"We have long since reached the limits of our capacity"

The growing number of asylum seekers is not only overwhelming many local authorities, but is also causing problems for AIDS service organizations. Snapshots from Freiburg, Nuremberg and Oberhausen by Axel Schock

They are fleeing war, violence and persecution from the world's crisis and conflict regions, hoping for a better life in dignity. In January 2015 alone, more than 25,000 new asylum applications were submitted in Germany - twice as many as in January of the previous year. Many cities and municipalities are no longer able to provide adequate accommodation. But the growing number of refugees is also a challenge for AIDS service organizations and other AIDS counseling services.

In Nuremberg, the situation is currently comparatively relaxed. For many of the HIV-positive asylum seekers at the nearby Zirndorf central reception camp, the AIDS counseling service of the City Mission is the first point of contact. "Our job is not to provide patients with all-round care and support, but to help them with everything to do with HIV and Aids," explains social worker Stephanie Herrmann. The focus is on providing information about the infection and treatment options as well as referring patients to HIV specialists.

"In Bavaria and Saxony, people are still routinely tested for HIV"

A well-functioning network is important, says Herrmann. In case of doubt, clients are referred on, for example to the specialist psychological service in cases of severe mental disorders or trauma. Cooperation with the reception center also works smoothly. "It forwards those who test positive to us immediately. In Bavaria, as in Saxony, asylum seekers are still routinely tested for HIV."

However, Sabine Herrmann is divided about these compulsory tests. "On the one hand, this is a clear violation of personal rights. On the other hand, it gives some people the chance to receive treatment and a residence status here on humanitarian grounds."

In 2014, 38 people were diagnosed with an HIV infection in this way, a third of whom came from Ethiopia. However, only nine ultimately found their way to the advice center. Sabine Herrmann can only guess at the reasons. Either many of them already knew about their HIV infection before they arrived in Germany and went straight to a specialist doctor. Or they ignore the test result because they are psychologically overwhelmed by it, because they fear discrimination from their fellow countrymen or because other problems are initially in the foreground. For example, drug addiction, as is the case with many asylum seekers from Russia, Chechnya and Ukraine.

Drug addiction is often the main issue for migrants from Eastern Europe

The situation in the Ruhr region is less relaxed than in Nuremberg. "We have long since reached the limits of our capacity," says Natalie Rudi, Managing Director of Aidshilfe Oberhausen. One and a half permanent positions are currently available for the care of around 150 clients. A third of them have a migration background. Among them are 15 asylum seekers who are hoping to obtain residence status - 15 out of 1,000 asylum seekers currently living in Oberhausen. Up to 700 more are expected this year. No one can yet estimate how many of them will need the support of Aidshilfe.

The only certainty is that every additional client will make the work situation at the AIDS service organization more difficult. "The amount of care required for asylum seekers is far greater than for a German-speaking HIV-positive person from the middle class, for example," says Natalie Rudi. The local health and legal system does not have to be explained to them first. Unlike the Nuremberg City Mission, Aidshilfe Oberhausen not only provides HIV care, but also supports asylum seekers with other social issues, such as visits to the doctor or visits to the authorities.

Very high support costs

Finding accommodation is particularly time-consuming. Rudi talks about two African clients who are threatened with deportation. One was diagnosed with Aids in Germany, the other has known about his HIV infection since his first stay in Germany three years ago. At that time, his asylum application was rejected and he was deported. Now he has made the long journey here again. Both are currently in collective accommodation.

"The conditions in the hostel are terrible," says Natalie Rudi. After a member of the Left Party photographed the completely filthy toilets and kitchens and posted them online, the public order office is at least making an effort to regularly dispose of the garbage and "go through the sanitary facilities with a water hose and disinfectant".

Aidshilfe has managed to ensure that the two Africans are allowed to move to other accommodation. But finding an apartment is almost hopeless. Over 70 other asylum seekers are currently in the same situation. Although the city council has a housing assistance service, it only has one office and is hopelessly overloaded. That leaves the free housing market. "But an asylum seeker with dark skin and an unresolved residence status has little chance on that market," says Natalie Rudi.

Finding an apartment is almost hopeless

Change of location. In Freiburg im Breisgau, work in the area of asylum and migration has also grown significantly in recent years. The local AIDS service organization is currently looking after 65 HIV-positive asylum seekers, in addition to those who already have a residence permit. The six full-time staff dedicate around a third of their working hours to supporting migrants.

At least AIDS-Hilfe Freiburg has managed to finance a separate position for this with EU funds. However, this is spread across several employees, including the administration. "And you wouldn't believe how much administrative work is involved in advising asylum seekers," explains social education worker and advisor Ralph Mackmull. Aidshilfe also has to contribute 50 percent of its own funds to the position.

