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How Can South Africa’s Healthcare System Better Support Migrants with HIV/AIDS and TB Co-Infections?

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Bridging the Treatment Gap: Supporting Migrants with HIV/AIDS-TB Co-Infections in South Africa

When Borders Become Barriers: The Silent Crisis

Thirty-five-year-old Grace* travels between Zimbabwe and South Africa’s Limpopo province every three months. She works on commercial farms near Musina during harvesting seasons. Grace lives with both HIV and tuberculosis (TB), requiring consistent medication for both conditions. However, each border crossing interrupts her treatment. Additionally, the nearest public clinic is 50 kilometers from her workplace. As a result, she often runs out of antiretroviral therapy (ART) before reaching Zimbabwe. Xenophobic attitudes at South African facilities further deter her from seeking care.

Grace represents thousands of migrants navigating this deadly intersection of disease, mobility, and healthcare exclusion. South Africa bears 50% of Africa’s HIV/TB co-infection cases while hosting an estimated 2 to 3.5 million Zimbabweans. Gauteng Province, in particular, has the highest concentration of people living with HIV nationally. Nevertheless, current health systems systematically fail migrants, creating treatment gaps that threaten both individual lives and public health objectives.

The Magnitude of the Challenge: HIV/TB Co-Infection Among Migrants

Case Example: Grace’s Journey

Grace’s experience illustrates key vulnerabilities faced by migrants: geographic distance from services, legal and documentation barriers, social exclusion, and mobility-induced treatment interruptions. These challenges are compounded by the complexity of managing HIV/TB co-infection.

Epidemiological Snapshot

By late 2024, approximately 96% of people living with HIV in CDC-supported districts knew their status, with 81% receiving ART. However, these figures mask critical disparities, especially among migrant men in urban Johannesburg, whose patterns of healthcare engagement remain poorly understood.

Geographic Disparities: KwaZulu-Natal shows 17.6% HIV prevalence compared to Gauteng’s 11.8%. Yet Gauteng hosts a massive migrant population. Consequently, absolute case numbers differ from prevalence rates.

Gender Dynamics: Among 524 HIV-infected migrants in Lesotho border districts, 65.6% were women, with 45.8% working as domestic workers. These women face compounded vulnerabilities including gender-based violence, economic precarity, and documentation barriers.

Co-Infection Burden: In CDC-supported districts, 88% of TB patients received HIV testing in 2024, with 50% showing co-infection. Among these patients, only 72% received concurrent ART and TB treatment—a notable achievement but insufficient for mobile populations.

Migration Patterns and Health Disruption

Migration disrupts healthcare continuity. Southern African public health systems are not designed for mobile populations, creating predictable treatment failures:

  • Circular Migration: Seasonal movement between rural homes and urban employment centers increases risk of treatment interruption.

  • Cross-Border Mobility: Migration between SADC countries exposes migrants to jurisdictional healthcare gaps.

  • Documentation Status: Undocumented migrants fear deportation and often avoid public facilities.

  • Language Barriers: Central African migrants who speak French struggle in English-dominant services.

Policy Framework: Promises vs. Reality

Constitutional and Legislative Protections

South Africa’s legal framework appears progressive:

  • Constitutional Rights: Section 27(1)(a) and (3) guarantees healthcare access for all, including emergency treatment regardless of nationality.

  • National Health Act: Section 4(3)(b) mandates healthcare for all residents.

  • Refugees Act: Section 27(g) grants refugees the same rights as citizens.

  • National Strategic Plans (NSP 2017-2022 & 2023-2028): Explicitly target mobile populations and migrants.

Implementation Gaps

Despite progressive policies, migration-aware planning is largely absent. Implementation remains inconsistent and shaped by frontline discretion.

  • SADC Regional Framework: South Africa has not ratified the 2009 Draft SADC Framework on Population Mobility and Communicable Diseases, weakening regional coordination despite available cost-sharing models.

