Netherlands

In the Netherlands sex work is legal. Sex workers from Africa began primarily arriving in the Netherlands in the 1980’s.  Sex work and migration policies (often in the form of anti-trafficking policies) have been shown to be restrictive and limiting women’s choices. Additionally, immigrants from outside the European Union (EU) may only work as a freelancer and need a residence permit with the status “freelance work permitted”.  Citizens of the EU may work in the sex industry as paid employee.

Since the introduction of licensing requirements for sex workers, many sex workers without valid residence and working permits have moved to other countries such as Italy and Spain or they have gone “underground”. Non-EU migrants are by law excluded from legally working in the sex sector. As a result, migrant sex workers are forced to work in the illegal and unprotected sector which makes them more vulnerable to violence, poorer health outcomes and at increased risk of HIV acquisition and transmission.

The estimated number of sex workers in the Netherlands is 25,000. The HIV prevalence among sex workers is 10.2% meaning that an estimated 2,250 sex workers are HIV positive in the Netherlands.

Information on migrant sex workers is sparse. No information was found on HIV incidence or prevalence among migrant sex workers.

Injection drug users are not considered a major risk group in the Netherlands. HIV incidence and injection risk behaviour in the Netherlands has declined since 1986. The Netherlands was one of the first European countries to implement harm reduction programs. In 1992, 1.1 million needles were exchanged in Amsterdam whereas in 2007 that number dropped to 150,000 needles. Injection drug use overall seems to be declining and the Netherlands appears to have the lowest initiation of injection drug use rate in Europe.

Information on migrant injection drug users is sparse. No information was found on HIV incidence or prevalence among migrant injection drug users.

Migration to the Netherlands has increased quickly from 1,556,000 migrants in 2000 to 2,057,000 migrants in 2017 constituting approximately 12% of the population.  Refugees account for 5.6% of the migrant population. Although the Netherlands has positioned itself as a relatively friendly country to migrants, the Dutch government recently pledged to fund special forces in Niger to control its border and prevent irregular migration to the Netherlands. Niger is one of the main routes for migrants with 90% of west African migrants passing through the country. Most migrants passing through Niger are trying to get to Libya and Algeria; both countries are key hubs for migrants trying to reach Europe.  Cracking down on migration forces migrants to take risky measures to get to Europe. In 2018, 3, 123 migrant fatalities have been reported with 1,989 migrant deaths in the Mediterranean alone. Most of the deaths recorded in the Mediterranean are the result of drowning.

In Europe, more than one third of all newly diagnosed cases of HIV are in migrants. Although it is unknown whether migrants acquire HIV before or after their journey there is growing evidence that migrants from high-prevalence countries are at risk of acquiring HIV after their arrival in the European Union. This is especially problematic given that the HIV prevalence in the Netherlands is 0.2%. However, in migrants from sub-Saharan Arica the HIV prevalence is 11 times higher at 2.3%. Sub-Saharan African migrants are at a much higher risk of acquiring HIV.

Migrants are one of the key populations disproportionately affected by HIV in Europe. Migrants experience barriers to accessing HIV prevention and treatment and generally have a HIV diagnosis at a later stage in the disease progression. In the Netherlands, more than 40% of people living with HIV are immigrants. In 2014, only 70% of the immigrant people living with HIV who were diagnosed and linked to care were virally suppressed.

The Dutch health care system is often cited as efficient and universally accessible. In 2006, the Dutch government reformed the health care system to provide health insurers a more prominent role. Every citizen in the Netherlands must be covered by a health insurance policy. Four major insurance companies provide insurance coverage to 90% of the population. Children, asylum seekers and migrants with no legal status who do not have the means to pay for health care are covered by the government. Basic health insurance covers medical care, some mental health care, dentistry, ambulance services, maternity care, most medications, dieticians, care from some specialists (i.e. speech therapists) and smoking cessation programs.

The Dutch health care system puts priority on primary care. General practitioners are the first point of contact for patients. General practitioners act as a gatekeeper as only they have the ability to refer patients to specialized health care services. Although the Dutch heath care system is reported to be performing well, an increasing number of people are not using the system due to user fees. It has also been reported that patient choice and equitable access to the health care system have suffered. In a health care system with market competition, the question of whether everyone is receiving the same high quality care must be considered.

