A long paper trail to accessing ARVs

France's tighter immigration policies are making it even harder for HIV-positive undocumented migrants to survive, despite laws allowing foreigners who are ill the right to stay in the country to seek treatment.

In theory, France treats its HIV-positive immigrants well - they are entitled to free healthcare, and even those whose residence status is still being determined get free treatment after three months if they cannot afford to pay.

But advocacy groups are concerned about the tougher stance taken by French immigration control officials, and the rising number of deportations of people living with the virus. They warn that the clampdown on immigrants and so-called "medical asylum" seekers will force HIV-positive people underground, further threatening their health and that of wider society.

This trend all the more worrying, considering that the HIV prevalence rate among illegal foreigners is 19 times higher than among the French population as a whole, the Paris-based charity organisation, Médecins du Monde (Doctors of the World in English), noted in a 2005 report.

Crackdown on illegal migrants

At the beginning of 2007, the French Ministry of Interior set a target of 25,000 illegal migrants to be expelled. Police, human rights groups, and even some officials, have argued that establishing arbitrary quotas for expulsions would not be effective, but the Ministry recently reaffirmed that this goal had to be reached.

French legislation prohibits the deportation of foreigners who are ill and will not have acceptable access to treatment in their home countries. Between December 2006 and March 2007, according to organisations working with migrants in France, at least three foreigners whose HIV-positive status had been proven, were deported, which led to their antiretroviral (ARV) treatment being interrupted.

Photo: Act-up Paris

Act-Up - fighting the "medical asylum" myth

Two of the three people were Africans. One has been allowed to return after intense lobbying by activists, but declined to be interviewed. The second HIV-positive African migrant cannot be traced since returning to his home country. The third was Fatma Yilmaz (not her real name), a divorced Turkish national, who received a document ordering her to leave France in February this year.

On 15 March she was arrested and held with no access to a doctor, despite her HIV-positive status being known to public health medical inspectors. "I was offered no food or water," she told IRIN/PlusNews. "I didn't have my medication, so I broke my treatment cycle."

Yilmaz was put on an aeroplane to Turkey and deported. Her family, who live in a small town, took her in and she immediately tried to restart her treatment, but her local health centre refused to treat her.

She had no means to make the journey to Ankara, the capital, or go to a private health clinic, but the director of her local health services told her the medication was too expensive, and she was "still standing, you're not dying".

Almost six months later, after her lawyer and lobby groups intervened, the French authorities recognised that her appeal was valid and allowed her to return to France. Overall, she missed out on nearly six months of treatment. Any interruption in ARVs can lead to the HI-virus becoming resistant to the medication, hastening progress towards AIDS.

Adeline Toullier, from the French NGO, AIDES, noted that assessing the migration status of HIV-positive applicants was now done on a "case by case" basis, which sometimes led to situations such as that of Fatma Yilmaz.

When government officials were asked to comment on the case, they maintained that the mistake was due to medical confidentiality, as administrative services in charge of deporting undocumented foreigners do not have precise information on the illness the migrants are suffering from.

"We get a report from a professional [the examining doctor] which tells us whether the illness affecting the person can ... be treated in their own country, or not. With reference to this information, the administration makes the final decision," said an official, who did not wish to be named.

"If the doctor says that [the ill migrant] can get the care they need in their own country, there is no reason to believe that the health [or] the life of the person is at risk."

Struggling to survive

The laws may be in place, but a recent survey by Médecins du Monde, found that "68 percent of foreigners do not know it is possible to get free HIV treatment in France".

Migrants generally get their information from the community or people close to them, said Guy Delbecchi, nursing executive for the Medical Committee for Exiles (COMEDE) but, for those who are unwell, overcoming the information barrier is just the beginning of a lengthy process bogged down in red tape.

68 percent of foreigners do not know it is possible to get free HIV treatment in France.

Once they receive state medical assistance (with the French acronym AME), migrants with HIV sometimes experience discrimination by health professionals.
"Recently a [migrant] man showed me his AME entitlement, which was all in order, but told me that it hadn't worked at the chemist. He had tried three or four different chemists," but they had refused to give him his medication, Delbecchi told IRIN/PlusNews.

People with a long-term illness are entitled to stay on a residence visa but it has become more difficult for HIV-positive Africans to qualify for that vital residence permit, which guarantees access to social services and provides some sense of stability.

To get a residence permit, immigrants must obtain a one-year temporary residency card or, if this is not possible, they must get authorised provisional residency (called an APS in France), which is valid for three to six months. In practice, the APS is most commonly issued, sometimes repeatedly, which leaves people in a state of ongoing instability.

Serge (not his real name), from Burkina Faso, who is in his fifties and HIV positive, told IRIN/PlusNews that he has "been very lucky". "I had help very early on from Act'Up [a lobby group working for the rights of people with HIV]", he explained.

After being in France for 18 months, and constantly being issued with short-term temporary visas, "a friend from Act'Up immediately stepped in to help. He talked [to the officials] and they agreed to give me a residency card for a year. If I had been alone, I would never have had the courage to argue it," he said.

According to COMEDE, the main problem with the APS is that it is only issued with a work permit in 60 percent of cases, and the right to work is indicated by a simple handwritten note on the document. Serge said, "Nobody wants to employ people with that, and you can't even open a [bank] account."

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