Migrant access to HIV care - Testing should always be free

Thursday 28th November 2013

The BMJ recently summarised the data on the extent to which migrants are a drain on NHS resources.1 In this regard the problem of HIV 'tourism' by the known HIV-infected is minimal. Moreover, while some visitors get HIV-tested at Sexually Transmitted Disease (STD) clinics, the numbers are modest and early diagnosis and treatment reduces the costs of care and infectiousness of those found to be HIV-infected.

Among 65,240 adults receiving HIV care in 2010, 2,560 (4%) had no evidence of receiving care in 2011. Of these 510 (20%) were UK born and an estimated 1800 (71%) were long-term UK residents born abroad (based on country of birth and date of arrival). This leaves an estimated 250 patients (0.38% of the overall 65,240) who were likely to have been short-term residents (<2 years), of whom 180 (0.28%) had ever received antiretroviral therapy.

A clinical audit2 of 2,198 patients not receiving HIV care in 2011 showed that 573 (26%) had left the UK, and no information was available on 618 (28%) patients. Extrapolation to the total suggests that between 700 and 1400, who received HIV care in 2010, left the UK by the following year. More detailed data on 195 cases who had left the UK showed that 32 (16%) were UK born, 116 (60%) had been in the UK at least two years, and 47 (24%) for less than 2 years. Therefore, short term visitors accounted for between 170 (0.3%) and 340 (0.5%) of individuals receiving HIV care during 2010. Furthermore, free text notes stated mentioned 7 of 22 non-residents as receiving emergency assessment and care for acute illness but not ongoing anti-retroviral medication.

HIV testing of those at higher risk occurs predominantly at open access STD clinics. In 2011 and 2012, 11.5% of 2.03 million clinic HIV tests were conducted on attendees born outside Europe including 193,215 tests on heterosexuals and 24,175 on men who have sex with men (MSM). Almost all HIV tested attendees born outside Europe were described as UK residents. Only 6,629 (0.3%) were either known to be visitors or of unknown residence and 79 of these were diagnosed with HIV infection. Over 90% of those diagnosed with HIV infection will have commenced anti-retroviral therapy and become non-infectious within a few months of diagnosis.

The data show that the receipt of specialist HIV care by short term visitors is rare, and when it does occur may reflect unplanned emergency care. In contrast, open access to STD clinics is an essential service, which provides earlier diagnosis of infectious HIV in visitors. Although the treatment of a sexually transmitted disease at an STD clinic is excluded from charging3, there is currently ambiguity around charging for an STD investigation4, including HIV testing of asymptomatic persons. This should be resolved now that routine HIV testing is recommended for general medical admissions, and new registrants at GP practices in high HIV prevalence areas of the UK.5 In order to incentivise the early testing and diagnosis that is essential for HIV control, it is vital that all possible information is conveyed to health care professionals and migrants alike that HIV and STD testing and treatment is free.

Valerie C Delpech1, (Consultant Epidemiologist and Head of HIV section),
Hilary Curtis2 (Clinical Audit Co-ordinator)
Alison E Brown1 (Principal HIV Scientist)
Edmund Ong3, (Honorary Clinical Senior Lecturer)
Gwenda Hughes1 (Consultant Epidemiologist and Head of STI section)
O Noel Gill1 (Consultant Epidemiologist and Head of HIV and STI Department)

1 HIV and STI Department, Centre for Infectious Disease Surveillance and Control, Health Protection Directorate, Public Health England
2 British HIV Association
3 Department of Infection & Tropical Medicine, Royal Victoria Infirmary, Newcastle

References:
1 Arie S. Are migrants a drain on health systems? BMJ 2013; 347: f6444.

2 British HIV Association and Health Protection Agency. Clinical Audit: People with diagnosed HIV infection apparently not in care. 2013. (http://bhiva.org/documents/ClinicalAudit/FindingsandReports/NotInCare2013webversion.pptx).

3 HIV treatment for overseas visitors in England from 1 October 2012 (https://www.gov.uk/government/publications/hiv-treatment-for-overseas-visitors-in-england-from-1-october-2012).

4 The National Health Service (Charges to Overseas Visitors) Regulations 2011. (http://www.legislation.gov.uk/uksi/2011/1556/made). Accessed 12th November 2013.

5 National Institute for Health and Care Excellence. Increasing the uptake of HIV testing among men who have sex with men and increasing the uptake of HIV testing among Black African communities in England. March 2011. (http://publications.nice.org.uk/increasing-the-uptake-of-hiv-testing-among-men-who-have-sex-with-men-ph34; http://www.nice.org.uk/guidance/PH33). Accessed 12th November 2013.

Source: http://www.bmj.com/content/347/bmj.f6444?tab=responses