Yesterday's problem: migration and AIDS

Migrant labour is one of the more problematic remnants of our Apartheid past, especially when considering its impact on HIV transmission. MRC-supported research shows that the problem is more complex than anticipated, and asks: should the mining industry act? LORENZO RAYNARD and ELMIEN WOLVAARDT report.

The highly acclaimed film, Yesterday, produced by the Durban film producer Anant Singh, tells the story of a young HIV-positive mother, from the Bergville area of KwaZulu-Natal, who was infected by her migrant mineworker husband.

Although this is an all-too-common scenario, it does not tell the whole story. MRC-supported researcher, Prof Mark Lurie, has found that the direction of spread of the epidemic is not only from returning migrant men to their rural partners, but also from women to their migrant partners.

Historically, it is not difficult to see how migrant labour has played a major role in the spread of HIV in southern Africa. 'Take millions of young men, remove them from their rural homes, house them in single-sex hostels, give them easy access to sex workers and alcohol and little or no access to condoms. Send those men back to visit their rural partners every once in a while and pretty soon you will have a major HIV epidemic,' says Prof Lurie.

This pattern of circular migration, so prevalent throughout South Africa, did not develop out of chance. On the contrary, its design was an integral part of government policy for more than a century. The aim of industry, and the colonial and apartheid governments, was to provide cheap black labour to the country's agriculture, mining and commercial sectors, while absolving companies of the responsibility of caring for their workers by simply returning the old and the sick workers to their rural 'homelands'.

It was against this background that Prof Lurie set up a research project in KwaZulu-Natal, the province with the highest HIV prevalence at the time.

He wanted to understand the role that migrant labour plays in the spread of HIV and STIs, and explore interventions for migrants and their partners.

Prof Lurie and his team measured the HIV status of both migrant and non-migrant couples in the region. 'We followed people who were migrants, and, by definition, hard to find and even harder to follow,' said Prof Lurie. 'Fortunately, we had significant funding from the Wellcome Trust which helped us to set up teams of field workers who were able to track and follow participants.

'We had a talented team that took the time to get to know people. Because we followed people over a period of time, we were able to build relationships with them, and we offered free testing and treatment for other STDs,' he said.

As expected, couples where the man was a migrant worker were twice as likely as non-migrant couples to have one or both partners infected.

What was surprising was that, in nearly a third of the cases where only one of the partners in a couple was HIV-positive, it was the woman who was infected, and not her migrant partner.

Because the migrant men in these cases weren't HIV-positive, it is nearly impossible that they could have infected their female partners.

'Although this confirms the importance of migration as a risk factor for infection in both men and women, it changes our understanding of the way in which migration enhances risk. We found that migration is a risk factor not simply because men return home to infect their rural partners, but also because rural women - both partners of migrants and partners of non-migrants - are likely to become infected from outside their primary relationships,' says Prof Lurie.

It is clear that a system that separates families for extended periods of time still has a direct link to the growth of HIV and AIDS in our nation.

'Where possible, interventions should deal with migrant couples as a social unit and not just with one or the other partner,' says Prof Lurie. These interventions could include couple counselling, more aggressive treatment of STDs, antiretroviral therapy for HIV-infected partners, and education messages aimed at couples.

'But on a bigger scale, the very tradition of migrant labour might need to be addressed, says Prof Lurie. 'Mining companies in particular should be making real attempts at providing family-friendly housing - at present only about 2% of miners live in such accommodation.'

This would give rural women, and their children, the opportunity to remain with their partners - which could go a long way to reducing the risk of HIV-infection for both individuals in the partnership.

Research ethics
The MRC Ethics Committee has stipulated that the dignity of the individual and the importance of informed consent have to be strongly emphasised in research studies, particularly since informed consent is entrenched in our Constitution's Bill of Rights. Prof Mark Lurie's study on migrant labour was respectful of the research participants' human rights in the following important ways:

• Participants were informed of why and how the study was conducted, and confidentiality was ensured.
• All HIV-testing was done voluntarily and included pre-and post-test counselling.
• Participants were able to learn their HIV-results if they chose to.
• Condoms were made available at every visit with the participants.
• Free treatment was given for symptomatic and laboratory-diagnosed sexually transmitted infections on ten-day follow-up visits, and symptomatic ulcers and discharge were treated on enrolment in the study.