attitude

needed to seriously consider return.

11.4 THE RIGHT COMBINATION OF CIRCUMSTANCES

While the agency of the potential returnee was seen as an important ‘ingredient’ for a possible

sustainable return, this is by no means the only general condition. Sustainable return, as

defined by the majority of our respondents, is dependent on a broad range of circumstances,

which have been listed above. Often, these circumstances are closely interconnected. For

example, appropriate medication, testing facilities and qualified staff should not only be

available in or near the place where the returnee wants to settle, but this treatment also has to

be reliable and affordable. This affordability is based on the costs of medication, treatment of

opportunistic infections, testing, health insurance fees and a range of other issues, while the

ability of the returnee to carry these costs depends on a sustainable income. Whether such

income generation is feasible is dependent on, inter alia, the general economic conditions, the

skills of the returnee, the health situation of the returnee, and whether or not he/she is known

to be living with HIV. Also, the returnee has to be able to rely on family or other social

network in case he/she gets ill and for psychological support. Whether this is the case depends

on, for example, whether any support network still exists in the country of origin and on the

returnee being accepted by this network. Particularly when the returnee comes back empty-

handed, this may make it less likely that he/she will be able find the necessary support.

Associations of people living with HIV, if present in the area of return, can provide some

‘surrogate’ support. Finally, the migrant him/herself has to be mentality prepared for what

could be a considerable struggle to reintegrate.

While the circumstances mentioned above relate to the post-return situation, many of these

circumstances are also connected to the situation of the migrant while still in the Netherlands.

Counselling and participating in support groups in the Netherlands can lay the groundwork for

the necessary positive attitude. Whether the migrant has sellable skills depends, to some

extent, on whether he/she has had the opportunity to learn and develop these skills while in

the Netherlands. The possibilities of the migrant to send remittances to family members

and/or to build up a ‘nest egg’ to take home also play an important role.

This enumeration is by no means exhaustive. Our point here is not to provide a list of all

possible factors of importance; these depend, after all, on the specific situation of the

individual involved. Rather, we have attempted to illustrate the interconnection of a diverse

range of factors, and that it is by no means self-evident that the right combination of

circumstances can be found in individual cases. In most cases, the combination of conditions

is so closely related that if one does not materialise, most others will probably also not be

attained.

Many of these circumstances are related to the situation of the individual, such as his/her

health or the presence of family in the country of origin, and are unchangeable. Others are

inherent to the situation in the country of origin, such as the general levels of unemployment

or the levels stigma and discrimination prevalent in the home society, and also not susceptible

to intervention at the individual level. These circumstances are just facts that have to be

accepted and dealt with; whether they provide an appropriate starting point for sustainable

return is a function of – for lack of a better word – luck. Given the broad range of

determinants, there can be many circumstances that make sustainable return, as defined by the

individual migrant, prima facie impossible. This would be the case, for example, when there

is no suitable follow-up treatment in the country of origin, or if the costs for such treatment

are so high that even with a steady income, these are unaffordable for the migrant.

However, there may also be circumstances that can be changed to increase the probability of

sustainable return. In the following chapter, we will look the possibilities for making

interventions to help maximise the chance of sustainable return, how these could be shaped,

and which limits there are on such interventions.

CHAPTER 12 – ASSISTING THE VOLUNTARY RETURN OF

MIGRANTS LIVING WITH HIV

12.1 A ‘ROAD MAP’ FOR RETURN

12.1.1 Role of assistance

As discussed in the previous chapter, a precondition for return is that an individual migrant’s

case shows a combination of circumstances that do not a priori preclude return. Additionally,

interventions might be possible that increase the chances of sustainable return and

reintegration. In this chapter we will discuss the scope and potential of return assistance

activities for migrants living with HIV. For each possible intervention, however, it should be

considered whether this is something that a migrant could do him/herself or whether active

intervention by a third party would be necessary. In general, we would suggest that return

assistance is merely complementary to migrants’ own efforts to try and realise their own

return.

Before listing some potential practical interventions, we will first discuss more general

framework preparing interventions. We suggest that this framework provides a possible ‘road

map’ for dealing with migrants who consider returning, and to assess the practical

possibilities for realising this. This road map is discussed below, and is illustrated in box 13.

