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As population of HIV-infected refugees rises, providers need to give them special care
Here's how Rhode Island dealt with challenge
By Melinda Young
This article originally appeared in the April 2007 issue of AIDS Alert. Editor Melinda Young reports no financial relationship relevant to this field of study. This article was physician reviewed by Morris Harper, MD, who reports consulting work with Agouron Pharmaceuticals, Gilead Sciences, Abbott Pharmaceuticals, GlaxoSmithKline, and Bristol-Myers Squibb; nurse planner Kay Ball also reviewed this article, she is a consultant and stockholder with Steris Corp. and is on the speaker's bureau for the Association of periOperative Registered Nurses.
Health care providers in less populated cities and states are seeing increases in both their general immigrant populations and their HIV-infected immigrant populations.
Before 2000, HIV-infected refugees were restricted from entering the United States. But a change in policy allows them to enter on the condition that their health care is arranged, says Curt Beckwith, MD, an assistant professor, division of infectious disease, Brown Medical School and Miriam Hospital in Providence, RI.
"The reasoning was they didn't want to let in refugees who would be a burden on the U.S. health care system, but if care could be arranged a priori to their arrival, then that would be okay," Beckwith explains. "Once that policy was put into effect, then refugees with HIV began to arrive here."
While most people applying for permanent residence in the United States are subject to an HIV antibody test, certain immigrants may qualify for an HIV waiver, according to the "HIV/AIDS and Immigrants: A Manual for Service Providers," published in 2004 by the San Francisco AIDS Foundation and National Immigration Project of the National Lawyers Guild.1
The waiver may apply to asylees, refugees, special immigrant juveniles, and others who applied through the legalization program. Those who apply for the waiver have to meet a public charge condition in which the applicant ensures that he or she will not hinder public health and will not cost a government agency, unless the agency has given prior consent for services or benefits.1
With the help of health care providers and humanitarian groups, more HIV-infected refugees have legal status in the United States, and some of them are ending up in smaller cities.
For example, many Liberian refugees and refugees from other parts of Africa have arrived in the tiny state of Rhode Island to receive care for their HIV infection, Beckwith says.
"We have a refugee population at our center of about 50 refugees—mostly from West Africa," Beckwith says. "We have a large Liberian refugee population in Providence, so we've seen a lot of Liberian refugees."
Typically the way it works is: the Providence clinic is contacted by an international institute that works with a federal refugee settlement agency, and the institute will say it has a number of HIV-infected refugees, Beckwith explains.
"We say, 'Great! We'll make appointments for them and do intakes and so forth,'" Beckwith says. "That works very well for us, although the relationship might be tougher if the numbers were higher."
So far, the clinic has incorporated about 50 refugees into its practice without a great deal of strain on resources, he adds.
The HIV-infected refugees need to have their HIV care assured prior to their departure from refugee settlement camps and organizations, Beckwith explains.
"Without care, they are not allowed to come into our country," he says. "So the refugee organization arranges for care through our clinic, and that has resulted in an influx of refugees over the past four to five years."
Although the total numbers of HIV-infected refugees moving to the United States are not large, the small population of refugees presents health care providers with many challenges, says Christine A. Kerr, MD, a clinical fellow at Beth Israel Deaconess in Boston, MA. Kerr previously worked with HIV-infected refugees when she was a chief resident at Brown University's Miriam Immunology Center.
For example, one woman who came to the United States from Liberia had lived in a refugee camp for several years, Kerr recalls.
"She had seven children, four of whom were killed in a civil war," Kerr says. "I think the other three were still in the refugee camp, and she was here by herself at great personal expense."
The woman's HIV infection was significant, but she faced a myriad of other problems that were more pertinent to her medical situation, Kerr says.
"She had a lot of depression and anxiety that were contributing to her difficulty in taking her medication while in this country," Kerr explains. "The patients we see, by and large, tend to be patients who are very committed to their medical care and follow-up, but they face significant challenges that are separate from their HIV care."
Providers working with this population need to keep both co-morbidities and psychosocial factors in mind, Kerr and Beckwith say.
"My interest has been to look at this population and say in general there are differences in the refugee population in terms of other disease processes and other co-infections," Beckwith says.
Beckwith has been researching the question of how the HIV-infected refugee population compares with the general U.S. population of HIV-infected individuals.
In the United States, HIV is transmitted because of three factors: injection drug use, men who have sex with men (MSM), and heterosexual activity, Beckwith says.
"In developing countries, such as in sub-Saharan Africa, that's not the case at all," he says. "It's much more of a heterosexual epidemic."
So Beckwith, Kerr, and other investigators decided to look at the risk factors for HIV among foreign-born people, as well as at which stage of disease they first presented for health care.
"We also looked at other infections with the thought that there'd be more hepatitis B and less hepatitis C among refugees than among HIV patients who were born in the United States," Beckwith says. "And they'd be more likely to have tuberculosis and parasitic infections when compared to people born in the U.S."
