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. A survey of doctors in genitourinary clinics in England 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 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 newly arrived asylum seekers with HIV in the resulting UKBA's Asylum Support Policy Bulletin 85, Dispersing Asylum Seekers with Healthcare Needs.²

In order for UKBA to take proper account of HIV in dispersal, HIV-positive asylum seekers in initial accommodation need to disclose their status.^2,3 HIV testing should also be offered at this stage if requested or clinically advised.

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.

UKBA 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.⁴ 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

UKBA 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.⁶

Dispersal should also 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 UKBA 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 4 to 6 weeks.⁷

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. The current doctor must be ready to discharge the patient and transfer his or her treatment to the new primary care trust. They must also advise on the asylum seeker's fitness to travel and provide them with sufficient medication to last until the new doctor has an opportunity to review the current treatment regime.

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 UKBA caseworker to inform decision-making about the appropriateness and type of dispersal for each person.⁸

In the case of HIV-positive women who are pregnant, the UKBA policy notes that additional care is required and instructs that the case be transferred to the Complex Casework Team.⁸ 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.⁹

Where there are families with children living with HIV, 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. Clinicians' advice should be sought on identifying specialist centres with facilities for family care.¹⁰

In both these cases 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.

Although delaying dispersal where necessary in order to ensure continuity of care and adequate accommodation in the dispersal area is advised by both HIV advocacy organisations and the UKBA guidelines, there will be 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.¹¹

The accommodation providers in the 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.^12,13 Case workers should inform the accommodation provider that the person has a pre-existing medical condition without specifying the actual illness.¹⁴

The providers are also required to provide accommodation suitable for the needs of a person with a medical condition in response to requests from 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 the dispersal of a person living with HIV in order to ensure continuity of care. The guidance also suggests that voluntary sector (HIV or asylum) organisations with which HIV-positive asylum seekers are in contact should provide their clients 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 UKBA, 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 UKBA which almost always involves dispersal from London or south-east England.