Important note: Information in this article was accurate in September 2007. The state of the art may have changed since the publication date.
In Canada, many people with HIV/AIDS (PHAs) come from countries with a high prevalence of HIV, such as those in southern Africa. They often arrive as refugees or asylum-seekers escaping difficult conditions in their homeland.
Little is known about how the health of HIV-positive refugees is affected by the stress of living as a refugee, living in a new country and living with the virus. In order to provide a clearer picture of this reality, a team of researchers at a Montreal-based HIV clinic followed a cohort of PHAs from sub-Saharan Africa for almost 10 years. Their findings highlight that non-medical issues such as immigration and separation can have a profound impact on the health of refugee PHAs.
From 1995 to 2004, researchers followed the study group (66 women and 26 men) at the Immunodeficiency Clinic of the Montreal Chest Hospital. They collected information about participants’ physical health and about the psychological and social aspects of their lives. Researchers also interviewed smaller groups of five to 10 participants about their own views of their health and about how they deal with HIV in their lives.
The 92 participants were from Burundi (27), Cameroon (13), the Congo Republic (6), Democratic Republic of the Congo (30) and Rwanda (16). The men and women in the group did not differ in terms of average age, distribution of country of origin, mean CD4+ counts, viral load and body mass index.
Most of the participants had advanced HIV infection when they came to the clinic. More than two-thirds (69 participants) had a CD4+ count below 350, making them eligible for highly active antiretroviral therapy (HAART). Another 21 participants had started HAART before coming to the clinic. Seven participants had an AIDS-defining illness when they were first seen at the clinic.
The incidence of other serious medical conditions was high among this refugee cohort, notably:
As well, 40% of women were pregnant upon arrival or became pregnant after arriving in Canada. Half of these pregnancies occurred before the mother knew she was HIV positive.
The researchers acknowledged that it was difficult to make definitive conclusions about the health of the group due to the lack of comparable data from HIV-negative refugees.
In addition to the 21 PHAs already on HAART when they came to the clinic, another 51 PHAs started treatment during the study. Fifteen people decided to wait for four months or more before starting. Their reasons were as follows:
Analysis of data on their HIV disease showed that participants who received HAART responded well to the treatment. Viral load dropped by more than 100-fold and CD4+ cell counts rose.
Participants’ HAART regimens lasted, on average, two years before they had to be changed. This result is similar to that found in a group of non-refugee patients followed in eight U.S. clinics.
The reasons cited for not starting HAART are just a few of the social and emotional issues that researchers uncovered as non-medical factors that impacted the health and well-being of these HIV-positive refugees. Participants reported that the long delays and complications of the refugee process significantly interfered with their general well being and sense of security. As well, feelings of isolation, stigmatization and discrimination often stopped participants from getting the services they needed.
Participants also mentioned many other factors that make it harder for them to adhere to their treatments and stay healthy, including:
The team summarized its findings on social and emotional issues in five main themes:
1. the stresses of arriving, living and finding work in Canada
2. legal issues including securing refugee status, remaining legally in Canada and reuniting with family members who were left behind in Africa
3. mental health concerns including depression, post-traumatic stress and coping with the consequences of abuse and war
4. pregnancy
5. accessing and using community services
Participants turned to the health care team at the clinic when looking for help with these non-medical issues. The team at the Montreal clinic included a psychologist, psychiatrist and a social services worker, but even with these resources, more than three-quarters of participants asked for extra help. The clinic made more than 200 referrals to 26 different community organizations during the study.
Commenting on these findings, the researchers said that while meeting the health needs of refugees and immigrants is challenging, it is far less difficult than meeting their social and emotional needs. The team drafted a series of recommendations to improve care for HIV-positive refugees. The recommendations addressed both medical needs (such as the need for multidisciplinary care by culturally sensitive providers and the diagnosis of hepatitis C infection) and non-medical needs (such as reuniting families and speeding up the processing of refugee claims).
To read some personal stories of PHAs immigrating to Canada and how AIDS service organizations can help, see the article “Uprooted Lives” in the Spring/Summer 2006 issue of The Positive Side.
REFERENCES:
1. Optimizing health outcomes for HIV-infected refugees from Sub-Saharan Africa. A report by The Immunodeficiency Service, Royal Victoria Hospital, Montreal, Quebec. March 5, 2007.
2. Palella FJ, Chmiel JS, Moormana AC, et al. Durability and predictors of success of highly active antiretroviral therapy for ambulatory HIV-infected patients. AIDS. 2002 Aug 16;16(12):1617-26.
3. Remis RS. Final Report: Estimating the Number of Persons co-infected with Hepatitis C Virus and Human Immunodeficiency Virus in Canada. March 2001. http://www.phac-aspc.gc.ca/hepc/pubs/hivhcv-vhcvih/tables_e.html
4. Geduld JE, Archibald C. TB among reported AIDS cases in Canada: 1994 to 2003. Canadian Journal of Infectious Disease 2005;16(Suppl A):24A.
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