The Xenophobia Crisis: Medical Discrimination as a Health Barrier

Defining Medical Xenophobia

Medical xenophobia encompasses negative attitudes and practices of health workers towards migrants, including:

  • Documentation Demands: Requiring ID or proof of residence before treatment.

  • Communication Refusal: Denying interpreters or communication in migrants’ languages.

  • Verbal Abuse: Insults or discriminatory remarks during treatment.

  • Discriminatory Prioritization: Non-South African patients often wait until all citizens are seen.

  • ART Access Denial: Migrants often rely on NGOs for HIV treatment due to barriers in public facilities.

Recent Escalations

Xenophobic practices have intensified. In August 2025, HIAS South Africa condemned scenes of medical xenophobia outside hospitals. Vigilante groups like Operation Dudula physically blocked migrants from clinics in Johannesburg, Hillbrow, and Tshwane. Elevated maternal mortality among black migrant women has been linked to such attitudes.

Counter-Narratives

Not all healthcare workers discriminate. In Musina, some frontline providers delivered HIV services to black African migrants, bypassing institutional barriers. Yet systemic obstacles create unpredictable and inconsistent access.

Treatment Continuity: The Core Challenge

Why Co-Infection Demands Uninterrupted Care

HIV/TB co-infection creates unique clinical challenges:

  • Immune Synergy: HIV and TB accelerate immunological deterioration.

  • Treatment Complexity: ART regimens require adjustment to avoid TB drug interactions.

  • Timing Criticality: Early ART for patients with CD4 <50 cells/mm³ reduces mortality.

  • Drug Resistance Risk: Interruptions promote resistance, worsening outcomes.

Barriers to Continuity

Migrants face structural barriers:

  • Administrative Hurdles: Facility registration requirements clash with mobile lifestyles.

  • Supply Chain Gaps: Standard dispensing assumes stable residence.

  • Record Fragmentation: Paper-based systems prevent cross-facility treatment history sharing.

  • Referral Breakdown: Reluctance to serve undocumented migrants undermines continuity.

Successful Interventions: Evidence-Based Solutions

The Musina Model of Care

Between 2008–2013, Médecins Sans Frontières piloted farm-based interventions in Musina:

  • Mobile Delivery: Services brought directly to farms.

  • Patient-Held Records: Ensured continuity across sites.

  • Three-Month Buffer Stocks: ART supplied for travel periods.

  • Community Health Workers: Trained 10 CHWs to support testing, treatment, and education.

Outcomes: High retention (92% return after temporary transfer-outs), with notable improvements among Zimbabwean migrants.

IOM Ripfumelo Project

IOM trained 103 farm workers as peer educators (“Change Agents”) to provide health education, fostering trust and improving adherence.

Integrated Decentralized Care in KwaZulu-Natal

Down-referring co-infected patients to primary health clinics achieved favorable TB treatment completion rates and low mortality, demonstrating integration feasibility.

Cross-Border Coordination

Musina and Vhembe District implemented mobile ART clinics with Zimbabwean collaboration, emphasizing that effective HIV/TB care cannot stop at borders.

Evidence-Based Recommendations

National Health Departments (0-12 months)

  1. Differentiated Service Delivery

    • Multi-month ART dispensing

    • Patient-held health passports

    • Travel planning integration

  2. Anti-Xenophobia Training

    • Cultural competency modules

    • Confidential reporting mechanisms

    • Link training to performance metrics

  3. Strengthen Legal Enforcement

    • Clarify migrant rights in departmental circulars

    • Rapid-response teams for access denial

    • Quarterly public reporting

Provincial Health Departments (12-24 months)

  1. Expand Mobile and Outreach Services

    • Deploy multilingual mobile clinics

    • Point-of-care CD4 and viral load testing

  2. Establish Migration Health Desks

    • Migration focal points in major hospitals

    • Referral directories and cross-border linkages

SADC and Regional Bodies (24-36 months)

