Immigration Removal Centres and HIV Clinical Care Jane Anderson Homerton University Hospital NHS Foundation Trust

Background Many asylum applicants come from countries with high background rates of HIV HIV is rarely seen as a legal reason to remain in the UK Access to HIV care is unequal and problematic Stigma impacts on disclosure

National AIDS Trust Survey Questionnaire survey of health care managers in 10 IRC 2005/6 159 detainees known to be HIV positive 140 diagnosed before detention 28 pregnant women 91 on ARVS

What can HIV Therapy offer in 2008? Improved quality of life Less HIV-related morbidity and mortality Restoration and/or preservation of immune function Maximal and durable suppression of HIV viral load Prevention of vertical transmission Prevention of transmission to sexual partners Preservation of future treatment options 1/08

Current Antiretroviral Medications 1/08 Atripla

“We believe that every person with HIV is entitled to a uniformly high standard of medical care. These standards are therefore applicable to the care of all adults living with HIV in the UK.”

“The new paradigm should be aiming for an undetectable and durable HIV plasma viral load suppression, wherever possible, leading to immunological improvement with lack of clinical progression and improvement in quality of life” Gazzard et al. BHIVA guidelines for the treatment of HIV-infected adults with antiretroviral therapy HIV Med Nov;7(8):

Circulatin g drug Viral replication Resistance

Inadequat e levels of drug Personal factors Toxicity Low potency Wrong dose Poor absorption Rapid clearance inadequate activation Drug Interactions Structural factors Intermittent dosing

Stopping drugs with different half-lives 0 Time (hours) Drug concentration Zone of potential replication Based on Taylor S et al. CROI 2004 Abs 131 Functional monotherapy Last dose

Basic Information How long has the HIV diagnosis been known? What is the nadir CD4 count? What is the most recent CD4 count? Higher risk if either is below 200 cells/mm 3 Is the patient on antiretroviral drugs? Primary or secondary prophylaxis?

Is the patient sick? How long has the HIV diagnosis been known? Thorough history and examination Remember unusual things are less unusual Usual things may look un - usual Could this be iatrogenic?

ARVs Is the patient on antiretrovirals? Are the drugs with the patient? Which ones? For how long? Stable? Effective? Has the patient been assessed by the local HIV clinic?

Who knows what? What's been happening in the IRC? Newly diagnosed? Data from the usual treating clinicians Data from local HIV treating clinicians NGO involvement

How IRCs should support those living with HIV during detention and the removal process How can NHS HIV specialist clinicians best work with IRCs? Access to high-quality clinical primary care services and secondary care with expertise in HIV and associated specialties Appropriate clinical handover to ensure continuity of care HIV testing (diagnosis for those infected) and prevention (for those uninfected) BHIVA/NAT project

Useful Resources British HIV Association (BHIVA) British Association of Sexual Health and HIV (BASHH). National AIDS Trust (NAT) Terrence Higgins Trust (THT) International HIV/AIDS Alliance