Qualitative assessment of the impacts of the COVID-19 pandemic on migration, access to healthcare, and social wellbeing among Venezuelan migrants and refugees in Colombia

Highlights

• •COVID-19 compounded vulnerabilities experienced by Venezuelans in Colombia.
• •Venezuelans experienced increased housing instability and mobility during the COVID-19 pandemic.
• •Economic hardship due to the COVID-19 pandemic caused Venezuelans to take on increased risk.
• •COVID-19 policies were often incompletely implemented or not fully understood.

Abstract

Background

Colombia hosts a large number of Venezuelan migrants and refugees who are uniquely vulnerable and have been markedly impacted by the COVID-19 pandemic. It is necessary to understand their experiences to inform future policy decisions both in Colombia and during disease outbreaks in other humanitarian contexts in the future. As part of a larger study focused on HIV among Venezuelans residing in Colombia, qualitative interviews were conducted to understand this population's experiences and access to healthcare.

Methods

Interviews were conducted with Venezuelan migrants and refugees as well as stakeholders such as care providers, humanitarian workers, and government officials. Interviews were recorded, transcribed, and coded using thematic content analysis. Select quotes were translated and edited for length and/or clarity.

Results

Venezuelan migrants and refugees reported high levels of housing instability, job instability, increased barriers to accessing healthcare, and complications in engaging in the HIV care continuum, among other impacts of the COVID-19 pandemic. Stakeholders reported complications in provision of care and obtaining medicines, difficulty maintaining contact with patients, increased discrimination and xenophobia targeting Venezuelan migrants and refugees, increased housing instability among Venezuelan migrants and refugees, and other impacts as a result of the COVID-19 pandemic.

Conclusions

This study demonstrates the unique impacts of the COVID-19 pandemic among Venezuelans residing in Colombia by both compounding extant vulnerabilities and introducing new challenges, such as high rates of eviction. Colombia has enacted increasingly inclusive migration policies for Venezuelan refugees and migrants within the country; findings from this study underscore the necessity for such policies both in and outside of the Colombian context.

Background

Political instability and an economic crisis, among a host of other associated factors, have led to the displacement of over 6 million Venezuelans who now reside outside of their home country as of July 2022, (R4V 2022) approximately 1.8 million of whom reside in Colombia, the country who hosts the most displaced Venezuelans (UNHCR 2021). This humanitarian emergency has been associated with worsening health outcomes among Venezuelans who have remained in the country as well as those displaced to neighboring countries (Page et al., 2019). The COVID-19 pandemic has exacerbated public health concerns and strained the capacity of host countries to meet the healthcare needs of Venezuelan migrants and refugees (Paniz-Mondolfi et al., 2020; Zambrano-Barragan et al., 2021).

Colombia has a mixed public-private healthcare system organized into two arms: one contributory and another subsidized (Arrivillaga, 2021). Health insurance coverage for Colombians is almost universal (95%), (Arrivillaga, 2021) and all people insured in the health system theoretically have access to comprehensive HIV treatment, although in practice there are several economic, geographic, and administrative to effective access, in particular for the poorest and people living in rural areas (Bran Piedrahita et al., 2020).

Prior to the COVID-19 pandemic, Venezuelans residing in Colombia faced tenuous access to health services. Of the 1.8 million Venezuelans in Colombia, an estimated 730,000 have regular migration status as of July 2021, meaning they entered Colombia through regular legal pathways and, thus, possess legal documentation. This status confers access to many benefits including the ability to enroll in the health insurance system, which broadens services available through the national healthcare system beyond emergency care, prenatal care, and other public health services, such as vaccinations, which are available to those without regular migration status (UNHCR 2021; UNHCR 2019; Ministerio de Relaciones Exteriores 2021; Bojorquez-Chapela et al., 2020). However, of these 730,000 Venezuelans with regular migration status, only 383,000 were affiliated with the national health insurance system as of July 2021 (Colombia et al., 2021). Previous studies in this context have found that accessing these services can be impacted by external factors such as administrative barriers, the availability of resources, and the interpretation of regulations by service providers (IRC 2022; Giraldo et al., 2021).

Existing research has demonstrated that the COVID-19 pandemic has contributed to increased social and structural vulnerability among Venezuelan refugees and migrants, including difficulties accessing care, housing instability, food insecurity, experiences of gender-based violence and xenophobia (Zambrano-Barragan et al., 2021; Zulver et al., 2021; Parkin Daniels, 2020; Espinel et al., 2020; Brito, 2020; Bojorquez et al., 2021; Zapata and Prieto Rosas, 2020). Research on migrants in other contexts has found they experience a higher burden of COVID-19 attributed to inabilities to maintain social distancing measures due to financial necessity, employment in high-risk occupations, overcrowded accommodations, and barriers to healthcare such as inadequate information and language barriers (Hayward et al., 2021).

Migration policies have changed in parallel with national COVID-19 policies; key COVID-related events and policy changes are detailed in Fig. 1. As with many countries, researchers have found that high poverty rates, unemployment, and continued delivery of essential services that forced a large portion of the population to continue working outside their homes challenged residents’ ability to adhere to prolonged lockdown measures (Idrovo, 2021; Fernández-Niño and Peña, 2021; Schultz et al., 2021; Blofield et al., 2020). To support compliance with lockdown measures and reduce transmission opportunities, particularly for people with vulnerable health conditions, Colombia enacted Decree 521, allowing healthcare providers to have three months’ reserve of medication sent to individuals’ homes and expand telehealth services (MdSyPS Colombiano, 2020). Official crossings along Colombia's border with Venezuela were closed from March to early April 2020 when international corridors formally re-opened for humanitarian passage between Colombia and Venezuela. The extent to which the COVID-19 pandemic and associated mitigation efforts and policies affected access to healthcare for Venezuelan migrants and refugees in Colombia is unknown.

