Dispersal of people living with HIV

Dispersal policy for people with HIV was changed in response to evidence of the adverse effects of rapid dispersal on HIV-positive asylum seekers. In 2004, a survey of doctors in genitourinary clinics in England had found problems of treatment interruption, with examples of deaths and mother-to-child transmission attributable to dispersal.1 It found that patients were dispersed against medical advice and at very short notice, and recommended improved arrangements for onward transfer of medical information.

Following the independent 'Scott review' of the healthcare needs of people seeking asylum generally, the National AIDS Trust (NAT) and the British HIV Association (BHIVA) surveyed HIV clinicians to better understand the experience of treating HIV-positive asylum seekers during dispersal. The survey found inadequate notice periods to prepare patients for dispersal, leading to interruptions in medication and poor handover of medical details.

As a result, NAT and BHIVA worked with NASS (National Asylum Support Service) to ensure its policy on dispersal and healthcare needs appropriately considered HIV-related needs during the dispersal process. There are a number of detailed instructions relating to the safe and appropriate dispersal of asylum seekers with HIV in the 2005 Asylum Support Policy Bulletin 85, Dispersing Asylum Seekers with Healthcare Needs,2 replaced in 2012 by Healthcare Needs and Dispersal Guidance.

The 2012 instruction covers the dispersal of any applicant for asylum support who has a medical need, including refused asylum seekers (sections 4, 95 & 98 of the Immigration and asylum Act 1999).3

In order for the Home Office to take proper account of HIV in dispersal, HIV-positive asylum seekers in initial accommodation need to disclose their status.2,4 HIV testing should also be offered at this stage if requested or clinically advised.

The Home Office has recognised that many people with HIV are fearful of disclosing their status. Staff are, therefore, instructed to explain to asylum seekers that neither requesting an HIV test nor disclosing HIV-positive status will adversely affect their asylum claim, and that support applications are treated quite separately from asylum applications, and with complete confidentiality.3 This assurance is the responsibility not only of healthcare staff, but also of staff assisting with applications for support. Asylum seekers living in the community who receive only one day's induction will have less opportunity to obtain such reassurance, or to get other information about HIV.5

Planning for dispersal requires information about health conditions so that appropriate steps can be taken to enable treatment to be started or continued without interruption. It is therefore important that applications for support (known as the NASS 1 form) include information about medical reasons for requesting dispersal to a particular area, or to remain in the same area, and about treatment needs.

Home Office policy states that newly arrived asylum seekers with HIV/AIDS who are not currently receiving ongoing treatment in the UK should be dispersed from initial accommodation as soon as possible in order to enable them to start treatment in the dispersal area. In other cases, dispersal of asylum seekers living with HIV should only take place after expert advice is received from the treating doctor. This will include advice about the availability of treatment in potential dispersal locations. Dispersal in the same area as the initial accommodation may be possible in order to minimise upheaval and to avoid delays.3

Asylum seekers who are already accessing HIV treatment in the UK should be dispersed “to an area where they can reasonably be expected to access their current treatment facility” (i.e. their current HIV clinic). This is a great improvement on the earlier practice of dispersal to areas which best suited Home Office’s accommodation availability, without reference to continuity of health care. Where this is not possible, dispersal should only take place after consultation with their clinician; when it will not cause the patient any harm; and when the patient and clinician have both had time to adequately prepare for the dispersal. In addition, in cases of co-infection the asylum seeker may be given temporary accommodation in the area where s/he is currently being treated, in recognition that it may take longer to prepare for dispersal.3  

Dispersal should therefore not take place until the asylum seeker and the current doctor have had time to prepare adequately for dispersal, and arrangements have been confirmed with the Home Office or the medical adviser at the initial accommodation. It should normally only take place if the asylum seeker is medically stable and has no other health complications. Such arrangements are expected to be completed within four weeks.6

