Research Report Border Health: Challenges on the Frontier of Health and HIV/AIDS Key Points • Factors, such as poverty and discrimination, that affect health and HIV transmission may be more intense at international borders than in non-border regions. • Mobile populations and people in conflict situations are at risk of HIV transmission in part due to lack of access to health services and to increased physical, social, and financial barriers. • Cross-border trade and migration may contribute to the development of HIV drug resistance if medication regimens are interrupted. • High prevalence of risky behavior, such as substance abuse, along borders increases risk of HIV transmission. • Poverty and instability undermine the development of an effective infrastructure to prevent the spread of HIV.
• Community involvement in development and implementation of border programs is crucial to successful interventions. • Collaborative programming and buy-in among stakeholders at community, national, and international levels has the potential to mitigate the impact of HIV in border communities. Introduction
As this report will show, when exploring the effects of these dynamics on the HIV/AIDS Border health can have many interpreta- pandemic, borders cannot be ignored. Not tions. Cross-border health risks, according only are these areas often hotspots of HIV to the World Health Organization (WHO) prevalence and incidence, but they present a are “risks to human health that cross national microcosm of the complex social, economic, borders. Examples include risks from climate environmental and political challenges that change and the illegal drugs trade, as well as characterize global public health in the 21st cross-border movements of people, which can century. lead to the spread of communicable diseases such as HIV/AIDS, malaria, TB and influen- Factors affecting health at borders za.” Today more than 2 million people cross borders each day. The time it takes to travel is Borders can serve as sites where disease transnow often shorter than the incubation period mission, and factors that influence transmisof certain communicable diseases.1 sion, are intensified; this has an adverse effect on neighboring countries.2-9 A multitude of In this report, border health refers to health factors come into play when considering in the regions between nations (and the sur- health in cross-border regions, including the rounding towns and lands); the unique chal- legal and financial vulnerability of people who lenges faced in these areas that are a result cross the border to find work, the unscrupuof movement and transition are highlighted. lous nature of some business transactions
that occur in these areas, and the physical risk of increases one’s discretion and isolation.13 harm for those who either cross the border or make a living in the cross-border region. Migration may be linked to substance abuse, including injecting drug use.3, 14, 15 For example, One of the most significant diseases, in which studies conducted in China show that migrants these and other factors play a role in government moving from rural to urban areas report frequent responsiveness, program development and service substance abuse and higher rates of sexually transdelivery is HIV/AIDS.10 In addition to the personal mitted infections (STIs). As seen in some parts of health threat of HIV/AIDS, the disease represents Asia, this pattern advances a bidirectional flow of a threat to countries by targeting men and women HIV between bordering countries.2 during their prime work years and, given the chronic nature of treatment, costing resources Conflict over an extended period of time.11 Globally, the main mode of HIV transmission is sexual contact, The dynamics of conflict – unsafe or unstable livwhich may be consensual or coerced, may include ing conditions, food insecurity, threats of violence, violence, and may include both hetero- and homo- unforeseen situations, frequent upheaval, and trausexual partners.2 In border regions, transmission matic experiences – often produce enclaves of via sex and injecting drug use are problematic. internally displaced persons (IDP) and refugees along the border of the countries in conflict. This was observed during the 2008 riots in Kenya and Factors that affect health continues as a result of the genocide in the Darfur in border towns: region of Sudan.16-18 xx Migration Because they are “physically, socially, and finanxx Conflict cially insecure,” refugees are, by default, vulnerxx Trade economies able to infection with HIV and other sexually xx Substance abuse transmitted infections (STIs).10 Conflict situations, xx Poverty which inherently introduce issues of displacement, xx Stigma & discrimination food insecurity, and poverty, are conducive to the spread of HIV/AIDS, e.g., “survival sex” for food or other basic provisions or turning to prostitution Migration as a means of employment.10, 16, 19 Refugees who The 2009 World Health Assembly in Geneva have lost their livelihoods and become removed addressed the issue of cross-border and overseas from their families and social networks are at an migration of workers, and its implications for the increased risk for HIV and STIs if they engage in HIV pandemic. While migration is not a risk fac- sex for money, even if not considered prostitutes; tor in itself, UNAIDS reports that migrants are they are also less empowered to protect themselves often the victims of harassment, discrimination, from sexual assault.20 As women are more physiand exploitation, both at home and abroad. Basic ologically vulnerable to HIV through heterosexual rights are not ensured and they are underpaid, transmission, their risk of infection is greater than which weakens their ability to obtain access to that of men. 2 Refugees are also often the victims of health services and increases their vulnerability to discrimination, where local populations may assoHIV infection.2, 12 ciate them with an influx of social, economic, or health issues, regardless of whether these percepWhen migrants come to a new country, they are tions are true.10 often unfamiliar with the health systems in place. They may live in crowded or unsanitary living situ- Refugees living with HIV/AIDS may not maintain ations. Additionally, language barriers likely limit treatment or support, as they are separated from their ability to seek services and employment. In their health care provider and consistent source certain cases, there is a fear of deportation that only of medication.21 An interruption of antiretroviral 2
therapy (ART) puts the person at risk of developing drug resistant strain of HIV, which subsequently will make the disease harder to treat.22 In addition, refugees may not have access to nutritious food, which is particularly crucial for those who are HIV-positive.