Fig. 1.

Timeline of COVID-19 Related Events Affecting Venezuelan Migrants and Refugees in Colombia (MdSyPS Colombiano, 2020; MdSyPS Colombiano, 2020; Colombia, 2020; Web, June 2020; UNHCR 10 April 2020; Colombia, 2021).

This manuscript builds on the existing research by assessing the qualitative impacts of the COVID-19 pandemic on migration patterns, provision of and access to healthcare and HIV services, and other lived experiences in Colombia from the perspectives of Venezuelan migrants and refugees, as well as key stakeholders in Colombia.

Methods

This qualitative research was conducted to inform a multi-site cross-sectional survey evaluating HIV and other health outcomes among Venezuelan migrants and refugees in two metropolitan areas in Colombia: 1) Bogotá and Soacha metropolitan area and 2) Barranquilla and Soledad metropolitan area (Wirtz et al., 2022). These sites were selected due to their high concentrations of Venezuelan residents, and their lack of HIV services available through humanitarian channels as can be found in other cities such as Cúcuta. Qualitative formative research was conducted to inform study design, logistics and measures for the parent survey. This study was led by a multi-disciplinary team, including Red Somos, a Venezuelan-Colombian community-based organization that provides social support, health, and legal services to Venezuelan migrants and refugees in Colombia; Johns Hopkins School of Public Health (JHSPH), an academic research institution with epidemiologic, clinical, and humanitarian health research expertise. Technical support was provided by the Ministry of Health and Social Protection.

Sample and recruitment: Formative research presented in this manuscript was conducted among two distinct participant groups: stakeholders and Venezuelan migrants and refugees residing in Colombia of diverse backgrounds. Stakeholders were individuals who worked within health and humanitarian networks, provided services, or had expert knowledge of the population. Inclusion criteria for stakeholders consisted of being aged >=18, employment of at least 1 year with an agency or organization in Colombia, had expert knowledge regarding migration or health of Venezuelans in Colombia, and consented to participation. Stakeholders were health care providers, government officials, and humanitarian workers. Participants worked for organizations which provide services in Bogotá, Barranquilla, Cúcuta, Arauca, Cali, Antioquia, Medellín, Maicao, Santa Marta, Cartagena, Soledad, La Guajira, and Venezuela, as well as on the national level in Colombia. A total of 29 stakeholders were interviewed. Stakeholders were purposively selected to represent a diversity of expertise and geographic location.

Eligibility criteria for Venezuelan migrants and refugees included: Venezuelan nationality, born in Venezuela, aged 18 years or older, migrated to Colombia as of 2015 or later, resided in Bogotá, Soacha, Barranquilla, or Soledad at the time of the study, and consented to participation. Participants were not asked to provide proof of nationality or birth. Candidates were not eligible for participation if they reported being in transit to a destination outside Colombia or lacked ability to consent. Data collection stopped at 39 participants once consistent redundancy of themes suggested proximity to saturation. Participants were selected using maximum variation sampling with a goal of enrolling diverse participants with representation across gender, age, location of residence, and HIV status.

Data collection procedures: Due to the onset of the COVID-19 pandemic, stakeholder interviews were conducted remotely by JHSPH staff via a secure videoconferencing platform from June – October 2020. Stakeholder interviews were conducted in both English and Spanish depending on the interviewee's preference.

Interviews with Venezuelan migrants and refugees, or key informants, (n = 31) were conducted by Red Somos staff remotely via a secure videoconferencing platform from April – June 2021. One focus group discussion (FGD; n = 8) was conducted remotely with women of mixed HIV status without video to protect participants’ privacy. Interviews and the FGD were conducted in Spanish. Migrant participants received a remuneration of $30,000 Colombian Pesos (COP) (about $7.50 USD) for their participation.

All interviews and FGDs followed semi-structured guides. Open-ended questions and probes focused on the following domains: experiences and context of migration; social networks, support, and services; access to basic needs, housing and job stability, and experiences of discrimination in Colombia; health history, healthcare utilization, health conditions, and health events during the COVID-19 pandemic; wellbeing and mental health in the contexts of migration and the pandemic; and considerations for the future study. Interviews with stakeholders had an increased focus on policies, programs, and implementation of services and changes that occurred during early phases of the COVID-19 pandemic.

Qualitative analysis: Interview summaries were generated immediately following data collection. Summaries and debriefing meetings were regularly conducted to review and assess depth of saturation. Audio files were transcribed verbatim by a professional transcription agency. Two qualitative analysts coded interview and discussion transcripts in their source language utilizing thematic content analysis to explore contexts and experiences along qualitative domains. The codebook was inductively developed based on research questions. Topical codes were applied to allow for sorting of quotations, followed by interpretive coding to organize into the themes displayed in this paper. Exemplary quotes displayed in this report were identified in the source language and translated to English by a professional translation agency. Translated quotes were reviewed by study staff for accuracy and edited for length and/or clarity. The remaining transcripts were then divided for coding by a single team member using ATLAS.ti 9 Cloud software.