  1. Harmonize Treatment Protocols

    • Align ART regimens across member states

  2. Create Regional Health Information Systems

    • Privacy-protected cross-border patient tracking

  3. Ratify and Operationalize Regional Frameworks

    • Implement SADC mobility frameworks and cost-sharing

NGOs and Civil Society

  1. Expand Community-Based Interventions

    • Peer educator programs, legal support, participatory research

  2. Advocate for Policy Implementation

  • Monitor NHI Act inclusion of migrants

  • Support litigation against discriminatory practices

Healthcare Providers

  1. Adopt Migration-Competent Clinical Practices

  • Ask about travel plans

  • Provide extended medication

  • Use interpreters and visual aids

Researchers and Academic Institutions

  1. Address Knowledge Gaps

  • Long-term outcomes for mobile populations

  • Cost-effectiveness of differentiated care

  • Mental health and xenophobia impact studies

Case Studies

1. Transitioning to Self-Management

Patrick*, a 42-year-old Mozambican, maintained viral suppression for 18 months using six-month ART refills, patient-held treatment cards, and WhatsApp reminders.

2. Farm-Based Peer Support

On a Limpopo farm, peer educators and monthly mobile clinics improved HIV testing, ART initiation, and adherence among 200 workers, reducing TB cases to zero.

3. Cross-Border Coordination Failure

Maria*, a Malawian migrant, interrupted ART for six weeks due to lack of cross-border referrals, resulting in hospitalization and treatment complications.

Intersectional Vulnerabilities

  • Gender: Women face maternal mortality, employer restrictions, and sexual violence.

  • Age: Young adults juggle employment and healthcare; undocumented children often excluded from ART programs.

  • Documentation: Undocumented or expired-permit migrants fear deportation.

  • Nationality/Ethnicity: Language barriers impede access for Francophone migrants.

Social and Structural Determinants

  • Economic Precarity: Limits clinic access and medication adherence; recommend transport subsidies and workplace-based care.

  • Housing: Overcrowded informal settlements accelerate TB; interventions should include infection control and medication storage.

  • Mental Health: Trauma and anxiety reduce adherence; integrate counseling and peer psychological support.

Research Gaps

  • Epidemiology: HIV/TB prevalence and healthcare engagement among migrant men.

  • Implementation Science: Scalability, cost-effectiveness, digital health solutions.

  • Policy Assessment: NSP Goal 3 effectiveness, enforcement of anti-discrimination policies, SADC cross-border initiatives.

  • Qualitative: Lived experiences, provider perspectives, xenophobia impact.

Conclusion: The Path Forward

Grace embodies millions making impossible choices. Her HIV/TB co-infection requires uninterrupted care, yet mobility, xenophobia, and documentation issues threaten her survival. Evidence shows that solutions exist: Musina Model, peer educators, and decentralized care work. Implementation—not policy—remains the barrier.

Five Imperatives:

  1. Migration-aware health systems: multi-month dispensing, patient-held records, cross-border referrals.

  2. Confront xenophobia: training, enforcement, and accountability.

  3. Regional coordination: ratify SADC frameworks, harmonize protocols, enable cross-border information sharing.

  4. Address social determinants: housing, food, and economic security.

  5. Migrant leadership: peer educators and community-based programs strengthen trust and sustainability.

Call to Action:

  • Policy Makers: Champion migration-aware provisions, allocate budgets, monitor equitable access.

  • Healthcare Providers: Question discrimination, adopt migration-competent practices.

  • Researchers: Prioritize migration health, use participatory methods, translate evidence to policy.

  • Civil Society: Document barriers, support legal advocacy, amplify migrant voices.

  • Regional Bodies: Operationalize SADC frameworks, invest in cross-border systems.

  • Migrants & Communities: Know rights, report discrimination, participate in peer programs.

Achieving the 2030 UNAIDS targets requires leaving no one behind. Grace deserves uninterrupted care; millions like her deserve nothing less. South Africa must bridge the treatment gap now.

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