drugs users are often higher than in the general population. A study in West Bengal revealed that rates of IDU were higher in the border region than further inland, affecting both the rates of HIV and hepatitis C virus prevalence in eastern India and bordering regions of neighboring countries.3
Formal and informal trade economies
Truck stops and boat harbors are signature features of border towns. At these sites, truckers and fishermen trade goods and services en route or gather as they await customs processing during border crossings.6 Borders often provide an opportunity to sell, purchase, or trade goods unavailable in neighboring countries, or serve as entry points to deliver goods further inland.23 They may also offer venues for employment for migrant or displaced populations.
Poverty affects the entire spectrum of factors that influence population health. People living in or passing through border regions may have limited resources and no source of additional resources. Regions of vast poverty, like borders, also become home to HIV-affected orphans and vulnerable children (OVC), as well as street children and refugees who are frequently at risk of exploitation and HIV transmission.28 In countries with high HIV prevalence, many children have lost one or both parents to HIV/AIDS; these children may be left to fend for themselves and care for younger siblings.29
Alongside the more formal economy there is an informal trade economy, where deeply rooted gender and power inequities place women and children at risk for sexual exploitation.24, 25 Issues like trafficking are fueled further by conflict situations, poverty, weak laws and policies and orphanhood.24 In these settings, IDPs, refugees or migrants may enter into agreements with dishonest players who financially exploit their situations, exacting money in exchange for promises of passage to another country, confiscating passports or using other coercive measures to benefit themselves at the expense of people in desperate circumstances.26 Substance abuse Border towns, as points of trade, are often rife with drug trafficking and substance abuse. A recent UNAIDS report noted that people residing in border communities have higher rates of injecting drug use or intoxication than the general population.2 Substance abuse is associated with unsafe sex, which puts the person at greater risk of HIV infection. Injecting drug users (IDU) are considered a mostat-risk population (MARP) in terms of HIV transmission, as intravenous transmission of HIV is more efficient than sexual transmission.27 In countries where HIV is prevalent, rates among injecting
Poverty is also associated with environmental challenges that play a role in overall community health, particularly water, sanitation, and hygiene.30, 31 For example, if one country maintains a sewage system on their side of the border and the neighboring country does not, the lack of infrastructure will inevitably affect the health of both communities. Mexican border towns do not have access to clean water; one-third of homes are not connected to sewage systems and only one-third of the wastewater produced is treated prior to being released.31 Poor hygiene and environmental conditions can undermine a personâ€™s health and, in the case of an individual living with HIV/AIDS, put them at greater risk of opportunistic infections.32 Stigma and discrimination As with migrant populations, marginalized populations are often targets of discrimination with regard to HIV/AIDS.10 The combination of being in a marginalized group and living in or passing through a border town makes it unlikely that health care services will be available. National foreign policies may play a role in fostering or facilitating HIV-related discrimination. Citing risks to public health associated with an open-door 3
travel policy, many countries have responded to the threat of HIV by imposing travel restrictions as a method of control.1, 9 However, travel restrictions are a potent form of discrimination against people living with HIV/AIDS (PLWHA). Although it is within the jurisdiction of every nation to control borders and immigration, these laws should not provide an avenue for discrimination against individuals living with HIV. UNAIDS reports, “The International Guidelines on HIV/AIDS and Human Rights state that any restriction on liberty of movement or choice of residence based on suspected or real HIV status alone, including HIV screening of international travelers, is discriminatory.”33 Other factors
West Africa’s HIV prevalence has not reached the rate of its neighbors to the south; however, there are issues in need of attention. Truckers often spend extended amounts of time at border crossings awaiting clearance, resulting in ample opportunities to engage in sexual activities in which they or others are at risk of HIV infection or other sexually transmitted infections. The HIV prevalence rates of truckers and sex workers in these large border towns are significantly higher than national averages – for example, estimates of HIV prevalence in Togo is 3.3 percent, whereas the prevalence rates among truckers and sex workers in Lomé, a border town in Togo, are 33 percent and 80 percent respectively.6 Abdijan-Lagos Corridor
