Putting the Most Marginalised at the Centre

Lessons for the COVID-19 Response from the HIV Epidemic

by | May 28, 2020

In the early days of the HIV epidemic, there were a few simple messages to help save lives: abstain from sex, have only one sexual partner, use a condom. Sounds simple, right? But despite huge awareness raising and education programmes, the epidemic continued to grow.  

During the COVID-19 pandemic, we are being advised to save lives by staying home and keeping two metres away from everyone else when we are outside our homes. ‘Social distancing’ and ‘shielding’ have entered our everyday lexicon. 

The problem with taking either approach as the sole solution is that they ignore societal structures and government policies that affect behaviour and determine people’s health. You can’t fight epidemics or improve public health by just telling people what to do and disregarding all the factors that affect our day-to-day decisions or force us to do things we wouldn’t otherwise do. You also can’t improve the health of a nation if you ignore people who are already sidelined. 

Both HIV and COVID-19 have been shown to affect certain groups more than others. Their effects are disproportionately felt by people already on the margins of society. In the case of HIV globally, this includes adolescent girls and young women, gay men and other men who have sex with men, trans women, sex workers and people who use drugs. In the case of COVID-19 in the UK, among those most affected are BAME people, including migrants, refugees and people seeking asylum. 

“You can’t fight epidemics or improve public health by just telling people what to do.”

To curtail the HIV epidemic and reduce the risk of people acquiring the virus or dying of AIDS, it became clear that the rights of the most affected populations would have to be upheld and protected. Activists and civil society organisations around the world called on governments to ensure that girls could stay in school, that women were economically empowered so that they were less financially dependent on men, and that people who use drugs could access harm reduction programmes.

Organisations have also campaigned for sex work and same sex relations to be decriminalised, to put an end, amongst other things, to police harassment and extortion that was preventing an effective HIV response. At the same time, there have been large-scale programmes to fight stigma and discrimination against all these populations. “Know your epidemic” was the rallying cry by UNAIDS, calling on countries to focus their HIV prevention efforts on those most at risk of acquiring the virus. 

In the UK, there are many reasons why people subjected to immigration control are more likely to be affected by COVID-19. They include overcrowded accommodation for people seeking asylum, homelessness among people whose asylum applications have been refused, and denial of access to public funds.  

“In the UK, there are many reasons why people subjected to immigration control are more likely to be affected by COVID-19.”

Added to this, charges for NHS care and data-sharing with the Home Office act as deterrents for people to seek healthcare. People seeking asylum or others with uncertain immigration status have long been afraid of accessing health services in the UK because of Hostile Environment policies. The government now wants them to come forward if they need testing or treatment for COVID-19, so they are exempt from charges. But it’s too little too late. Other conditions may still be charged for, and the NHS may still share their data with the Home Office.

As a recent report by Doctors of the World found, “Fear and distrust of health professionals, the NHS and government caused by legislation” and “previous negative experiences with … immigration services and social care are preventing people seeking advice on and healthcare for COVID-19”. 

NGOs in Britain have been calling on the Home Office to change its policies in these areas for many years. With the onset of the COVID-19 pandemic, suddenly some of our demands have been met on a temporary basis. We were pleased that the Home Office decided that until the end of June, they would not to evict anyone granted or refused asylum, and that they would continue support payments to people seeking asylum until they receive mainstream benefits.

Both of these extend the usual 28-day ‘move-on’ period, at the end of which people are often left destitute. It was also good news when the Home Office decided that nobody should be left street homeless and made arrangements for every single person to be accommodated regardless of immigration status. 

But these changes don’t go far enough.  

Firstly, these positive measures are only temporary; they should be made permanent. The government must reduce the risk of people becoming ill in the long-term, not just as a reaction to the current pandemic.  

Secondly, the measures are insufficient in themselves. Asylum accommodation is often crowded with shared cooking, eating and bathroom facilities. It can be impossible to practise strict hygiene and keep two metres away from others. This has been a long-standing issue that the government should rectify to protect people seeking asylum now and in the future. Singapore’s experience demonstrates the risk of leaving people to live in cramped conditions. 

“Policies enacted over the last 20 years have put people seeking asylum at increased risk.”

On top of that, many adults seeking asylum are obliged to share bedrooms with strangers. For LGBTQI+ people seeking asylum, sharing with strangers carries a risk of harassment. At UKLGIG, we have clients who have chosen street homelessness over vitriol or physical or sexual abuse inflicted upon them by roommates. Shared bedrooms also fly in the face of advice to stay two metres apart and self-isolate if displaying symptoms of COVID-19. The government should put an end to forced bedroom sharing for all unrelated adults.  

Additionally, people seeking asylum are given less than £38 a week to live on. This is 74% below the poverty line. Before the onset of the COVID-19 pandemic, people were already having to choose between food, clothing and other essentials. Now, they are struggling to meet the extra costs of cleaning materials, higher prices in the shops and phone credit as public Wi-Fi spots have closed. The government should increase asylum support rates by £20, the same COVID-related uplift given to Universal Credit. In addition, it should set the long-term asylum support rate at 70% of Universal Credit to help ensure the health and wellbeing of people seeking asylum at all times. 

“To respond to the HIV epidemic, we have fought for the rights of most at-risk populations.”

Finally, the government should not prevent or deter anyone from accessing health services. This must include ending all data-sharing between the NHS and Home Office and scrapping health charges based on immigration status. Access to healthcare is not only a human rights issue but also a public health one. The World Health Organisation (WHO), the International Organisation for Migration (IOM) and the British Medical Association (BMA) have all been clear Covid-19 responses must address the needs of migrants in order to be effective. 

As we’re fighting COVID-19 and trying to build ‘a new normal’, there are lessons to be learned from the global response to HIV. To respond to the HIV epidemic, we have fought for the rights of most at-risk populations, not only to have access to health services and for those services to be free but also to have an education, to have a livelihood, and to be equal to others. 

Similarly, as we fight COVID-19, the UK government must make sure that the most at-risk of acquiring or dying of the disease are at the centre of the response. Policies enacted over the last 20 years have put people seeking asylum at increased risk. Now more than ever, every single person in the UK should have free and confidential access to all health services, an income that keeps them out of poverty, and safe and secure housing. Human rights and public health are inextricably linked, and putting the needs of the most marginalised people at the centre of policy-making will result in better outcomes for us all.  


  • Leila Zadeh is the Executive Director of the UK Lesbian and Gay Immigration Group (UKLGIG). She previously worked on the global HIV response at Frontline AIDS, Oxfam GB and ActionAid EU. Her role at Frontline AIDS focused on advocating for the rights of LGBTQI+ people, sex workers, adolescent girls and young women, and people who use drugs. Leila came to the UK as part of a refugee family when she was 13 months old.

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