Ethical considerations: Qualitative research activities conducted with Venezuelan migrants and refugees were reviewed and approved by the Ethical Review Committee at the Universidad El Bosque in Bogotá, Colombia, and the Johns Hopkins School of Public Health Institutional Review Board. The protocol was also reviewed in accordance with CDC human research protection procedures. Formative research with stakeholders was deemed not human subjects research by ethical review committees and commenced prior to other study activities.

Oral consent processes were used prior to conducting remote interviews with stakeholders. Written consent was obtained prior to all key informant interviews. All interviews and discussions were conducted anonymously. Additional COVID-19 prevention measures were employed at the study sites.

Results

Table 1 displays the demographic composition of stakeholder participants (SH). Participants included care providers, representatives of humanitarian organizations, and government officials.

Table 1.

Demographic characteristics of stakeholders (n = 29).

Demographic Characteristic	Participants N (%)
Mean age (SD, range)	41.8 (9.9, 24 – 63)
Gender
Man	16 (55%)
Woman	13 (45%)
Organization Primary Service Area*	(n = 24)
Healthcare Services	10 (41%)
HIV Services	6 (25%)
Policy	3 (13%)
Humanitarian Services	10 (41%)
*categories are not mutually exclusive

Table 2 summarizes the demographic composition of key informants (KI).

Table 2.

Demographic characteristics of key informants (n = 39).

Demographic Characteristic	Participants N (%)
Mean age in years (SD, range)	30.2 (5.9, 20 – 47)
Gender
Man	16 (41%)
Woman	23 (59%)
Migration Status
Regular	20 (51%)
Irregular	19 (49%)
Self-reported HIV Status
Living with HIV	12 (31%)
Not living with HIV	27 (69%)
Site
Bogotá and Soacha	24 (61%)
Barranquilla and Soledad	15 (39%)

Participants’ reported experiences focused around distinct areas: health and healthcare context prior to the COVID-19 pandemic; impacts on migration; impacts on health and healthcare; impacts on HIV care; impacts on humanitarian services impacts on structural determinants of health; and impacts on social support and stigma.

Health and healthcare context prior to the COVID-19 pandemic

Key Informants reported that access to healthcare was one of many motivating factors for migration to Colombia prior to the COVID-19 pandemic:

“Many people come to Colombia looking for stability in terms of the health system and access to medication. There are many people, we have health conditions, and there isn't medication in Venezuela” (KI2, 35, female).

Populations described unique reasons for migration. Pregnant individuals reported a desire to give birth in Colombia as a reason for their migration, attributed to fear of giving birth in Venezuela due to the standard of care available, a desire to acquire Colombian citizenship for their child, or lack of healthcare in Venezuela for their children.

“I was afraid to give birth in Venezuela in case the electricity failed; maybe there was no water or no supplies to attend to me at the time of delivery and afterward. There were no vaccines for the children at that time, not to mention all the other things regarding food, diapers, etc. That was one of the main reasons for me to come here. I already had information that they were taking care of pregnant women here, for example, and I knew that at least I was going to get good medical attention. I think that yes, many people leave Venezuela looking for better medical attention.” (KI1, 24, female)

Among people living with HIV (PLHIV), accessing HIV care was a major motivation for migration to Colombia; many PLHIV reported that they received their diagnosis in Venezuela, however they were unable to initiate antiretroviral therapy (ARV) until they had arrived in Colombia. Others reported that they had initiated treatment in Venezuela, but were then unable to acquire ARV, or were given expired medications:

“My decision to emigrate here was … because I'm a patient living with HIV and it was too difficult for me to find treatment in Venezuela, in Caracas, in fact, which is the capital. Many times they would even give us expired treatment, expired antiretrovirals, and one took them out of necessity… I decided then, in 2019 … to come here to Colombia once and for all. To leave everything behind in Venezuela and came here with only the clothes on my back to see if I could try to solve my health situation.”(KI10, 30, male).

“They gave me my positive diagnosis and I did not take the news well. Worse than that, there was no medication … they gave me these medications that were expired and said ‘Look, this is what we have, we are not giving this to you as the foundation… They are expired, but we are confident that they may be effective.’ They were like five years expired and despite this, I still took them… I went about a month and a half without taking anything, then more arrived… I never had a viral load test. I never knew if the medication was working for me … finally now I am taking medication and, thank God, have been able to get a viral load test.” (KI16, 27, male)

Accessing HIV care in Colombia was described as fraught, especially for Venezuelans with irregular migration status as it does not fall under definitions of emergency care. Healthcare providers reported seeing patients with exacerbated HIV conditions among arriving Venezuelans due to inability to access HIV treatment either in Venezuela or Colombia:

“Many arrive in deplorable conditions because of the advancement of the disease, to the point where – we see that their viral loads are too high and their CD4 are on the floor. These are patients where we have even had to find a way to hospitalize them” (SH12, 46, male)

“There's a big problem and it's that delays in attention complicate, in the case of people living with HIV, their viral load” (SH11, 43, male).