The arrangements that need to be in place before dispersal of an HIV-positive asylum seeker include a requirement that the treating clinician is informed of the new address and is satisfied that the accommodation being provided is suitable, and that other facilities are in place to ensure continuity of care. This should include advice about the availability of treatment in potential dispersal locations and confirmation that the patient is medically stable to travel and does not have any other complications. The current doctor must be ready to discharge the patient and transfer his or her treatment to the new primary care trust and provide them with sufficient medication to last until the new doctor has an opportunity to review the current treatment regime. Dispersal in the same area as the initial accommodation may be possible in order to minimise upheaval and to avoid delays.3

BHIVA and NAT have produced further advice on the dispersal process for health and voluntary sector professionals working with HIV-positive asylum seekers. This details the information which should be given to the Home Office caseworker to inform decision-making about the appropriateness and type of dispersal for each person.7

Pregnant women and families

In the case of HIV-positive women who are pregnant, the Home Office policy notes that additional care is required and instructs that the case be referred to the Asylum Support Medical Advisor.7 If accommodation is available, dispersal should be to an area where they can reasonably be expected to access their current medical facilities. In the event a baby is born to a HIV positive mother and is due to be dispersed out of the area she can access treatment at her current medical facility so that continuity of care is ensured. There are already special guidelines for the dispersal of pregnant women from initial accommodation, but it is a requirement that doctors confirm a woman's HIV status in writing if specialist treatment is required so that other arrangements can be made. There are already special guidelines for the dispersal of pregnant women from initial accommodation, but it is a requirement that doctors confirm a woman's HIV status in writing if specialist treatment is required so that other arrangements can be made.3

The new asylum instruction also introduces a "protected period" for heavily pregnant women, which runs from four weeks before the estimated date of delivery until four weeks after the birth. During the period, dispersal should be deferred.

The dispersal of pregnant women has been investigated by Maternity Action and the Refugee Council. They found that women were dispersed against medical advice, and too close to their due date; women were moved multiple times during their pregnancy, with journeys causing them additional problems. Women found they had insufficient funds to meet their needs and accommodation was often unsuitable. In one case, the researchers noted that dispersal meant a major disruption to the well-established healthcare she had been receiving to control her HIV – she was dispersed 50 miles away from her HIV consultant, despite her consultant asking the Home Office not to move her.8

In the case of families with HIV-positive children, the guidelines state that extra care should be taken in finding accommodation that is located where there are appropriate facilities for treating children with HIV. The Asylum Support Medical Advisor’s advice should be sought on identifying specialist centres with facilities for family care.3

In addition, the guidelines stress the need to respect the confidentiality of individuals’ HIV status even within family groups.

In both these situations, the BHIVA/NAT guidance advocates that health and voluntary sector professionals seek to secure a delay in dispersal if the caseworker for the pregnant woman or child has not previously made contact.

Support and continuity of care

Although delaying dispersal in order to ensure continuity of care and adequate accommodation in the dispersal area is advised, where necessary, by both HIV advocacy organisations and the Home Office guidelines, it can lead to a consequent delay in the asylum seeker receiving section 95 support. During this time, the asylum seeker will have no cash for basic needs such as travel or any additional food other than what is provided in the initial accommodation. This could be harmful for a person on antiretroviral medication.9

Accommodation providers in dispersal areas have responsibilities to ensure that asylum seekers with pre-existing health conditions (including HIV) are registered with a general practitioner (GP) as soon as they arrive.10,3 Case workers should inform the accommodation provider that the person has a pre-existing medical condition without specifying the actual illness.3

The providers are also required to provide accommodation suitable for the needs of a person with a medical condition if requested to do so by the medical adviser at the initial accommodation. In the case of a person living with HIV/AIDS, this might include the need for an individual rather than a shared bathroom, for the sole use of a refrigerator, or for damp or draught-free living conditions, as well as to be situated in an area where particular services are available.