Although some people cross national borders permanently to relocate in another country, others may cross on a regular basis. Many people cross borders to visit relatives who live in neighboring countries. 9 Others seek to buy or sell goods, such as food or oil, at prices that are more affordable than in their country of origin.5, 34 Job requirements result in some workers, such as truckers, routinely crossing national borders and traveling routes that are characterized by the formal and informal markets of border towns. This cross-border movement increases in times of economic crises.35 West African Intervention With respect to HIV infection, people may cross the border to seek cheaper medications or free and anonymous testing services that are not available in their villages.8 This may result in shortages of medicines at clinics, as governmental treatment programs may not have accounted for the crossborder influx and thus do not have the capacity to supply medicines for these populations.34 This can also lead to the growth of an informal pharmaceutical market that promotes and distributes counterfeit or substandard medications.53 Regional perspectives West Africa
Originally funded and established by the World Bank and currently supported by the Global Fund, the Love Life Caravan initiative is implemented by the Abdijan-Lagos Corridor Organization. Running between Lagos, Nigeria and Abdijan, Côte d’Ivoire, this caravan, stocked with voluntary counseling and testing (VCT) counselors and a profusion of condoms, travels the most trafficked highway in West Africa, with an estimated 14 million travelers per year. The caravan’s goal is to spread awareness through HIV prevention messaging to 4 million people across five countries. To accomplish this, the program calls for strong governmental commitment and the involvement of stakeholders from national to community levels. Technical assistance for the program was provided by the World Bank.6,
National HIV prevalence of selected countries: Benin (1.2 7 percent), Côte d’Ivoire (3.9 percent), Ghana (1.9 percent), Nigeria (3.1 percent), Togo (3.3 percent).36 The target population of this initiative includes truckers, sex workers, travelers, border commu4
nities, and military and customs officials. Since its inception, the program has reached hundreds of thousands of people, distributed 8.8 million condoms (by 2007), established 600 additional condom distribution sites, provided VCT services to 28,000 people (by 2007), increased knowledge of HIV/AIDS among target population; increased reported condom use among target population; strengthened the antiretroviral therapy (ART) referral system; and improved waste management in project areas.6, 7 In addition to delivering needed services and raising awareness, key program components include: building partnerships; aligning program goals with the national strategic plan; garnering government support; insuring community involvement and ownership, including PLWHA; using local languages to reach the maximum number of people; and monitoring for program effectiveness.6, 7
East Africa National HIV prevalence of selected countries: Burundi (2 percent), Democratic Republic of Congo (4.2 percent), Djibouti (3.1 percent), Ethiopia (2.1 percent), Kenya (6.7 percent), Rwanda (2.8 percent), Sudan (1.4 percent), Tanzania (6.2 percent), Uganda (5.4 percent).36 East Africa has been a focal point of the HIV response, particularly with early gains made by Uganda through their strategic response to the epidemic at the country level.37 In recent years however, HIV incidence among heterosexual couples has increased in Uganda and transmission among high-risk populations continues to be an issue across East Africa.2 The communities along the East African Northern Corridor, also known as the â€œHIV corridorâ€?, remain necessary targets of intervention. The cities and towns on these routes are dynamic economic hubs. People are drawn to
East African Northern Corridor
these areas and may engage in high-risk sexual behavior, which frequently involves mobile workers such as truckers and sex workers. As a result, a high prevalence of HIV infection is observed along these routes among these populations.6