Migration status also shaped access to care for individuals not living with HIV. Venezuelans with irregular migration status are able to access emergency services through the Colombian health security system, however participants reported inconsistent and discriminatory practices in determining what qualifies as an emergency. One key informant expressed that “you have to, to put it bluntly, have your intestines hanging out, so that they will attend to you” (KI3, 47, male). Stakeholders’ reported the same frustrations surrounding emergency care:

“I have had cases of people who have arrived weighing 40 kgs with tuberculosis, syphilis, HIV, unable to speak, and almost unable to walk. They were not considered a vital emergency, and we have had to fight for the admission of these people and even seek ombudsmen. There are gaps in care” (SH1, 39, female).

“Sometimes we have a hard time because the on-call physician's perception varies; I do not understand why; when it comes to defining whether or not it is a vital emergency” (SH2, 48, male).

Although Colombian policies dictate that emergency services be provided to Venezuelans free of charge, participants also often reported unanticipated and arbitrary charges:

“At the health center, say it's an emergency, it depends on the situation, there are ways. I know there is a fund to help finance [care] for migrants, because they still charge them knowing it's an emergency. They keep them there, give them the run around. If someone advises them well, they are able to leave there okay, without paying,” (KI5, 46, female).

Key informants, especially those with irregular migration status, reported a lack of knowledge as a barrier to accessing healthcare. Participants reported that local humanitarian organizations facilitated access to care, but that many Venezuelan migrants and refugees were unaware of these services. One participant explained, “It's that really when one arrives, you arrive with your eyes closed, because we come accustomed to a totally different way. One arrives totally lost” (KI8, 24, male).

Migrants and refugees with regular status reported distinct barriers to care, but still relied on humanitarian organizations for support. These barriers included bureaucratic complexity and prohibitive delays to get appointments through the national health security system:

“I wanted to go to the odontologist. Last year I was on a contributory plan .... My molar broke. I went with half my molar in my hand with intense pain and they told me, “Your appointment is in two months." I said “But I am in pain, I have the piece of my tooth here, it's broken and it hurts." No, there is only an appointment in two months. I haven't used any other service. Same for my children” (KI12, 33, male).

COVID-19 impacts on migration

Participants reported that during border closures, there was still significant, but reduced, informal foot traffic of Venezuelans crossing the border in both directions:

“The proximity makes it possible for people to move between Colombia and Venezuela. The situation of the pandemic and other things have made many Venezuelans residing here in Colombia … [return] to Venezuela, regular or irregular. The fact is that they move easily between Colombia and Venezuela” (KI9, 29, male).

Stakeholders and key informants reported that many migrants and refugees returned to Venezuela, either to wait out the pandemic with their family and/or because of loss of employment in Colombia:

“COVID's situation in [Colombia] is forcing many Venezuelans to leave the country because… they do not have a livelihood. So they prefer to return to their country where they can have a place to live that does not cost them what they have to pay in Colombia. They also have family support networks or access to food through community or family management” (SH3, 43, male).

It was also reported that many ultimately return to Colombia, often out of financial necessity, as the pandemic endured longer than anticipated. Conversely, other Venezuelans remained in Colombia during the early stages of the pandemic, then returned to Venezuela in response to emerging pandemic hardships: “People who have been kicked out of the places where they were living…have gone to live on the streets. This has increased their vulnerability and has made many Venezuelans finally decide, "I prefer to go back to Venezuela” (SH4, 40, male). One participant also reported knowing Venezuelan families who migrated to Colombia very early in the pandemic out of distrust of the Venezuelan state's ability to respond to the pandemic: “When the quarantine started, some Venezuelans decided to migrate immediately to Colombia due to the health situation in Venezuela. Many people from Venezuela came to Colombia, where their family was already established here in Colombia” (SH5, 48, male).

While much of the border remained closed, two official border crossings opened in April 2020. However, these crossings imposed daily limits on how many people could cross. Participants explained that because Venezuelans had traveled to these cities with the intention of crossing the border, bottlenecks developed as Venezuelans awaited their opportunity to cross, usually without housing, income, or accessible food as they waited: “[Crossings] are receiving about 80 people a day and [are open] only three days a week, which has necessitated that many people have been sleeping in the streets in various border cities” (SH3, 43, male).

Participants reported that the COVID-19 pandemic increased internal migration among Venezuelans in Colombia, pushing Venezuelans out of cities such as Bogotá to cheaper cities: “After the pandemic, many people had to look for something farther away and more economical because of eviction issues and things like that. Living in Bogotá is a little more expensive than going to Funza. To avoid returning to Venezuela, what many people did was move within Colombia to other small towns not too far from Bogotá. After the pandemic, they had to stay there because there was no other option” (KI12, 33, male). High rates of evictions among Venezuelans during the pandemic exacerbated the situation as well, which are discussed in more detail later.

Impacts of the COVID-19 pandemic on health and healthcare

The reported impact of the COVID-19 pandemic on health and healthcare was profound. As one participant noted, two primary study cities, Bogotá and Barranquilla (which is located in the Atlántico department), led Colombia in per capita infection rates at the time of interviews: “Currently Atlántico has become the first department, outside of Bogotá city, in highest COVID-19 contagion. … The metropolitan area has become a focal point of COVID, and Barranquilla practically has become the second highest city, after Bogotá” (SH8, 31, male). Care providers reported insufficient and/or severely delayed personal protective equipment (PPE), medications, staffing, and capacity in the initial stages of the pandemic:

“They say that the capacity of the ICUs in Barranquilla is almost collapsing. We are talking about 90%, 95% of the available capacity, there are no more beds. Here now they are deciding … who is the person they will help to survive” (SH5, 48, male).