12.1.2 A road map90

Initial inventory of migrant’s situation

Given our focus on voluntary return, the starting point is a desire of the migrant to, at the very

least, explore the possibilities of return. This desire may lead to a request to assist exploring

these possibilities, and to ultimately realise return. The request will have to be regarded in the

context of the willingness of the migrant (is he/she really committed to return?); the personal

characteristics of the migrant (including gender and age); his/her wishes (i.e. under which

conditions will he/she consider return as a viable option); the migrant’s current conditions in

the host country (for example, which medical treatment is provided and legal status); and the

situation in the country of origin. Particularly the latter will require some extensive

information gathering activities. Some information (such as the existence of a social network)

can be provided by the migrant, but he/she might not always be aware of the current state of

treatment options and/or economic opportunities in the area where he/she wants to return.

Inventory of barriers and possible interventions

An initial inventory of options enables the identification of certain constraints to return and

reintegration. As discussed in the previous chapter, it is not possible to influence all of the

circumstances which provide these constraints. An essential part of the assessment process,

therefore, is to provide a realistic picture of which circumstances cannot be changed and for

which interventions might be possible. If unchangeable circumstances provide barriers that

preclude return, this will lead to the end of the return process (unless the migrant readjusts

his/her criteria for return). For those circumstances that can be influenced, interventions in

both the host country (pre-departure) as the country of origin (post-arrival) need to be

examined.

90 Although developed in the context of returnees living with HIV, this road map may be equally applicable to

other categories of returnees where a particular focus on sustainable reintegration is desirable/necessary.

Assessment of intervention options

If a clear picture of desirable interventions has been produced, the feasibility of implementing

these interventions need to be assessed. Again, this process will likely involve a lot of

information gathering in the country of origin, but may also include a further exploration of

pre-departure assistance possibilities in the host country. It is obvious but important to

mention in this respect that the resources at the disposal of the organisation providing

assistance as well as its mandate will play an important role in the feasibility of implementing

certain assistance activities. The assessment of intervention possibilities will likely lead to the

conclusion that some interventions, although desirable, might be practically unfeasible (for

instance, due to resource limitations). Here again, the question needs to be asked whether

return is still possible even in the absence of these interventions. The limitations and practical

possibilities for intervention need to be communicated clearly with the migrant. It will then be

up to the migrant to make a decision on whether to proceed with the return process91.

Implementation phase

When a decision is made to try and realise return, interventions need to be prepared. As

mentioned, the migrant him/herself has an important role to play in this preparation. However,

assistance providers might complement the migrant’s activities by, for example, mobilising or

providing resources. This stage would also include agreeing on clear terms about the extent to

which assistance will be provided. Clear mutual expectations between the migrant and the

assistance provider are crucial to avoid ethical complications (see 12.4). Also, there needs to

be a realistic time frame that is shared by both the migrant and the assistance provider. There

might be a substantial time gap, for example, between the start of the implementation of pre-

departure interventions and the actual return. If, for instance, these interventions include skills

training, this may take a considerable amount of time92.

When the actual return takes place, it should also be clear which post-arrival interventions still

need to be implemented, and whether it is the responsibility of the assistance provider (or a

partner in the country of origin) or the returnee to instigate these interventions. In some cases,

the assistance providers may not be able to do more than provide referrals to local

organisations in the country of origin, without actually being able to influence the way in

which these organisations deal with the returnee. This, also, needs to be communicated clearly

with the migrant before the actual departure.

Finally, the assistance provider and the migrant may make arrangements to monitor the way

the migrant is getting on after his/her return. However, the effectiveness of such monitoring

arrangements may be limited (see 12.4).

91 Although the ‘return decision’ is described here as a specific point in time, in reality this is more likely to be a

process, which already begins long before a request for assistance is made. Also, the voluntary nature of return

would mean that this return decision is not a ‘point of no return’. Even after the decision is made to go ahead

with preparations for return, the migrant should have the possibility to change his/her mind.

92 The extent to which a migrant might actually have this time depends, among other things, on his/her legal

status (see chapter thirteen).

Migrant considers return

Request for return

assistance

Willingness Personal

characteristics and

wishes

Current situation

Situation in

country of origin

Identification of

potential barriers

Barriers for which

no interventions

are

ossible

Barriers for which

interventions may

ossible

Return possible

despite these

barriers?

Possible pre-departure

interventions

Return cannot be

realised

Yes

Possible post-arrival

interventions

Information gathering on feasibility of

interventions

Unfeasible

interventions

Return possible

despite lack of

interventions?