ROADS is a community-driven, community-led program that addresses the underlying factors driving HIV risk and inhibiting uptake of services. These include economic inequality, which can lead individuals to adopt high-risk survival strategies; alcohol and other substance abuse, which East Africa Interventions can undermine HIV prevention, care and treatment efforts; and gender-based violence, which can Since August 2005, the Regional Outreach inhibit women from accessing such services as HIV Addressing AIDS through Development Strategies counseling and testing.38, 39 (ROADS) Project, managed by Family Health International and funded by the U.S. Agency for The core of ROADS programming is a communiInternational Development, has extended HIV and ty-organizing approach—the “cluster” model— broader health services along the major transport designed to dramatically expand grassroots parcorridors of East and Central Africa. Many cor- ticipation in locally driven, sustainable programs of ridor communities, including border sites, have their own design. With technical assistance from historically been underserved by national programs ROADS, clusters of indigenous volunteer groups and health systems. The combination of economic (women, youth, PLWHA) identify their needs and inequality, concentration of truck drivers and other plan and implement HIV interventions together, transient workers, hazardous sexual networking, drawing on many of their own resources (volunhigh levels of alcohol abuse, and dearth of qual- teer time, facilities such as school halls) and using ity health services have created an environment donor funding as a catalyst, not a mainstay. This of elevated risk for HIV. Major corridors targeted type of coordination minimizes duplication and by ROADS have included the Northern Transport gaps. The groups inform ROADS of their training Corridor linking Kenya, Uganda, Rwanda, Burundi needs; ROADS provides technical training to build and the Democratic Republic of the Congo; the their capacity and basic funding for activities.38, 39 TanZam Highway linking Tanzania and Zambia; the Addis Ababa-Djiboutiville Corridor linking In 2009 alone, the program trained almost 6,000 Ethiopia and Djibouti; and several key transport individuals in HIV prevention, established about routes in Southern Sudan. ROADS is also set to 1,500 condom outlets, promoted HIV prevention begin working along major transport routes linking to over one million people, administered ART to Mozambique with South Africa and Zimbabwe.38, over 2,000 people, and reached out to over 26,000 39 OVC – an effect several-fold higher than in 2006.40 Participants recognize the need for and value this ROADS has developed a unique concept—SafeT- program, and as ROADS makes a community-drivStop—to brand and link facility- and community- en approach a priority, it not only sustains itself, based HIV and health services targeting mobile and but has grown to include new countries.38, 39 sedentary populations. A key component of the program is a regional network of branded SafeTStop Another effort underway at the Ministerial level in Resource Centers providing HIV education, coun- East Africa is the Great Lakes Initiative on AIDS seling and testing, condoms, STI diagnosis and (GLIA), an intergovernmental organization estabtreatment, referral and other services for truck lished in 2004. In conjunction with each country’s drivers and other mobile workers. The alcohol-free National AIDS Coordinating Committee, GLIA centers also offer satellite television, billiards and works with leaders in Burundi, the Democratic other games to attract the primarily male audi- Republic of Congo, Kenya, Rwanda, Tanzania, and ence away from bars and other risky environments. Uganda. Although full implementation of this straSpecial promotions, including screening of World tegic plan awaits additional funding, the program Cup 2010 matches, are developed to counteract the targets transnational populations affected by HIV/ isolation and loneliness that characterize life on the AIDS. Objectives of this initiative are to build the road and contribute to risky sexual behavior.38, 39 capacity of and implement activities to combat 6
HIV/AIDS effectively by improving access to prevention, care, and treatment for mobile and vulnerable populations; and to develop common regional HIV/AIDS prevention, care and treatment policies and best-practices for use by key stakeholders in each participating country. Efforts will be made to integrate protocols with other health issues, such as tuberculosis, and services will include outreach to refugee camps, long-haul truck drivers, and other cross-border populations.41 North America National HIV prevalence of selected countries: Mexico (0.3 percent), United States of America (0.6 percent).36 It is difficult to account for and track transient populations, who often fall through the cracks in the health system. Border communities exemplify this situation, as reflected in the case of the US-Mexico border, where northbound crossing is estimated at over 400 million people each year.31 This frequent movement significantly affects the HIV epidemic in Mexico, particularly in terms of IDUs. UNAIDS estimates that 29 percent of the more than 2 million Latin Americans who inject drugs are infected with HIV. These populations with high HIV prevalence are in the southern cone of South America and in the northern part of Mexico, along the USA border.2 In some parts of Mexico, HIV prevalence rates among Mexicans who had lived in the United States were five-fold higher than for those who had not lived in the U.S.
