Access to HIV treatment Issues of working with HIV positive refugees and asylum seekers Linda McDonald MA MSc RN

Background Refugee A person who has a well-founded fear of persecution for reasons of race, religion, nationality, membership of a particular social group or political opinion and who is outside the country of his nationality or formal habitual residence and is unable or, owing to such fear, is unwilling to avail himself of the protection of that country or return to it ( Refugee Convention article 1A)

Asylum seeker in the UK a refugee as defined by the refugee convention refusing the application would mean returning to a country where his life or freedom would be threatened….

Article 3 of the Human Rights Convention An asylum seeker who would suffer torture or inhuman or degrading treatment or punishment if returned to his/her country of origin, should not be expelled from the UK.

Economic impact on UK There has been an increase in individuals seeking asylum in the UK CDSC reports that most HIV positive individuals in the UK contracted their infection abroad The cost of HIV treatment and care has escalated in the last few years More and More HIV positive individuals are being refused permission to remain in the UK on compassionate grounds

Who is eligible for NHS treatment If individual has permanent residency in the UK Students on a course longer than six months Refugees/asylum seekers who have made an application to remain in the UK If individual has been detained by the immigration authorities If individual has diplomatic status If from a country with a reciprocal agreement with the UK

Who is not eligible for NHS treatment Visitors Students on a course less than six months Individuals who are intending to seek Asylum or Refugee status in the UK, but who have not yet submitted an application to the Home Office Illegal immigrants

Exceptions A&E treatment Diagnosis and treatment of some communicable diseases (not HIV) Compulsory treatment of psychiatric treatment District Nursing, midwifery and health visiting

VD ‘‘V’ NHS regulations National Health Service (1982) Access to hospital treatments regulations HIV treatment available only to eligible individuals HIV testing is free, treatment is not (HIV is not considered a communicable disease under the Act)

Venereal Diseases 1976 Regulations Treatment of STI’s is free and patients are not required to give names or addresses All HIV prescribing is done under the auspices of GU clinics As patients can remain anonymous, therefore no way of checking who is eligible for HIV treatment However, if patients are admitted to hospital, they are out of the GU cocoon and will be expected to pay

Challenges for GU clinics HIV positive individuals often assume that as treatment is free in the GU clinic, it will be in all other aspects of health care Different interpretation of venereal disease regulations by clinics Clinicians put under pressure to commence patients on ARV’s earlier than they would wish to support asylum claims False personal details cause great confusion when responding to solicitors requests

Ethical/ Medical considerations Is it ethical/ good medical practice to commence treatment, when the patient may be refused leave to stay in the UK? HIV testing in pregnancy is recommended to all pregnant women. Is it ethical to test all individuals, when some may not have access to treatment? Patients who are known to be HIV positive come to the UK for treatment. This has added considerable pressure on the NHS to fund antiretroviral treatment, often at the expense of other HIV services. How do we respond?

What level of HIV care is available to individuals in detention centres? Will HIV testing be initiated at ports of entry? Is this ethically, legally or morally permissible?

Conclusion Diversity between NHS regulations/GU regulations mean HIV positive individuals, who may not be eligible, can access treatment and care through GU clinics However, NHS services may not be free outside the GU setting Interpretation of regulations vary between clinics