“It has been very difficult to access personal protection elements. They are not readily available … we have to be very vigilant” (SH4, 40, male).

A common theme in stakeholder interviews was that the COVID-19 pandemic response syphoned resources from the treatment of other illnesses. As one participant said, “it seems as though COVID has hidden all other pathologies” (SH6, 47, male). This phenomenon was not specific to Venezuelans; care providers reported that already existing difficulties were exacerbated, especially for indigenous peoples and those living in isolated communities:

“It is said that there are many indigenous people [in Leticia] who may be infected, and the problem is that the health services do not have sufficient response capacity. In addition, of course, the great distances will have a significant impact” (SH7, 47, female).

Key informants reported difficulties obtaining healthcare during this time without explicitly referencing the pandemic: “I have a pending surgery that they have spent eight months trying to do for me, and I haven't been able to [have the surgery] because the health system is in such a grave condition. There are so many difficulties, so many” (KI14, 33, male). Further, many individuals, of both Colombian and Venezuelan nationality, reportedly lost their health insurance due to the economic shocks, as health insurance is employer-provided in Colombia: “Unfortunately, they lost their jobs in March and April, and they lost their medication in April-May. That is to say, the little opportunity they had…COVID-19 took it away” (SH9, 58, female). Participants reported this despite the establishment in March 2020 of Decree 417, which safeguarded persons who lost their health insurance during the pandemic (Colombia Pd 2020). This protection ended along with other temporary measures as the state of emergency expired in June 2020.

Due to early lockdown orders and subsequent capacity limits, there was a large shift in Colombia to telehealth services for both health visits and educational groups or workshops, and follow-up was often conducted through WhatsApp. This shift was particularly complicated for migrants and refugees due to the high turnover of cell phones and SIM cards, which cannot be registered if one does not have regular migration status. As such, it is common for irregular migrants and refugees to change SIM cards, and thus phone numbers, on a frequent basis. Providers reported that this shift to telehealth and WhatsApp was particularly disadvantageous to Venezuelans for this reason and complicated their efforts to follow-up with Venezuelan patients: “Lately, the most essential thing for Venezuelan migrants is to have a telephone, but this has been reduced… you leave them messages, and they do not answer, [They say] ‘no, what happens is that I do not have the phone, I have no money’” (SH9, 58, female). Stake holders also noted that the cessation of presence-based services may disproportionately impact Venezuelan migrants and refugees due to lower levels of healthcare seeking behaviors within the population:

“We brought services to the population, which is to say, they didn't seek us out, rather we sought them out… [COVID] transformed reality, because with the social isolation and [decree] from the Ministry of Health, all these types of activities stopped… What we do is provide sexual health education from our houses … However, the challenge is still to be able to get back to distributing condoms and HIV tests. COVID-19 has stopped us” (SH10, 24, male)

Despite stakeholders’ concerns that a reliance on digital methods for care provision disadvantages Venezuelans, key informants reported a preference for virtual methods: “Now virtual is more comfortable. Virtual because many people won't even be able to pay for transportation … and people risk contracting COVID and many don't even have medical insurance” (KI14, 33, male).

Reflecting on Decree 521, (MdSyPS Colombiano, 2020) which allowed 3 months’ supply of medication to be sent to patients’ homes, it was widely reported that home delivery of medications was often unsuccessful or impractically delayed and ultimately people found it necessary to leave their homes to acquire their medication, although this was not unique to migrants and refugees. In addition to logistical difficulties in disbursing medication through these channels, providers also reported that sometimes EPSs would only provide one month's medication at a time.

“You call the insurance lines, the EPS, and the different entities here; they do not answer. They say that supposedly they will take the medicines to your home, but they are not taking them to your home either. It is a lie. In Barranquilla, none of this is being fulfilled” (SH6, 47, male).

“Patients ultimately had to go look for their medication at their EPS.... They had to give it for three months, but they don't give them the entirety, they only give them one month” (SH5, 48, male).

Many services and resources that were specific to COVID-19 were not made available to irregular migrants and refugees, such as government-funded PPE kits. One participant with regular migration status recounted a story in which he sought out a PPE kit and was told “you deserve a kit because you made the effort to find one, you paid for your passport, and you are here legally” (KI13, 31, male).

Impacts of the COVID-19 pandemic on HIV care

Stakeholders reported that ARV provision was complicated by the pandemic, but that they were largely able to avoid an interruption of services for PLHIV: “These processes have been delayed, there are delays in distribution, there are delays in importing medicine into the country. However, we have been able to stay ahead of this. We've been able to provide for the patients we have” (SH2, 48, male). As with other medications, the government advised that PLHIV be given three months of ARVs at a time, however both stakeholders as well as migrants and refugees reported that ARV provision was plagued by the same difficulties previously discussed: “People say, ‘We are going to take [medicine] to your house immediately’ it turns out that it is not immediate. They take them 15 days, 20 days later, after legal advice has been given or after a call has been made or it is said that the person needs the medicines” (SH5, 48, male). Stakeholders reported that they were not always able to provide three months’ supply at once, but were able to continue providing monthly prescription refills. Due to delays in acquiring medication, one organization reported the deaths of three individuals who were unable to access their medications in an appropriate timeline: “Ultimately here in Barranquilla three people living with HIV have died and they had looked for help to get medication on the national level” (SH5, 48, male). Humanitarian organizations also reported that the loss of health insurance resulting from loss of employment resulted in interruptions to care for some PLHIV as they were diverted from the national health security system to humanitarian avenues: “Our programs have increased in number because there are a lot of regular [migrants] who ended up without work … and they can't obtain their ARVs. We have had to absorb these types of populations, so they can have continuity in their treatment” (SH2, 48, male). Humanitarian organizations also sent medications directly through the postal service to individuals who live outside of, and would otherwise travel to, Cúcuta or Bogotá to access HIV care. This increased the cost of providing each medication disbursement, but eased the burden of acquiring medications for patients. Participants living with HIV reported difficulty obtaining ARVs during this same time frame without explicitly referencing the pandemic: “To tell you the truth, I have spent months without taking [ARVs] because they didn't even have the decency to give me my medication” (KI14, 33, male).