North America Interventions To address this gap, Population Services International (PSI) Mexico, in conjunction with the Mexican National HIV/AIDS and STI Program (CENSIDA) is running a harm-reduction program in the towns of Mexicali, San Luis Rio Colorado and Hermosillo. These programs improve access to clean needles, condoms and other health services, and promote sharing of information through peer education about preventing the initiation of new intravenous drug users. Their health promotion teams operate needle exchanges, distribute condoms and Prevenkits (contains a needle/syringe, cotton, condoms, and HIV prevention information); provide referrals for IDUs for HIV counseling and testing and treatment of STIs; and teach IDUs how to sterilize needles properly, among other activities. The program also serves to address the issue of stigma and discrimination against IDUs among health care providers. It endorses the promotion of communications campaigns to address the social norms around needle sharing, such as “No la roles” (Don’t pass it on), “No enganches” (Don’t get someone hooked) and “El Amor no lo comparte todo” (Love doesn’t share everything) at “shooting galleries” and other places in the border towns. The program tailors its interventions to address gender differences, as program implementers observed that female IDUs are a more vulnerable population than their male counterparts. To date, the team has observed increases among their target population in knowledge, attitudes, and beliefs surrounding injecting drug use.15
While the presence of IDUs in the border area is high, the services available are minimal. Mexico has legislation in place for HIV treatment, which stipulates that only specially trained personnel can administer ART. As such specialists are limited, the poorer rural areas consequently lack the capacity to reach those in need effectively. Specific services for IDUs and HIV exist in larger border towns, but are scarce in mid-sized and smaller towns, where one tends to find limited and basic services.42
PSI Mexico harm reduction program in Mexicali 7
without health facilities to serve local residents. Those able to cross the border into neighboring National HIV prevalence of selected countries: Burma (0.7 Thailand, China or India may find services in those percent), Cambodia (0.8 percent), China (0.1 percent), India countries. Much of the challenge is due to military (0.3 percent), Thailand (1.4 percent).36 restrictions for humanitarian assistance and lack of military support for health infrastructure in The Thailand-Cambodia and Thailand-Burma bor- Burma’s border regions.14 der regions have drawn much attention recently, since this region has faced issues related to several In addition, many people cross the border into infectious diseases – HIV, tuberculosis and resis- Burma seeking illicit drugs. Burma is one of the tant strains of malaria.4, 43-45 Exacerbated by the largest sources of opium and heroin in the world. political instability of Burma, providing compre- 14 This has led to a high occurrence of injecting hensive health coverage has been complicated and drug use in Burma, which has affected HIV rates not only in Burma, but also in neighboring China challenging. Vast areas of the country are left and India. The Indian state of Manipur, bordering Burma, has the highest rate of drug users.14 Burma and her Bordering Countries Furthermore, several states and provinces in China and India that border Burma were found to report the highest prevalence of HIV in those respective countries.45 Neglect by the junta, the military regime, to address this issue effectively leads to difficulties for neighboring countries as well. Challenges presented by the power struggle with the military and the lack of infrastructure, particularly for healthcare, have limited programs for HIV in Burma. Interestingly, however, efforts have been made to address the issue of malaria. Southeast Asia Intervention
Available from: http://www.appliedlanguage.com/maps_of_the_world/ map_of_burma.gif
Grassroots efforts to improve malaria treatment and control on the Thai-Burmese border have been led by the Global Health Access Program (GHAP) in conjunction with Johns Hopkins University and other partners. They initiated a pilot project at four sites along the border, targeting 1,800 internally displaced peoples (IDPs) in Karen district. The intervention has grown to reach 60,000 villagers in about 140 villages along three of Burma's borders – Thailand, China and India.46 While there have been challenges associated with the projects, overall results indicate that through community involvement – in this case, the target population of IDPs – local residents whose care is overlooked at the national level can benefit from local outreach efforts. Similarly, residents can benefit from behavior change messages to lower incidence of malaria and maintain health-seeking behaviors to protect themselves and their families. These efforts
are encouraging in that a similar model of care and region, but the establishment of diverse partoutreach could extend potentially to HIV/AIDS in nerships is a large component of demonstrated Burma. successes – from local grassroots organizations to international stakeholders, cooperation and One long-standing clinic on the Thai border – Mao engagement are essential. Tao Clinic – has been in operation since 1988. Supported by GHAP, it has expanded from focus- Recommendations ing on outreach for refugees to include HIV counseling and testing, dental and medical care, phar- Border health assessment is needed early and maceutical access, and surgical and other services. often, before an epidemic has a chance to spread. This clinic has trained more than 800 health work- Governments and local entities need to become ers and, in 2006, saw more than 100,000 cases.47 engaged to address HIV in cross-border settings Consistent outreach and treatment to PLWHA effectively and at all levels. Intergovernmental is vital, especially given that new recombinant efforts can minimize gaps and/or duplications in strains of HIV have been identified in Burma at outreach and service provision and consolidate high rates.4 While new drug combinations may resources; this cooperation can reduce the problem preserve the effectiveness of some treatments, drug of inaccurate statistics related to HIV incidence resistance (particularly to multiple drugs) under- and prevalence in both nations by accounting for mines treatment efforts and greatly challenges a those who test positive or seek services in a neighhealth system’s capacity to respond effectively to a boring country.8 Working with transit authorities rising epidemic.43 It also necessitates the develop- to coordinate efforts along main highways and ment of new drugs, which take many years to reach transport corridors, including seaports and docks/ the market. harbors (e.g., Lake Victoria) is essential for proMany challenges exist in border health in this gram and policy uptake and institutionalization.
