Dispersal of HIV positive asylum seekers: national survey of UK healthcare providers

Introduction

In April 2000, the UK National Asylum Support Service started a policy of dispersing asylum seekers from London and southeast England to alternative locations around the United Kingdom in an attempt to spread the cost of care.1 Although the number of people with HIV who are affected by this policy is unknown, more than 100 000 asylum seekers have so far been dispersed, many of whom are from regions with HIV/AIDS epidemics.2 Asylum seekers may only receive 48 hours' notice, and, if they decline dispersal, then they face immediate cessation of income, housing, and legal support. Decisions about the dispersal of HIV positive asylum seekers should take into account expert medical and professional advice as dispersal may detrimentally affect the health of HIV positive asylum seekers.3 We asked doctors working in genitourinary medicine about their experiences and opinions of the dispersal of HIV positive asylum seekers.

Participants, methods, and results

We sent an anonymous questionnaire (see bmj.com) to all lead clinicians in English genitourinary medicine clinics in December 2003. We excluded centres which do not treat HIV infected patients. We contacted doctors who work at more than one site only once. The questionnaire asked about the doctor's experience of and opinion about the appropriateness of dispersal in 10 clinical scenarios and also about perceived barriers to effective dispersal (table). For each centre we recorded its location and the number of patients dispersed.

Of 75 eligible centres, 56 returned questionnaires; 34 of these were outside London and a third (20) had had an HIV infected asylum seeker dispersed to them. A total of 13 centres had had patients dispersed both to and from them. Of those who did not respond, 15/19 were from outside London. Thirty six centres had no experience of dispersal.

Of the 56 returned questionnaires, often cited barriers to successful dispersal were dispersal at short notice (37) or with no prior arrangement (43). Only three centres had experienced appropriate transfer of care. Other barriers included lack of community support (41), lack of facilities to support vulnerable asylum seekers with psychological problems (43), and low staffing levels in the receiving centre (40).

Although the questionnaire did not ask for specific negative consequences attributable to dispersal, some doctors added spontaneous comments. These included problems relating to unintentional interruption to antiretroviral therapy (4), mother to child transmission of HIV infection (3), and HIV related death (2). Of 33 centres reporting experience of patients being dispersed away from their service, 19 had experience of dispersal against medical advice.

Many of the 56 doctors felt that dispersal of HIV infected asylum seekers was inappropriate in specific situations—during initiation of antiretroviral therapy (47), in patients receiving salvage treatment (43), in those currently undergoing medical investigations (50), where care involved multiple medical specialties (52), and in those with AIDS (45).

Comment

We identified several potential barriers to the safe dispersal of HIV infected asylum seekers. Of particular concern is that dispersal is done at short notice and often without appropriate transfer of medical details. Although hand held medical records have been suggested as a potential solution,4 they are unlikely to resolve all the issues that could compromise patient care. Inappropriate dispersal of an HIV infected patient could lead to HIV resistance, onward transmission of HIV infection, and avoidable morbidity and mortality for the asylum seeker. Before the decision to disperse, the National Asylum Support Service should seek specialist advice and consider the impact on the infrastructure and staffing of the receiving centre.

This study is a reflection of doctors' opinions and is subject to reporting bias. However, the serious concerns raised warrant further investigation if we are to ensure that dispersal is not to be detrimental to patients' health.