Return cannot be

realised

Feasible interventions

Yes

Return decision

Preparation of interventions

Return

Implementation of post-arrival interventions

Monitoring

Inventory of barriers and

possible interventions

Assessment of

intervention options

Implementation

phase

Box 13: Voluntary return process

Implementation of pre-departure interventions

Initial inventory of

migrant’s options

100

Box 13 provides a schematic representation of a possible return trajectory. However, in reality

such a trajectory might not always be as linear as suggested here. In practice, it might be

possible to go back to a previous phase, sometimes even various times. Also, the starting

point might be different. For example, there might already be information about intervention

options from experience with previous cases or because the migrant has already gathered this

information. It is therefore a model that can act as a reference, but which should always be

employed with a large degree of flexibility.

12.2 INTERVENTIONS

In this section, we describe a number of practical interventions, which have been extracted

from the interviews with migrants in the Netherlands and from our country studies. Box 14

provides a list of possible constraints to return and the interventions and considerations

relevant to these constraints. This list is not exhaustive. Return assistance to migrants living

with HIV is an unexplored area of practice, and as such it is very likely that new barriers and

possible interventions would be identified if return would actually take place. Also, the

feasibility of each of these proposed interventions can only be assessed on a case-by-case

basis.

Box 14 : Intervention possibilities

Barrier to return

Considerations for intervention

Medical issues

Antiretroviral medication not available or appropriate

medication not available

Is migrant planning to return only for a short period93

or permanently?

Short term return:

• can migrant take a stock of medication?

• is it possible to import medication from

Netherlands or another country?

Long term return:

• no intervention feasible, unless broader

treatment services and broader medication

options become available

Other crucial medical facilities not available

(qualified health care staff, testing, treatment of

opportunistic infections, etc.)

• no intervention feasible

Appropriate treatment available elsewhere in the

country of origin, but not near preferred location of

return

• is migrant willing/able to settle closer to a

treatment site? Does he/she have

economic opportunities and a social

support network there? (see below)

• Will migrant have the financial means to

travel to treatment site? (see economic

issues)

Appropriate treatment and monitoring is available

but (parts of) treatment are not free

• what are the migrant’s short and long-term

economic prospects? (see economic

issues)

• is it reasonable to assume that the migrant

will be able to afford treatment if he/she

has a sustainable income?

93 For example, a migrant might return in order to prepare another migratory movement to another country.

101

Appropriate treatment is available but treatment

centres have waiting lists for entering of

programmes

• information gathering on state of waiting

lists. When will migrant be able to enter the

treatment programme?

• Are there other treatment sites reasonably

accessible to migrant without waiting lists?

Concerns about the continuity of the availability of

treatment at the treatment site

• Information gathering about the history of

the treatment site (start of provision of

treatment, interruptions in supplies, etc.)

Economic issues

High levels of poverty and/or unemployment in the

country of origin

• No intervention feasible

Migrant needs income generation strategy

• Can migrant rely on family to sustain

him/her?

• Does the migrant want to find

employment?

• Does the migrant want to become self-

employed?

Migrant wants to find employment

• Information gathering: are there job

opportunities that match the

skills/experiences/physical possibilities of

the migrant?

• Are there opportunities for training (before

departure or in the country of origin) to

improve the employability of the migrant?

• Is some kind of mediation with potential

employers possible (e.g. job placement)?

• Information gathering: what protection is

there against work place discrimination of

persons living with HIV? Is legal assistance

available and do effective remedies exist?

Migrant wants to become self-employed • Can the migrant be advised on developing

a viable business plan?

• Information gathering: are there particular

activities that are more likely to generate a

sustainable income?

• Does the migrant have the

skills/experience to engage in these

activities?

• Is skills training (in the Netherlands or the

country of origin) available?

• Are there possibilities for micro credit or

other financial assistance for business

start-up?

Social issues

Migrant has no social network in country of origin

• Can lost family be traced and contact re-

established?

• Are there alternatives for social support

(e.g. local associations of people living with

HIV)? Do these provide sufficient levels of

support?

Social network does not know migrant is HIV-

positive

• Are there possibilities for counselling and

advice on disclosure process from host

country?

• Is family counselling available in the

country of origin?

102

Stigma and discrimination in wider society

Individually:

• Can support groups in host country and

country of origin help migrant develop

coping strategies?

