New guidelines for treating HIV-positive refugees and migrants

Machozi is a young HIV-positive woman from the Democratic Republic of Congo who fled to Zambia to escape the conflict in her home country. Her health is failing, and with a CD4 count (a test that measures the strength of the immune system) of 124, her doctor advises her to begin antiretroviral treatment (ART), but Machozi tells him she has decided to return to the DRC.

The small health centre in her home village is staffed by one nurse and often lacks any drugs. Under these circumstances, should her doctor still begin ART?

Providing HIV care and treatment to Southern Africa's estimated 300,000 refugees and asylum seekers, and an unknown number of undocumented migrants, presents health workers with enormous challenges. National HIV policies do not provide answers for doctors faced with situations like these.

Now the Southern African HIV Clinicians Society, in partnership with the United Nations agency for refugees (UNHCR), has released a set of guidelines that focus on providing ART to displaced populations. They include advice on how to deal with patients who have been on ARV drugs that are not available in their new country, who do not speak the language, or have been traumatised by experiences in conflict areas.

"With ARVs now available all over the region, we had the situation of people crossing borders with a handful of pills, showing up at a clinic and saying 'treat me'," said Francois Venter, director of the Clinicians Society. "It was creating some very complicated clinical situations."

International human rights laws and many local constitutions guarantee access to health care as a basic right for all, but national laws often fail to enshrine these rights. Even where they do, implementation often depends on the attitudes and knowledge of health workers.

Policy makers - take note

In South Africa, where the law guarantees refugees and asylum seekers access to the national ART programme, individuals often report being turned away from health facilities when they cannot produce proof of South African citizenship. Economic and undocumented migrants face even higher levels of discrimination by health workers.

"Some health care workers are under the impression they're there to ration care," said Venter. "We're trying to say to clinicians they have an ethical duty to treat patients."

Although the guidelines are meant as a practical desktop reference rather than an advocacy tool, Venter was hopeful that policymakers would "look at it carefully."

Laurie Bruns of UNHCR viewed the guidelines as one step closer to the goal of "a harmonised treatment programme in the region that would give treatment to anyone who needs it."

A 'Mythbusters' section of the guidelines lays to rest accepted wisdoms often presented as reasons why refugees and migrants should not access ART. Dispelling the perception that displaced people are too mobile to adhere to treatment, the guidelines note that refugee populations remain in their host countries for an average of 17 years.

Machozi's story is one of several case studies presented at the end of the guidelines to give health workers real-life examples to work from.

The Clinicians Society will distribute the guidelines and a poster summarising some of the key points to their 12,000 members in the region, as well as nongovernmental organisations (NGOs) working in the HIV/AIDS sector and health departments.

UNHCR is working to inform refugees about their rights to health care via outreach programmes and its partnerships with NGOs, and facilitating access to ART through interpretation services and referrals.