The findings showed that heterosexual sex was a primary risk factor among the immigrants, and they had relatively high CD4 counts and low levels of HIV viremia.2
Investigators also hypothesized that the refugee population would have higher levels of psychosocial issues than the general HIV population, but that their levels of drug abuse and severe disabling mental illness, such as schizophrenia, would be lower, Kerr says.
"By and large, that did turn out to be true," Kerr says. Investigators found that the immigrant population had a high incidence of psychiatric co-morbidities.2
"The levels of drug and alcohol abuse were quite low among the refugees," she adds. "Depression and post-traumatic stress disorder [PTSD] were higher in the refugee population than what might be expected in the general HIV population in the U.S."
One of the most difficult aspects to caring for refugee populations is the cultural differences, Beckwith says.
"Our western model of medical care is something they're not familiar with, and it's hard for them to accept our model of care," he says. "So it's challenging to sit down with a refugee who just arrived in the United States and try to explain what HIV infection is and what our treatment is and when we'll start treatment."
From many refugees' perspective, HIV is a disease that kills people, so their outlook on being infected is impacted by this.
"Communication can be difficult, and you have to do it in a culturally sensitive way, and it may take multiple conversations," Beckwith says.
For instance, an HIV-infected refugee might not understand why a physician would withhold treatment and say the person is doing well clinically without it, he notes.
"They think, 'I have HIV, so why wouldn't I need treatment?' and that's very hard to explain and may take multiple appointments," he says. "The international institute may need to get involved, and there could be a distrust of our medical system."
When there is an available clinical trial for HIV patients, the trust and communication barriers become even more prominent.
"Trying to explain what a clinical trial is and the benefits of the trial can be very difficult," Beckwith says. "So our enrollment of refugees in clinical trials is very low."
Here are some ways HIV clinicians can improve the care of immigrant patients:
• Check for foreign diseases: "They should be tested for parasites and have their blood checked for malaria," Kerr says.
Typical clinical care includes tuberculosis testing, chest x-ray, parasite screening, and viral hepatitis screening, Beckwith says.
"Everyone has these done upon entrance to the United States," he says.
"Providers also need these patients' vaccination records, and most of them do not have records and may not have had any vaccinations in their lifetime," Beckwith adds.
"This is a population that was forced out of their homes unexpectedly," Kerr says. "Many of these patients grew up where there was no vaccination program."
The Providence clinic staff found it very difficult to vaccinate immigrant patients, she notes.
"There were significant challenges to doing a multi-series vaccination program because it requires a bunch of visits and psychosocial issues at each visit," Kerr says. "It was challenging to providers to get all of the preventive health services done."
For one thing, finding out if the patients had any previous vaccinations was important, but difficult to ascertain, she adds.
• Assess for psychiatric illness: "Because of their traumatic experience of being a refugee and being in camps for many years before coming here, for all of our patients we make an assessment as to what other psychiatric illnesses might be present," Beckwith says. "And if they are present, we may get help through a psychiatric referral or through the international institute."
Often if there is a psychiatric illness, it will involve PTSD, and in refugee patients this disorder may be manifested differently than it manifests in people who were born in the U.S., Beckwith notes.
"It's different in terms of cultural issues and experiences, and, to be honest, I'm not sure it's adequately addressed in refugees," he says.
However, if PTSD is present then it could impact medical care, and so it has to be treated, Kerr says.
"PTSD is huge," Kerr says. "The woman who had four children who had been killed had a limp and sore leg, which was a result of when she was raped in Liberia."
• Deal with cultural/language differences: The Providence clinic used translators both in person and by telephone, Kerr says.
"The hospital had telephone translators available all the time," she says. "Language problems definitely add another layer of complexity, and it partly explains why it's so hard to get so many of these things done."
It would be helpful if HIV providers were trained about certain cultural differences among refugee/immigrant populations seen in their area, Beckwith suggests.
One way to help with the cultural barrier would be to train peer educators from the patients' same culture, he says.
Some of the cultural differences include the patients' attitudes toward stigma and conceiving children, he notes.
"We generally counsel HIV-positive patients to not get pregnant, but a lot of patients from developing countries and refugees want to get pregnant, and cultural reasons drive this desire," Beckwith says.
Beckwith's research found that the immigrant population had high rates of pregnancy.2
The key is to cultivate peer educators within the impacted community to help with the care and transition, he adds.
There are financial and medical insurance obstacles, as well, but HIV clinics are accustomed to dealing with these for the sake of improving both the individual patients' care and for protecting the community against further HIV infection, Beckwith says.
"This is an interesting and challenging population, but you can make real differences in their lives," Beckwith says. "These people are going through a really tough time, and HIV can be a big component of that, and so the more care you can provide for them—the better."