Structurally:

• No interventions feasible

Other issues

Fears of violence or persecution in country of origin

• No interventions feasible

12.3 THE SCOPE AND POTENTIAL OF RETURN ASSISTANCE

As already suggested, return assistance does not have an unlimited scope and potential. In this

section, we will discuss some issues related to the effectiveness of such institutionalised

interventions. The limitations to return assistance should be clear to both the assistance

provider and the migrant receiving this assistance.

The impact of return assistance should not be overestimated

The limits on the impact of return assistance are primarily related to structural circumstances

in the country of origin, as well as the migrant’s own possibilities and proactiveness. To

provide both migrants and policy makers with a realistic view of the scope and potential of

return assistance, it is important that its impact should not be overestimated. It is a tool that is

complementary in nature; in isolation, no form of return assistance can create the appropriate

conditions for sustainable return and reintegration.

The availability of assistance does not lead to a desire to return

Seeing return assistance as complementary is also important to understand the place it might

occupy in policies towards migrants living with HIV, who do not have a legal status. In

general, there is a tendency to see return assistance to rejected asylum seekers and irregular

migrants as a tool to manage migration flows. In other words, return assistance is sometimes

perceived as an instrument to maximise the number of returns of migrants who have a legal

obligation to leave the host country. The underlying assumption seems to be that the

availability of assistance will play a major role in the migrant’s decision to return. Our

interviews suggest that this assumption may not hold true for migrants living with HIV. Since

return assistance can only marginally impact on the possibilities for return and reintegration, it

only plays a very limited role in shaping the decisions of the interviewed migrants. In other

words, the availability of assistance does not evoke a desire to return. Only if such a desire to

return already exists does return assistance have a potential added value.

Interventions may reduce some uncertainties, but return remains a ‘gamble’

Finally, it is important to emphasise that, despite the fact that both migrants and assistance

providers might look for the highest degree of certainty of sustainable return and reintegration,

the sustainability of return can never be guaranteed. Given the broad range of factors of

importance and their close interconnection, no level of preparation can provide complete

certainty. Plans may not work out and unforeseen circumstances are likely to occur. This

inevitably makes return a bit of a ‘gamble’. For migrants living with HIV the stakes in this

gamble are very high. A failure to find a sustainable situation after return can have disastrous

consequences. There is very little margin for error, particularly considering the fact that they

103

will not be able to return to the Netherlands if things do not work out (see 13.2). Solid

preparation and well-considered interventions may help reduce some uncertainties, but a

degree of risk remains inevitable when returning. In the run-up to return, these potential risks

should be clearly communicated to the migrant, so that he/she can make a decision based on

realistic considerations.

12.4 RETURN ASSISTANCE: ETHICAL CONSIDERATIONS

As suggested at the start of this report, a discussion of return for migrants living with HIV

cannot take place in a moral vacuum. Not only are there practical limitations to providing

return assistance, but engaging in such assistance can have ethical implications. In this section

we will explore some of these issues, without a pretence to definitive answers.

Can returnees living with HIV be a positive influence, or are they an added burden on already

vulnerable communities in their countries of origin?

The current debate about return migration policies is heavily influenced by the concept of

migration and development. This concept emphasises the possibilities of migrants to

contribute to the development of their countries of origin. This issue also played a role in

various discussions with experts in the Netherlands and in the countries of origin. These

usually centred around the assumption that some Africans living with HIV in the Netherlands,

who had received extensive counselling and had been able to create an attitude of ‘positive

living’, would be able to share their experiences as peer educators in their countries or origin.

This experience, it was suggested, would be a valuable asset upon return. The desire to

contribute something to the well-being of people living with HIV in their countries of origin

was also voiced by some of our respondents (see 5.5.3).

However, despite these possible benefits, there is also good reason to question whether it

would actually be possible for returning migrants living with HIV to be ‘agents of change’.

Given the considerable barriers that returning migrants would need to overcome, not least

because of stigma and discrimination, it would already be an immense achievement to re-

establish themselves, without the additional pressure of having to be an ‘added value’ in terms

of development objectives. Much more than the difficulty of positively contributing, however,

becoming an ‘added burden’ on family members or the wider community is an important

consideration for many respondents. Their return, as a person coming empty-handed and

being ill, could put pressure on the already fragile situation of their families and networks.

