For the past decade, the Russian labor force has been progressively shrinking. As a result, the Russian labor supply has not been able to meet the labor demand required to maintain economic growth [1]. Economic analysis of data from the Russian Federal State Statistics Service predicts that the Russian Federation’s current labor shortages will only increase if drastic policy measures are not taken to increase the labor force [2]. To maintain economic productivity, Russia relies on migration from former Soviet Union states, most notably from Central Asia. Central Asian labor migrants act as a failsafe for the Russian economy in the context of a declining native-born working-age population, national financial instability, and international sanctions.
Migration has been a defining aspect of Central Asian social and economic structures since the fall of the Soviet Union. The Tajikistani civil war which accompanied the republic’s independence in the 1990s instigated the first major flow of forced migrants from Central Asia in the post-Soviet period. The country never recovered economically, and today relies on the exportation of its labor force for a large portion of its economic output. In 2013, Tajikistan was the country with the world’s greatest proportion of its GDP (41.7%) coming from remittances [3].
Media reports claim that, as of 2015, the Russian Federation has implemented stricter requirements for work permits, with special relevance for Tajik migrants. Tajik migrants must now pay relatively high fees (reportedly between $200 and $500 USD), prove sufficient proficiency in the Russian language, pass certain exams, and submit complicated paperwork in order to receive a valid work permit. As Tajik migrants can enter Russia without a visa, strict labor registration requirements arguably encourage illegal labor [4]. Without medical insurance or the right to care, as well as the fear of legal recourse if found to be working unregistered, it is very possible that Tajik migrants in the Russian Federation forgo much-needed HIV testing and treatment. Moreover, the Russian Federation restricts entry to the country based on HIV-status, presumably to protect the country from an exacerbated HIV epidemic, mirroring the former policy of the United States. A qualitative study conducted among migrants in Moscow revealed that, because of the Russian Federation’s mandatory reporting of confirmed cases of HIV, at least some migrants refused HIV-tests out of fear of expulsion or refusal of re-entry into the Russian Federation [5].
Due to the ban on migrants with HIV in the country, migrants are generally unable to access HIV treatment or care through the Russian healthcare system. Although few alternative HIV treatment options exist, there are NGOs such as Moscow Based group “Shagi Foundation”, which works with HIV positive migrants to find solutions to any barriers they may face including the procurement of antiretroviral therapy through informal networks [6, 7]. There are also informal community-based healthcare providers, such as the so-called “Kyrgyz clinics”, which specifically target Central Asian populations and provide them with a range of health care services and assistance with navigating the formal medical system in Russia [8].
Migrants must prove an HIV-negative status in order to obtain an annual work permit in Russia [9]. As citizens of the Commonwealth of Independent States, Tajik migrants can enter Russia without a visa and apply for a work permit after arrival to Russia [10]. Therefore, migrants who were infected pre-migration could enter and work in Russia without a work permit [7]. Working in Russia without a legal work permit, however, confines migrants to jobs within the black-market and bars them from accessing healthcare and other resources in the country.
In Tajikistan, HIV testing is readily available and prioritizes labor migrants [11]. After pregnant women, migrants (defined as all citizens who stay abroad for three months or more) constitute the largest portion of people tested [12]. As of 2018, returning migrants are required to undergo HIV testing upon re-entry to Tajikistan [13]. Recent qualitative data suggest that migrants who are diagnosed with HIV in Russia often choose to remain in the country until advanced symptoms force them to return to Tajikistan to seek adequate medical treatment and free ART, which is otherwise unavailable in the Russian Federation [7, 14].
Russia has higher HIV prevalence than Tajikistan among its adult population (> 1% of the population vs 0.3, respectively) [11, 15]. Previous research also suggests that Central Asian migrants are more likely to engage in HIV risk behavior in Russia than at home [16]. An elevated incidence of HIV has also been recorded among wives of Tajik migrants following their husbands’ return home [17]. The higher prevalence of HIV in Russia combined with the high-risk that Tajik migrants face in contracting the disease implies that migrants are more likely to become infected in Russia than in Tajikistan.
If Tajikistani migrants do not receive testing or treatment for HIV infections in the Russian Federation, they may face the health consequences associated with late presentation. Late presentation with HIV and subsequent late initiation into antiretroviral therapy increases the risk of HIV-related complications, reduces life expectancy and quality, and reduces the net benefits of ART generally. On the other hand, those virally suppressed on ART have virtually no risk of transmitting the virus to HIV-negative people [18]. Importantly for the public health of the Russian Federation, not initiating migrants in antiretroviral therapy may increase the risk of HIV infection being spread even beyond migrant populations. The heightened vulnerability of migrants in Russia has the potential to spill-over beyond the boundaries of the Russian Federation and puts local population in home countries at heightened risk of an exacerbated HIV epidemic.
Additionally, studies conducted among migrants with HIV to European countries, suggests that a substantial proportion of migrants acquired HIV following migration to Europe [19, 20]. A cross-sectional study by Alvarez-del Arco, et al. showed that the proportion of post-migration acquisition of HIV among migrants to nine European countries was 63% overall, but as high as 79% for people who inject drugs (PWID) and 71% for men who have sex with men (MSM). The factors associated with post-migration acquisition among migrants to the nine European countries included length of stay with longer duration of residence tied to a higher probability of HIV post-migration acquisition [19]. Similar histories of migration pathways, social hardship, and healthcare barriers may indicate an epidemiological pattern of post-migration HIV acquisition applicable to Central Asia and the Russian Federation. Given the previously reported barriers to healthcare access for migrants in to the Russian Federation, and the rapidly expanding HIV epidemic in Eastern Europe and Central Asia, this present study set out to determine the characteristics of HIV-positive migrants