Humanitarian organizations also reported that some Venezuelans with irregular migration status who had been receiving care and treatment were forced to return to Venezuela out of economic necessity, despite not having access to ARVs in Venezuela: “They intend to return [to Colombia] for treatment, but they do not dare to do so yet because they would arrive in a street situation. Being in a street situation at the time of COVID is doubly risky. So the decision they have made is to return to Venezuela” (SH2, 48, male). Some organizations were able to provide such patients with a few months of medication at a time to hold them over while in Venezuela: “There are some patients that have crossed the border whom we see in Cúcuta who come to pick up [medication],and, depending on our availability, we try to give them one or two months’ worth, so they have to return less frequently and have at least this time, because we do not know how long COVID is going to last. There are others who have gone to Venezuela and have had to stop taking their antiretroviral treament” (SH2, 48, male). Providers continued to follow these patients remotely over WhatsApp and other social media. UNAIDS also assisted in delivering medication to some of these patients in Venezuela and the WHO and Global Fund donated antiretrovirals to Venezuela. One organization estimated that of their patients who returned to Venezuela, approximately 35% were able to continue accessing treatment. In the same interview, another stakeholder from the same organization added: “This is important because it's not like they ended up on the other side and received nothing, no … 35% of them have been able to get their ARVs, but that's not attention, only antiretrovirals, nothing else…. Also, within that 35%… some of them have decided to buy medicine themselves in Venezuela, which is very expensive, the prices are extremely high” (SH14, 52, female).

The same organization said that they had generally not seen adherence impacted among their patients who remained in Colombia, but primarily among those who returned to Venezuela. This experience was echoed in interviews with other providers, although accessing care was generally complicated. One organization located in Barranquilla, whose services previously consisted of care navigation and social support, began purchasing medication themselves to help meet the needs of their community: “Most IPSs deliver antiretroviral drugs to users insured by the Health System. It has been quite complex; we have had to buy medicines to meet the demand of the users that we have” (SH8, 31, male).

One participant reported that increasing numbers of PLHIV who had not wanted to start treatment were beginning to seek services due to heightened sense of health vulnerability brought on by the pandemic: “As a result of the pandemic, something very significant is that people who had not wanted to start HIV treatment have begun to seek health services due to the pandemic. Why? Because they have felt more vulnerable. They have seen the consequences of the coronavirus” (SH7, 47, female).

Impacts of the COVID-19 pandemic on humanitarian services

Prior to the COVID-19 pandemic, humanitarian organizations were reported to be a major facilitator to accessing care for migrants and refugees with both regular and irregular status: “Here, currently, the only opportunity that every migrant sees is humanitarian aid” (KI7, 27, female). During the pandemic, these services reportedly expanded to include COVID-19 vaccinations, nutritional kits, biosecurity supplies, and more. Migrants and refugees reported that the facilitating role these organizations played was amplified after the pandemic's onset. Organizations which provided medications or clinical care augmented existing services by providing nutritional kits and PPE during medication pick-up.

Stakeholders, however, also reported financial difficulties due to the pandemic's onset. The cost of providing care would often increase due to increased PPE and sanitation costs: “It has been very complicated, and I'm talking about community organizations, to adapt to protocols and be able to access PPE, because this isn't something that we expected and the costs are very high and not all [organizations] can access them” (SH1, 39, female). Organizations also absorbed the cost of mailing medications and faced larger upfront costs as they provided larger quantities of medications per disbursement: “There were some [organizations] who already had ambulatory services, and they could respond a little more quickly, but there are others for whom this whole issue of being able to mail medications to patients’ houses, for example, has been difficult” (SH7, 47, female).

Other humanitarian services which had been in the process of opening new sites or services were forced to delay or close. “Last year was so good for them that we even had a center; there was even an attention center for migrants, specifically Venezuela. But unfortunately, with this pandemic, the center was closed, and everything was closed” (SH9, 58, female).

COVID-19 pandemic impacts on structural determinants of health

Housing, food, and job insecurity were widely reported as the most significant issues facing migrants and refugees as a result of the COVID-19 pandemic:

“The difficulty of access to essential services, food, and housing. Mainly, perhaps the most significant problem that the Venezuelan population has is being able to pay the rent where they live and food; these are probably the two most important and most profound needs. When I say conditions are severe, because many are without food, they have nothing to eat, given the impossibility of working during the quarantine period”

(SH4, 40, male).

Evictions were one of the most frequently discussed COVID-related difficulties, especially among Venezuelans with irregular migration status. Although evictions were legally prohibited during this time, participants reported high levels of housing instability and homelessness because many Venezuelans had informal housing at the onset of the pandemic and were not legally covered by this protection.