Also, if family members accept the returnee back in their midst, stigma and discrimination

might also be deflected towards those family members, who then might have even more

difficulty maintaining themselves.

Does providing return assistance to migrants living with HIV discriminate against other

migrants?

Our focus here has been exclusively on migrants living with HIV. However, many of the

issues we have identified, especially the problems of availability, accessibility and

affordability of treatment (including the necessity of a sustainable income at a certain level)

will be no less crucial for other returnees with chronic mental and physical illnesses which

may be life-threatening or have a severe impact on the health of the migrant if untreated.

Additionally, economic and social reintegration is also an important consideration for

migrants without health concerns. This leads to the question whether providing return

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assistance for migrants with HIV, which is likely to be a very costly exercise given the scope

of their needs, while excluding others from similar high levels of assistance, is justifiable.

Where does the responsibility of assistance providers end?

Providing return assistance to returnees living with HIV might put assistance providers in a

difficult position. As already suggested by several of our respondents, assistance should be

focused on long-term results, and not be a short-term stopgap. However, at the same time it is

unrealistic to expect assistance providers to keep supporting returnees for the rest of their

lives. Does this mean that assistance providers should only provide certain types of (pre-

agreed) assistance and then cut all ties with the returnee? As noted above, returnees may

encounter unexpected circumstances and problems, some of which they may not be able to

overcome on their own. Should those institutions providing the initial return assistance – even

if it has already fulfilled its obligations as agreed – then step in again with new interventions?

This is an issue that needs to be considered carefully by assistance providers before engaging

in interventions for migrants living with HIV.

The extent of responsibilities also becomes a topic for debate when looking at the issue of

post-return monitoring. In general, the consulted experts agreed that it would be necessary to

monitor how returned migrants were getting on. However, this raises the question of the

purpose of such monitoring. Is monitoring exclusively a tool for improving future

interventions for other returnees, or does it also entail an obligation to intervene when

problems occur for the monitored returnee? As such, while monitoring might be a desirable

and necessary part of any return assistance programme for migrants living with HIV, it may

also drag assistance providers in an untenable, possibly life-long, relationship with returnees,

who, as a consequence, may become increasingly dependent on the assistance provider.

Will the voluntary return of migrants living with HIV lead to negative consequences for those

who do not wish to return or cannot return?

A recurring theme in our discussions with experts in the Netherlands was that of the legal

consequences of facilitating the voluntary return of migrants living with HIV. There were

worries that the provision of return assistance would send out a signal that it was generally

possible for migrants living with HIV. This, it was argued, could lead to stricter measures to

enforce the return of migrants living with HIV who do not have a legal status, and to

difficulties in obtaining a legal status. Theoretically, at least, this seems unlikely. After all, the

objective availability of treatment is the main consideration in legal procedures (see 3.3.4).

Voluntary return assistance activities do not influence this availability; at most they can have

a positive influence on accessibility of treatment. Considerations related to accessibility are

explicitly excluded from legal procedures. Nevertheless, until significant numbers of migrants

living with HIV would have returned, the legal and policy implications of return assistance for

this group remains unclear.

Can the return of migrants living with HIV lead to public health problems in their countries of

origin?

The final issue of concern that we mention here is the possibility of returnees living with HIV

having an impact on the public health situation in their countries of origin. Given the fact that

this report did not have a medical focus, this issue has not been explored further. However,

during the visit to Ghana this issue was raised (see 7.3). If large-scale return of migrants

living with HIV to a certain country would take place – a situation that seems unlikely under

current circumstances – this issue would warrant more attention.

105

CHAPTER 13 – THE IMPACT OF IMMIGRATION

LEGISLATION AND POLICIES ON THE

POSSIBILITY OF RETURN

13.1 LEGAL STATUS AND THE POSSIBILITY TO RETURN

This report has taken the current Dutch legal and policy framework as its starting point for our

subsequent discussion of voluntary return for migrants living with HIV. One of the main

aspects of this framework is that it puts an obligation to leave the Netherlands on all migrants

who do not have a legal status. However, in addition to determining when a migrant living

with HIV would be expected to return, Dutch legislation and policies do not only set the

conditions for when a migrant living with HIV would need to leave the Netherlands, but also

have a distinct impact on whether migrants are inclined to meet this obligation. In this final

chapter, some dimensions of this impact are discussed.

