In February 2018, I arrived in Canada as a Zimbabwean refugee. Upon landing, Immigration, Refugees, and Citizenship, the government department that processes refugee claims, demanded I take my first combined HIV/syphilis test. The test is mandatory for all refugees coming into Canada who want to obtain a work permit and social security number. I had enormous personal fear, not least because I hailed from Zimbabwe—at the time, the country with the world’s fifth-highest HIV prevalence rate.
I sweated on the days leading to the test. Where I come from, Zimbabwe, dozens of my family members are living with HIV. Some died from AIDS-related complications. Antiretroviral medicines didn’t arrive in Zimbabwe until the mid-2000s. Before introduction of medication, HIV was synonymous with helpless patients or humiliated adults wearing diapers in their last days. In my village, AIDS accounts for the majority of funerals, and it is considered “honorable” to die from malaria, diabetes, or a bus accident rather than AIDS. Many people believe that AIDS is a family-devouring demon and that, after AIDS claims a life in the family, the illness’s appetite won’t subside until another family member is infected and, ultimately, buried too. Such is the blanket of stigma surrounding HIV and AIDS in Zimbabwe.
I trembled while booking an immigration doctor from a paper catalogue of physicians available in Montreal. Confidentiality was at the top of my mind, in case the doctors detected HIV in my blood. In Zimbabwe, doctors and nurses are paid a paltry $30 salary a month. So it’s common for nurses to accept $5 bribes in WhatsApp groups to disclose the identities of patients who come to collect HIV antiretroviral drugs at their clinics. In Zimbabwe, pilfering clinic files and illicitly sharing the HIV status of patients is a sport of name-and-shame for some.
Now I was faced with a situation not only of undertaking a first HIV blood test but a requirement that within 60 days I must inform my fiancée if I were found to be infected with the virus—or I could face jail or deportation if I transmitted something to them. This sounds like a hard law to me, up to today. My close friend Yasin, an author and Uber driver, who remained in Boston to apply for asylum too, told me: “Ray, in America refugees are not required to take an HIV test before applying for asylum or a work permit. The only time I took an HIV test in America was when seeking life insurance.”
I feel, in terms of Canada’s HIV requirement, this could be frightening for some refugees who have faced unspeakable trauma, say in Syria or Venezuela, to arrive in Canada and be immediately commanded to take an HIV test. Just like fellow refugees I interviewed, I too feared that if my HIV test results turned out to be positive, I would not be allowed to work immediately.
To be fair, testing asylum-seekers upfront for HIV is a sensible policy, as Canada does. Among asylum seekers living with HIV in Canada, 43% were newly diagnosed, an important 2019 study in the BMC medical journal revealed. Some of the refugees were late presenters of the infection, which should be worrying, but as soon as antiretroviral medicine was commenced, viral load was quickly suppressed. Only 45% of the newly diagnosed were linked to care within 30 days, the study found. This is personally disappointing for me, because I was only informed that an HIV test is required for work permit processing. I was never briefed about post-diagnosis treatment options! Refugees, I suppose, are more fearful of what happens post-HIV diagnosis test than the single prick to draw blood from the finger.
Hence, my fear of being found to have HIV and being left to think out my future on my own was reasonable. I’m told the cost of treating an HIV-positive resident in Canada shoots up to $15,000 a year. Provincial governments offer either partial or full drug coverage. Instead of merely fearing an HIV diagnosis, I dreaded to think of how I could afford coverage for drugs knowing that I was a refugee subsisting on a $700 monthly public benefit. Was I going to skip drugs and lapse into infection drug resistance? My thoughts were so because where I come from, though a poor country, HIV drugs are provided free each month to those in need, courtesy of the Global Fund to Fight HIV, Tuberculosis, and Malaria.
The Day of the Test
So on the day of the test at Medisys, a corporate travel clinic in Montreal, a nurse stood in the reception area, waiting for me.
I was desperate to hide my gaping two upper front teeth and obvious bloody gums from the doctor, lest HIV be spotted in a dental exam.
“Any syphilis catch in last 12 months? Hepatitis?” asked a doctor.
The doctor noticed my cold sweats and duly released me into the care of the nurse. Then she fondled my arm to measure blood pressure before the actual HIV test. “Sorry, it’s high, I’ll do a manual check,” she said and dashed out of the room, with her stethoscope swinging wildly down her chest. She returned and squeezed my arm with the blood pressure monitor cuff belt again. “Oh, cheers, 139/111 blood pressure—it’s very normal,” she said.
I smiled and sat down. She ploughed the needle into my vein. Swoosh, surprise. It felt painless for me, but she panicked anyway. “Are you OK? Tell me, Ray, if you feel dizzy.” She had failed to drill a puncture into my vein properly.
I shut my eyes when she pinched the other arm’s vein. She called a colleague into the room to help. The skillful second nurse left my veins charred with wounds when I was finally released and loitered back to the Medisys clinic reception area. I was told I’d get results in seven to 10 days.
For 10 days, I feared the HIV test results. Every morning, I would freeze when the postman raced up to our door. What if he brings a khaki envelope letter from immigration, saying, “Ray, we have found problems with your blood test results?”
Under-the-Table Job Solution
Someone, a dubious entrepreneur who owns a car-wash, invited me to dodge the immigration blood test results and take up a cash job at his car-washing garage, working “under the table”—getting paid 50% below the minimum wage.
After lengthy thoughts, I was at first persuaded. Perhaps I should not have taken the HIV test and went straight for the car wash job. It paid $7 an hour and required no social security number. I kept entertaining thoughts of joining them. However, thoughts of HIV diagnosis stopped me. What if I live unknowingly with HIV, work in the shadows at the car wash with no health insurance, watch the infection progress to AIDS suddenly, and am forced to take a test at death’s door? I have seen firsthand in Africa the high mortality rate from late HIV diagnosis and poor responses to antiretroviral medicines. Some of my relatives only began taking antiretroviral medicine when they could no longer walk and were being ferried in wheelbarrows. They didn’t last a week.
It was my imaginary fear of me having late-stage, untreated AIDS that finally brought me to the immigration clinic to have my blood drawn for the first time. After three weeks, I was mailed a work permit approval. I rolled on the lounge floor, ecstatic. The letter stated that I was clear of HIV.
But I imagined an opposite scenario. What if my HIV test had detected the infection? Fellow refugees who are told they got the virus, how do they fare? It’s comforting that, on paper, convention refugees in Canada are exempted from paying for antiretroviral drugs. But roadblocks emerge. For example, to buy life insurance packages in Canada or work in immigrant-friendly sectors like social work, an HIV test is required. Yes, treatment is free, but the job market and purchase of insurance products get harder or pricier for HIV-positive refugees. Hence, a diagnosis likely keeps them in unfruitful, under-the-table jobs.
Ray Mwareya is a freelance journalist and Africa editor at World Ethical Data Forum. Find him on Twitter at @rmwareya.