BHIVA/NAT guidance provides detailed recommendations as to the procedures which should be followed by both current and 'receiving' clinicians and GPs in the event of dispersal in order to ensure continuity of care. The guidance also suggests that voluntary sector (HIV or asylum) organisations supporting HIV-positive asylum seekers should provide any clients who are dispersed with information about similar organisations in the receiving areas.

The guidance advocates that clinicians encourage their patients to let them know immediately if they receive a dispersal notice so that appropriate planning and arrangements can be made. If asylum seekers are moved a second time, after having been dispersed, similar criteria and procedures for safe and appropriate dispersal should be applied.

The effect of the revised policy has been to disperse people with HIV to areas where treatment is available and so it has become more difficult to challenge dispersal decisions, even if someone is very ill, unless there are other considerations such as significant mental-health needs or serious disruption to the welfare of children.

In the past, many people with HIV were able to stay in a particular area to continue treatment by requesting a community-care assessment and support from social services under section 21 of the National Assistance Act 1948. Since the House of Lords judgment in M. v. Slough Borough Council, many HIV-positive asylum seekers are no longer able to receive housing and support from social services under Section 21 of the National Assistance Act.

For asylum seekers, this means that if their support needs involve only accommodation and medication, they will have to be supported by the Home Office, and thus are likely to be dispersed. This judgment has implications for people living with HIV who wish to challenge dispersal, as well as for refused asylum seekers who receive Section 4 support from the Home Office which almost always involves dispersal from London or south-east England.

References

  1. Creighton S et al. Dispersal of HIV positive asylum seekers: national survey of UK healthcare providers. British Medical Journal, 329: pp322-323, 2004
  2. UKBA Dispersing Asylum Seekers with Health Care Needs. Asylum Support Policy Bulletin 85 V.3 2005. www.bia.homeoffice.gov.uk/sitecontent/documents/policyandlaw/asylumsupportbulletins/medical/pb85.pdf, (date accessed: 12 March 2010), 2009
  3. Home Office Healthcare Needs and Dispersal Guidance. www.ukba.homeoffice.gov.uk/sitecontent/documents/policyandlaw/asylumprocessguidance/asylumsupport/guidance/healthcare-guidance-.pdf?view=Binary (date accessed: 1 July 2013), 2012
  4. Terrence Higgins Trust Telling people: UK Border Agency. www.tht.org.uk/myhiv/Telling-people/UK-Border-Agency (date accessed: 1 July 2013), no date
  5. National AIDS Trust (NAT) HIV and the UK asylum pathway www.nat.org.uk/Media%20library/Files/PDF%20documents/HIV-and-the-UK-Asylum-Pathway.pdf, (date accessed: 5 March 2010), 2008
  6. UKBA Dispersing Asylum Seekers with Health Care Needs Asylum Support Policy Bulletin 85 V.3: p.8 , 2005
  7. British HIV Association (BHIVA) and National AIDS Trust (NAT) The Dispersal Process for Asylum Seekers Living with HIV: advice for health care and voluntary sector professionals. www.nat.org.uk/Information-and-Resources/Asylum-and-immigration.aspx, (date accessed: 1 July 2013), 2006
  8. Refugee Council and Maternity Action When maternity doesn’t matter. www.refugeecouncil.org.uk/assets/0002/6402/When_Maternity_Doesn_t_Matter_-_Ref_Council__Maternity_Action_report_Feb2013.pdf (date accessed: 1 July 2013), 2013
  9. Willman S and Knafler S Support for Asylum Seekers and Other Migrants. London: Legal Action Group , 2009
  10. BHIVA and NAT The Dispersal Process for Asylum Seekers Living with HIV: advice for health care and voluntary sector professionals www.nat.org.uk/Information-and-Resources/Asylum-and-immigration.aspx, 2006
This content was checked for accuracy at the time it was written. It may have been superseded by more recent developments. NAM recommends checking whether this is the most current information when making decisions that may affect your health.