“They have been taken out of their respective places where they used to live because they cannot pay, so they are living together so as not to have to leave for Venezuela; imagine that. So you find groups of 15, 20 people living in one apartment” (SH9, 58, female).

A key informant said they “have known people who have moved up to five times in the same neighborhood… I saw a lot of that because there were many dislodged people. They were evicted a lot” (KI11, 29, female). In interviews the heightened risk of eviction was not only attributed to job insecurity, but also discrimination: “We have been accompanying the migrant and refugee population to prevent evictions in the last three months because we have realized that they are being evicted during the COVID-19 pandemic for the fact that they are Venezuelan, that they are foreigners” (SH10, 24, male).

Before humanitarian organizations were able to consistently offer PPE, participants reported that the financial situation of some Venezuelans was so dire that they could not purchase masks: “Public services, water, and electricity continue to be charged… Some do not have enough to buy a face mask because they prefer to buy a piece of bread than buy an expensive face mask. A portion of bread can cost 500 COP in the store, and a face mask costs 3000 COP” (SH5, 48, male).

Impacts of the COVID-19 pandemic on social support and stigma

During lockdown measures, Venezuelans reported a comfort with digital methods to maintain connections, spread information, and access telemedicine and other forms of support. One key informant noted that prior to the COVID-19 pandemic, Venezuelan migrants and refugees were used to using digital methods to maintain social support: “Even before the COVID-19 situation, we Venezuelans were adept at managing digital strategies and establishing support networks across countries. Digital methods have been essential” (KI15, 28, male).

Stakeholders reported concerns of elevated xenophobia in Colombia after the onset of the COVID-19 pandemic: “The xenophobia phenomenon skyrocketed in the last three months abruptly. I am not exaggerating” (SH10, 24, male). Several stakeholders reported that they had heard claims Venezuelan migrants and refugees were driving infections in Colombia: “Even xenophobia may now be more evident than ever. Some have even blamed Venezuelans for the epidemic in Colombia” (SH4, 40, male). Stakeholders also reported perceiving anti-immigrant attitudes within Colombian institutions: “The phenomenon of xenophobia was triggered by the pandemic… unfortunately, also by declarations of local governments, which many said at the time that Venezuelan migrants and refugees were not the responsibility of local governments and that there was no budget for them, that they were the responsibility of national entities, and they washed their hands of the matter” (SH10, 24, male). Although they did not reference the pandemic specifically, Venezuelan migrants and refugees reported perceiving similar sentiments: “There are people who generalize and deepen the xenophobia, who are like ‘Venezuelans came here to rob us of everything, to take things from us’ or ‘they are given everything, they should go back to their country’” (KI10, 30, male).

One participant summarized the situation for Venezuelans as such: “There is a lot of fear in the Venezuelan population. Of having to go to quarantine, that many Venezuelans depended on their work in the street and did not have a livelihood, that many social programs of the State did not take them as a really vulnerable population for attention and that they can really access many of the State's benefits. Faced with this impossibility, many Venezuelans have seemed really affected” (SH4, 40, male).

Discussion

Access to health services and HIV care has historically been complicated by migration status in Colombia and these complications were exacerbated by the pandemic. Changes to migration policies, including border closings, also had unintended effects on maintenance of treatment and access to healthcare among this population. These results reinforce and expand upon the existing literature exploring the impacts of the COVID-19 pandemic on Venezuelans in Colombia (Zambrano-Barragan et al., 2021; Parkin Daniels, 2020; Zambrano-Barragán SRH et al., 2021; R4V 2021).

Key impacts on healthcare service provision include the shift to telemedicine and household delivery of medications, when possible, as well as the increased mobility of the population and the need to service persons living outside of organizations’ catchment areas. The results show an exemplary effort by service providers to ensure the continuity of care and highlight the critical role of humanitarian services in supporting this population.

The loss of employment and housing experienced by Venezuelans during the COVID-19 pandemic in Colombia is a key finding of this study. Previous work identified homelessness as the main consequence experienced by Venezuelans who were evicted during the pandemic with 75% of participants who experienced eviction reporting homelessness; followed by 61% of whom experienced increased risk of contagion (from COVID-19), and 44% who reported lack of access to basic services (R4V 2021). This same survey showed that in households of five or more people, 60% were residing in a dwelling with 0 or 1 bedrooms (R4V 2021). Such impacts on these structural determinants of health were reported in these interviews to increase risk of violence victimization, contribute to the loss of basic services, and increase the risk of COVID-19 transmission and acquisition. These findings strengthen existing literature conceptualizing increased vulnerability among this population due to the pandemic (Espinel et al., 2020; Brito, 2020; Bojorquez et al., 2021; Zapata and Prieto Rosas, 2020).

Many of the barriers to equal access to health services faced by migrants and refugees are similar to those faced by the most vulnerable Colombians. However, these obstacles can be aggravated by xenophobia, discrimination, administrative barriers, and lack of knowledge of rights and care routes by both migrants and refugees as well as health service providers (Giraldo et al., 2021).