UNAIDS reports that stigmatisation and incidents of discrimination due to HIV infection are still a problem in Dutch society. Normalising and standardizing how HIV tests and treatment is offered could help to reduce stigmatisation and discrimination. General social acceptance of key populations such as migrants and men who have sex with men could contribute to the success of initiatives throughout HIV prevention and response efforts.

Although the Dutch heath care system has a provision for care entitlements for migrants with no legal status who cannot pay for their own care, it is very likely that migrants are not accessing health care services because they do not know how to navigate the system. Additionally, migrants with no legal status are likely to be fearful about whether accessing health care services might lead to an arrest or a confrontation with authorities.

Dutch responders to a European Centres for Disease Control report on migrants reported that the Netherlands has laws, regulations or policies that are obstacles to effective HIV prevention, treatment, care and support for migrants. These laws relate to categories of migrants eligible to receive health services, in general, and anti-retroviral therapies, in particular.

Migrants from high HIV prevalence countries are generally diagnosed later than the general population in the Netherlands. Access issues are likely a reason as asylum seekers in the Netherlands have reported barriers to accessing HIV services.

Adequate HIV treatment depends on the availability and access to medical care and support services. These services are important to support adherence to treatment as well as prevention and management of HIV-related infection. Referral to HIV services requires health care providers to know about what services are available. Policies that target heath care workers and their responsibility to adequately provide referrals for HIV prevention, treatment and services should be developed to provide a standard by which migrants requiring HIV services are able to access them.

In the Netherlands there is a high prevalence of HIV among sub Saharan migrants (2.3%) as compared to the general population (0.2%). Given the disproportionate burden of HIV among sub-Saharan African migrants, HIV programs and services that are culturally relevant and with language interpretation services could help to increase increase the number of migrants who are on HIV treatment and virally supressed. It has also been found that additional support services are required for people living with HIV such as peer support and psychosocial care specifically for refugees and undocumented migrants in the Netherlands. The need for these services is higher in rural areas than urban areas.

Additionally, in a study of HIV related consultations in the Netherlands, 77-93% of discussions about HIV during a consultation with a general practitioner were initiated by a patient. This study did not include analyses on migrants although it was found that 24% of patients at sexually transmitted infection (STI) clinics originated from HIV endemic areas. The study highlights that HIV consultations require standardization among general practitioners so that every patient who passes through a general practitioner’s office is asked about whether they have had a HIV test and are offered one. The study also highlights that migrants should be prioritized for HIV prevention, treatment and counselling.

Given that the majority of late HIV diagnosis occur in migrants in the Netherlands, promoting earlier and increased uptake of HIV testing is required. However, because migrants in Netherlands face stigma and discrimination by health care workers, education of health care workers around their care responsibilities should be prioritized as an intervention to reduce inequities in health care access for migrants.

Controlling the transmission of HIV depends on migrants’ access to HIV testing, antiretroviral therapy and ongoing health care. Inconsistencies between health and immigration policies are generally seen to be counterproductive to public health. For example, although the Netherlands is generally accepting of migrants, ability to pay is a stipulation to health care access. If a migrant is unable to pay for health care services, the government may pay for health care services. This is counterproductive to public health as migrants are more vulnerable to HIV infection in the Netherlands. The prevalence of HIV in the Netherlands is 0.2% among the general population, however it is 11 times higher in sub-Saharan migrants (2.3%).

The largest unemployment gap in Europe between ‘natives’ and sub-Saharan Africans is in the Netherlands. Highly skilled sub-Saharan Africans encounter many barriers when seeking employment in the Netherlands due to their lack of knowledge of the local labour market and the under appreciation of foreign education. Under employment of sub-Saharan Africans is also likely the result of stigma and discrimination. Half of adult Somalis and Eritreans in the Netherlands depend on social assistance.

The economic returns to school acquired in a migrant’s country of origin is much lower than in a migrant’s country of residence. Reforms that include transfer of education credentials from country of origin to the Netherlands should be pursued to offer sub-Saharan African migrants the opportunity to gain entry into the skilled labour market in the Netherlands.