All of this is only possible thanks to voluntary commitment and foresight, says Managing Director Ulrike Hoffmeister. AIDS-Hilfe Freiburg has been working in the field of migration for ten years, cooperating with the German Red Cross Freiburg and has submitted project applications to the EU with them - with success. Together they can provide a comprehensive range of services for asylum seekers: Aidshilfe offers HIV counseling, support and prevention, while the DRK colleagues are responsible for general health issues and violence prevention.

A comprehensive range of services for migrants thanks to cooperation

"However, project funding is not ideal for sustainable work," Ralph Mackmull points out. This is because the approved positions are up for grabs every two or three years. For this reason, Aidshilfe has now applied to the city for funding for a half-time position for asylum and migration - it is not yet clear whether this will be approved.

If Freiburg is given its own state reception center this year as planned, the number of refugees to be cared for is likely to increase. Asylum seekers who have tested positive for HIV in the initial reception center in Karlsruhe are already being referred to Freiburg because good care and medical treatment can be guaranteed there by the AIDS service organization. The management of the reception camp in Zirndorf in central Franconia is also far-sighted and generally places asylum seekers with HIV in the vicinity of Fürth and Nuremberg, where there are HIV specialist practices.

There are also good examples of cooperation in language teaching. For example, the Office for Migration and Integration of the City of Freiburg is currently setting up a pool of translators that can also be used by the AIDS service organization and to which it can also contribute its own experts. This is thanks to the DAH pilot project MuMM, in which so-called health interpreters from various migrant communities were trained at three Aidshilfe locations in 2012.

"At best, refugee policy is reactive, but not active"

When it comes to language barriers, the aid organizations usually know how to help themselves. However, the really pressing problems must be solved at federal or European level. And this is where refugee policy is at best reactive, but not proactive, criticizes Ulrike Hoffmeister. "It is unacceptable for people to be pushed back and forth within the EU." Her colleague Ralph Mackmull illustrates the dilemma with an example: in Italy, a heavily pregnant Nigerian woman was advised to travel on to Germany. She was told that if she gave birth there, she would have a better chance of having her asylum application approved. "Such cases have become more frequent in recent months," says Mackmull.

In order to be able to help these women, he has to reopen the asylum procedure that has already begun on a transnational basis. The legal situation is extremely complex, so that even experts are overwhelmed - as are the authorities responsible for the so-called Dublin procedures. There are two half-time positions for this in Karlsruhe. "It is completely unpredictable whether and when the cases will be processed, who will receive a tolerated stay and who will not. This also makes it difficult to develop a perspective for these people," complains Ralph Mackmull.

The bureaucratic labyrinth requires special expert knowledge

Finding a way through this bureaucratic labyrinth requires not only persistence, but also special expert knowledge, which is not necessarily one of the core competencies of AIDS service organizations. "I also see it as our task to prevent the deportation of refugees who would not receive HIV treatment in their home country," emphasizes Natalie Rudi.

The German AIDS Foundation often steps in to cover the costs of the legal assistance required in such cases. However, when Ralph Mackmull applied for legal aid for the proceedings of the pregnant woman who had entered the country via Italy, he was turned down. This was because adequate healthcare would have been guaranteed in the country of first reception - at least in theory. However, Mackmull doubts that refugees actually receive the same healthcare in all EU countries. This is not even the case everywhere in Germany.

Responsibility for the care of refugees has now largely been left to non-governmental organizations and voluntary helpers, writes Antje Sanogo, migration expert at the Munich AIDS service organization, in an open letter on Bavarian refugee policy. Without support, such as from the AIDS service organization, HIV-positive refugees only receive treatment certificates for medical treatment unreliably, even though they are entitled to it.

Supply situation differs depending on the federal state and municipality

The individual federal states and cities handle the care of refugees very differently and sometimes even contradictorily. If you are lucky, as in Oberhausen, there is a person in a key position who recognizes how important it is, for example, that the costs of substitution medication for drug-addicted asylum seekers are covered as easily as possible.

As a rule, the federal states and local authorities make an honest effort to provide housing and basic medical care for refugees within their means. However, in times of tight budgets, what is feasible will always be far too little. As long as these burdens are not redistributed and the municipalities are not relieved, the refugees will be left to their fate. "Who will look after them then?" asks Natalie Rudi. "And what about these people's right to work, health and family reunification?"

Joint strategies are needed

If refugees are to be given a real chance of integration, social institutions such as the AIDS service organizations will have to increase their staffing levels in this area. "But many decision-makers are completely unaware that this increased need for care ties up resources," says Mackmull. He also believes that Deutsche AIDS-Hilfe has a duty to intervene at the highest level, such as the Federal Office for Migration and Refugees and the Ministry of Health. A round table with the main responsible parties could, for example, be a first step towards finding joint strategies for a long-term improvement in the situation of HIV-positive asylum seekers.