13.2 NO WAY BACK: RETURN AS PERMANENT RETURN

Once a migrant without a legal status leaves the Netherlands, there are very few possibilities

to re-enter the Netherlands legally. This may seem like stating the obvious, but it actually has

a strong negative impact on migrants’ willingness to return. Dutch immigration law, as we

have discussed, provides for a broad range of reasons for entering and staying in the

Netherlands. As long as a migrant – even if he/she has previously left the country due to a

lack of a legal status – meets the eligibility criteria, he/she will be allowed to re-enter the

Netherlands. However, few migrants who are currently in the Netherlands without a legal

status expect that they will be able to meet these eligibility criteria. For some, this may

actually have been a reason to enter the country in an irregular manner. As such, for these

migrants, leaving the Netherlands would mean a permanent farewell to their host country.

This is problematic because this leaves them with no ‘back up option’ should things in their

countries of origin not work out as planned. As discussed in chapter five, even those

respondents that tentatively consider returning at some point in the future are worried about

the sustainability of their access to medical treatment. For many of them, returning now, with

no possibility of re-entering the Netherlands if they encounter problems in accessing their

medication, or the alternative treatment regime turns out not catch on, would constitute too

much of a risk. As such, many said they would prefer to remain in the Netherlands without a

legal status, but with guaranteed access to medical treatment, at least until that time that

medical conditions in their countries of origin have improved considerably. This, they usually

do not expect to happen in the short term.

This also explains why some of our respondents with a residence permit are more open to

thinking about return. Some of them even suggested that they might travel back temporarily to

see for themselves what conditions would be like, and how they would cope with being back

in their countries of origin. For them – even though they would only be able to visit their

countries of origin for a short time – this would give them some peace of mind. And if they

would still think the risk of returning was too great, they would at least have the certainty that

106

they resided legally in the Netherlands94. It should be noted too, that if migrants with a legal

status choose to return using the facilities offered under the REAN programme, this would

require them to relinquish all claims to a legal status in the Netherlands. Therefore, a ‘go and

see’ visit to the country of origin would have to be arranged by the migrant from his/her own

means.

13.3 WILLINGNESS, PROACTIVENESS AND LEGAL STATUS

In the previous chapter we have already discussed the situation of HIV-positive migrants who

were exclusively focused on ‘surviving’. While this ‘survival-mode’ was sometimes seen as a

consequence of the psychological difficulties of the respondents in accepting their HIV-

positive status, it is also clear that legal status played an important role. The results of not

having a legal status, i.e. the exclusion from public services, resulted in a daily struggle for

survival. As such, these measures that seek to ‘motivate’ migrants without a legal status to

return voluntarily seem to significantly contribute to the inability of migrants living with HIV

to focus on their futures. As discussed, for sustainable voluntary return to be considered a

viable option by these migrants, such a positive focus on their futures is indispensable.

This leads to a paradoxical situation. On the one hand, we have approached voluntary return

primarily as an alternative to irregular stay in the Netherlands. Particularly because of the

difficult situation that rejected asylum seekers and irregular migrants living with HIV may

find themselves in, the existence of such an alternative may be desirable. However, at the

same time, the lack of a legal status may actually become a major deterrent to think about

voluntary return.

13.4 NO LEGAL STATUS AND NO PROSPECT OF VOLUNTARY RETURN:

WHAT NEXT?

We have already noted that there is a significant gap between migrants’ criteria for

sustainable return and the legal criteria for staying in the Netherlands. The availability-

accessibility debate is the most obvious example of this. From our interviews it is also clear

that most of our respondents are unwilling to return voluntarily under current conditions.

Additionally, we have just suggested that measures to induce migrants to leave of their own

volition may not work and may actually have an adverse effect on return. So where does this

leave us?

This is where we must admit that we have reached the limits of our study. It is clear from our

study is there is a significant gap between the objectives of the Dutch legislation and policies

towards voluntary return and the interests of migrants with HIV. This gap can be assumed to

be undesirable both from the perspective of the host state and of the migrants themselves. The

state, for example, is confronted with considerable costs due to the presence of uninsured

migrants living with HIV (see box 7), and the potential public health implications of the

presence of groups of HIV-positive migrants who are ‘off the radar screen’95. Alternatively,

94 As discussed in chapter three, there are also limits to this certainty. Residence permit on medical grounds are

generally awarded for a maximum period of one year, and have to be renewed. This means that – at least until a

migrant receives a permanent residence permit – uncertainty will remain about whether or not a migrant can stay

in the Netherlands for a prolonged period of time.