As in many countries, the COVID-19 pandemic exposed the differential impacts of public health emergencies across socioeconomic status, which if addressed, could improve access for both Venezuelans and vulnerable Colombians. A nationwide retrospective analysis of COVID-19 cases in Colombia from March to October 2020 demonstrated increased hazard of death among people with subsidized health insurance regime and in people living in the very low socioeconomic strata (Cifuentes et al., 2021). While case rates and mortality estimates were not reported by nationality or migration status, these findings coupled with our qualitative findings and extant literature, suggest that Venezuelan migrants and refugees may have been at greater risk of SARS-CoV-2 infection and associated illness and mortality given typically lower socioeconomic status and access to health insurance.

Colombia has made several advances in the social and economic inclusion of migrants and refugees, (Bank, 2021) as well as in their regularization (News, 2021). Most notably of Colombia's increasingly progressive migration policies is Decree 216 of 2021, establishing the Temporary Protection Statute for Venezuelans (ETP) which provides social protection for Venezuelan migrants and refugees for 10 years. By the end of 2022, it is anticipated that roughly 900,000 additional Venezuelans will be affiliated with the national health security system and that this number will reach over 2 million in the next decade (UNHCR 2021). Despite these positive trends, it remains necessary to continue moving from an emergency approach towards a response based on institutional strengthening and sustainability.

During the initial COVID-19 response, social protections for Venezuelans in Colombia were often ambiguous, imprecise, or inconsistent; (Vera Espinoza et al., 2021) however, Colombia has since introduced legislation to broaden and clarify these social protections. The impacts of this ambiguity were echoed through this paper's findings, highlighted by reports of lack of knowledge among both migrants and refugees as well as care providers; and difficulty navigating bureaucratic barriers – both of which often resulted in severely delayed or altogether abandoned care acquisition. Similarly, these findings underscore the existing discussion regarding the provision of immediate and short-term responses to the needs of migrants and refugees’, the burden of which has primarily fallen to community-based organizations (Blofield et al., 2020; Vera Espinoza et al., 2021; IOM 2021).

Several findings from this study have utility to inform policy decisions for future outbreak response in humanitarian crises. Other investigators have expressed concern that Colombia's closed-border response to the COVID-19 pandemic may encourage a negative view of migrants and refugees and increase their health risks (Fernández-Niño et al., 2020). We found evidence of these concerns through reports of experiences of pandemic-related xenophobia; increased housing and food insecurity; and interruptions to chronic disease management.

Our findings should be viewed in light of study limitations. Responses by stakeholders and key informants may not all be complementary given that their interviews occurred during different phases of pandemic response. Because interviews were conducted in Colombia, migrants and refugees who returned to Venezuela were not included in this research and their experiences were reported second-hand. While reports were consistent, the distinct experiences of these migrants and refugees may be underreported.

Strengths of this study include the size and diversity of the sample, allowing for the capture of varied backgrounds, experiences, and perspectives; the reputation of and trust key informants have in the implementing partner, facilitating the sharing of sensitive experiences; and the timing of data collection, allowing for reports of experiences during varied phases of the progression of both the pandemic and national policies.

Conclusions

Venezuelan migrants and refugees, as well as the agencies serving this community were uniquely affected by the COVID-19 pandemic in Colombia. Humanitarian organizations and healthcare providers reported oversaturation of care facilities, a shift to remote and telehealth care provision, financial difficulties, and a subjugation of non-COVID-19 pathologies. While not unique to migrants and refugees, these challenges collectively worsened provision of and access to health and social services for migrants and refugees in need. For Venezuelans residing in Colombia, the pandemic exacerbated existing vulnerabilities related to housing insecurity, loss of employment, and food insecurity. These factors often resulted in increased COVID-19-related risk as migrants and refugees adjusted to meet basic needs for survival. Under the recent ETP, access to legal services to support the regularization process for migrants and refugees can address multiple disparities in the ability to access basic rights, find gainful employment, and access healthcare. Findings also suggest intervention opportunities in future pandemic surges, including inclusive policy approaches and legal services to prevent evictions, support for nutrition and food programs, telehealth navigation, and financial cushions for organizations to absorb increased costs during a pandemic.

Ethics approval and consent to participate

Study activities with Venezuelan key informants were reviewed and approved by the ethical review committee at the Universidad el Bosque in Bogotá, Colombia, and the Institutional Review Board at Johns Hopkins School of Public Health. The protocol was also reviewed in accordance with Centers for Disease Control and Prevention human research protection procedures. Formative research with stakeholders was deemed not human subjects research; all stakeholders provided oral consent. Written consent was obtained from all key informants.

Consent for publication

Not applicable

Availability of data and materials

The datasets used during this study are available from the corresponding author upon request and approval.

Authors contributions

ALW, PS, KP, RLN, JRG, and MS conceptualized the design of the study; JRG, ALW, and MS designed the interview guides; KGB and SA coded the qualitative data; JRG was the site principal investigator in Colombia; MS coordinated the overall study and conducted stakeholder interviews; JO, JJL, JFR, CQ, AV, YM, and FR supervised and coordinated data collection at each site; RLN, JAFN, and MBT provided expert input to interpretation of findings. MS wrote the initial drafts of this manuscript. All authors reviewed, contributed to, and approved this manuscript.

Funding

This work was supported by the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) through the U.S. Centers for Disease Control and Prevention under the terms of Cooperative Agreement number NU2GGH002000–03–01. Centers for Disease Control and Prevention investigators do not interact with human subjects or have access to identifiable data or specimens for research purposes. The contents of this paper are solely the responsibility of the authors and do not necessarily represent the official position of the funding agencies.

Declaration of Competing Interest

The authors declare that they have no competing interests.