Other Initiatives Angola-Namibia border Angola and Namibia have collaborated on border-based programs related to HIV and malaria, two of the major infectious diseases in the region. The countries have sponsored activities for implementation and set up national, provincial and municipal monitoring systems for project follow-up and information exchange. Other efforts between these nations include: synchronizing national immunization days against polio and activities for residual spraying; increasing coverage of drugs for tuberculosis (TB), AIDS and malaria; harmonizing protocols for disease treatment along the border; and producing educational materials for use along the border.48, 49 Afghanistan-Pakistan-Iran border The United Nations Office on Drugs and Crime (UNODC) has recently launched an initiative as part of the UNAIDS Outcome Framework 2009-2011. This comprises a cross-border regional network of HIV services for drug-injecting Afghani refugees in Iran and Pakistan to ensure that they have access to care, treatment and prevention services when they return home. UNODC awarded grants to two local NGOs that, in conjunction with health care workers and women prison employees in Afghanistan border provinces, underwent capacity building training. Knowledge of HIV among IDUs is low and prevalence in the major cities has increased from 3 percent to 7 percent. Eighty percent of the IDUs in the program were mobile, having changed residence at least once, mostly due to conflict. This program hopes to address these issues and halt the rise in transmission.50 9
By consulting with residents and key players who live in border towns, a more accurate picture of the gaps in programming can be drawn. 4 Other recommendations include:
Border health tends to be subsumed under issues of migration and conflict. Although these issues are important and need careful study, specific atten• Programs should integrate HIV prevention tion should be paid to borders. While programs and treatment efforts into other ongoing addressing border health do exist, they are relacross-border collaborations, with shared tively rare and substantive information on border infrastructure increasing the chance of sus- health is scarce. tainability.49 There are lessons to be learned from models used to address other disease The effect of other infectious diseases - such as malaria, tuberculosis, and neglected tropical disburdens, such as malaria. eases - on the HIV pandemic is an area of concern. • Countries need to address the issue of In addition, epidemics like avian flu and H1N1 mobility in revising their national AIDS demonstrated that regional and global efforts are frameworks, particularly in Asia where needed to address, contain, and reverse emergcross-border migration is frequent. Some ing health concerns.4, 51, 52 Furthermore, regional countries, including Bangladesh, India, responses are important – whether in the regions Nepal and China, have already taken action mentioned above, borders in Eastern Europe or in other parts of the world – and priorities for border in this regard.2 control will no doubt need to be addressed, as • More research is needed to identify the HIV issues that affect one nation affect the region as a prevalence and incidence among these high- whole.53 risk groups along the border. Multilateral agencies in global health would benefit In this age of high mobility, globalization and from requesting this type of data from unpredictable economies, borders have become hot spots for information. Consistent and susnational ministries of health. tained funding is needed to incorporate elements • Grants and other funding mechanisms of collaboration within and between countries; to would benefit from incorporating elements integrate border health programs within existing of interstate collaboration. This would structures; to encourage engagement and parallow border health to be a natural line ticipation of affected communities (including local NGOs and PLWHA); and to address regional item when prioritizing programming. health concerns, such as reducing the impact of HIV/AIDS. Inter-regional programs are not a new concept, but their relevance is growing; many programs are demonstrating positive outcomes, even Key components for effective interventions in their early stages. The recognition that crossborder solutions can be developed and employed Strategic partnerships among multi-lateral, to address cross-border health concerns will facilibilateral, regional, national & municipal tate international progress in HIV prevention, stakeholders control and treatment. Integration into existing collaborative infrastructure Community ownership and participation Involvement of PLWHA
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This report was prepared with support by the Bill and Melinda Gates Foundation. It was written by Neda Dowlatshahi and Susan Higman.