95 As suggested earlier, there may be a significant group of migrants living with HIV without a legal status, who

have not sought treatment and therefore are not registered in the hospitals.

107

migrants living with HIV may face serious consequences for their mental and physical well-

being when they continue to live in the Netherlands without a legal status. Providing

assistance to the voluntary return of migrants living with HIV may provide a solution for this

clash of interests in some cases, but – under current conditions – is unlikely to be the answer

in many others. It will therefore be essential that further research and debate take place on

what governments, migrants living with HIV and other stakeholders can do to find durable

solutions.

108

109

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1-22

IOM International Organization for Migration

IOM

P.O. Box 10796

2501 HT The Hague

The Netherlands

HEALTH, HOPE

AND HOME?

The possibilities and constraints of voluntary return

for African rejected asylum seekers and irregular

migrants living with HIV in the Netherlands

HEALTH, HOPE AND HOME?

The legitimisation of the policy objective of sustainable reintegration

Chapter

Jan 2022

Migration From and To Ghana: A Background Paper

Article

Full-text available

Dec 2010

projects to promote poverty reduction globally. DFID provided funds for this study as part of that goal but the views and opinions expressed are those of the author(s) alone.

Understanding Voluntary Return

Article

Full-text available

Jan 2004

From access to adherence: the challenges of antiretroviral treatment. Studies from Botswana, Tanzania and Uganda

Article

Full-text available

Jan 2006

Reconceptualizing the Myth of Return: Contuity and Transition Amongst the Greek-Cypriot Refugees of 1974

Article

Mar 1999

Roger Zetter

The contrasting concepts of refugee transition and the myth of return are used to investigate some of the strategies and processes by which refugees adjust to the meaning of exile, the dilemmas of their status and, especially, the meaning of home. The paper is based on longitudinal data collected over the last decade from Greek-Cypriot refugee households in Cyprus. The paper argues that refugees seek to retain, to a greater por lesser degree, the social and cultural attributes of the past, whilst adjusting to future needs in exile and aspirations of return. This relationship is mediated by the present conditions of exile—refugee assistance programmes and the political discussions about return. Since the refugees are cut off from the material and symbolic representation of the past, this is reconstructed and preserved in a mythical form which becomes the basis for subsequent strategies of adjustment and transition examined in the paper. Two contrasting positions are suggested—‘reproduction’ of the myth and ‘replacement’ of the myth—which are associated with contrasting aspirations of ‘belief’ in return and ‘hope’ of return. The pape examines some of the consequences of the strategies used to reconstruct the triangular relationship between the pase, the future and the present.

Towards a better embeddedness? Monitoring assistance to involuntary returning migrants from Western countries

Article

Facing HIV in The Netherlands: Lived experiences of migrants living with HIV

Article

Jan 2008

The Social Networks of Asylum Seekers and the Dissemination of Information About Countries of Asylum

Article

Jan 2002

When Forced Migrants Return 'Home': The Psychosocial Difficulties Returnees Encounter in the Reintegration Process

Article

Jan 2003

Tania Ghanem

IOM International Organization for Migration

Article

Access to Health Care for Illegal Immigrants in the EU: Should We Be Concerned?

Article

Sep 2004
Eur J Health Law

Román Romero-Ortuño

Summary The presence of illegal immigrants in EU countries is increasing despite consider- able immigration policy efforts over the last years. EU Member States have responded by strengthening their fight against illegal immigration, with different multi-level measures that include the curtailment or denial of social security rights such as access to publicly funded health care. Although significant differences exist between Social Health Insurance and National Health Service countries with regard to legislative provisions, access to health care for illegal immigrants is generally limited to situations that are life threatening (emergencies) or pose a risk to the public health (i.e. infectious diseases). In practice, strong barriers to access exist even in those situations. Because health care needs of illegal immi- grants are not being met, access to health care for this population should be an issue of utmost concern to both policy makers and the public. National legislations and implementation practices need to be upgraded in order to grant illegal immi- grants effective access to health care, as mandated by Human Rights laws. That is feasible and not necessarily incompatible with current immigration policies.

HEALTH, HOPE AND HOME? The possibilities and constraints of voluntary return for African rejected asylum seekers and irregular migrants living with HIV in the Netherlands

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