UK conference discusses ‘disastrous’ impact of the myth of ‘HIV health tourism’

The UK Government’s policy of charging so-called ‘health tourists’ for HIV treatment and care is a “public health disaster” based on myth not fact, Yusef Azad, Director of Policy and Campaigns for the National AIDS Trust (NAT) told last week’s British HIV Association (BHIVA) Autumn Conference during a session on treating migrant populations and their eligibility for care.

HIV health tourism is one of the Government’s main justifications for “a harmful, costly and inhumane charging policy,” according to a new NAT report, The myth of HIV health tourism. The results of that policy were highlighted at the conference by a panel consisting of an HIV clinician, a human rights lawyer, a GP who has cared for many asylum seekers with HIV, an HIV-positive migrant advocate, and Mr Azad.

Since April 2004, overseas visitors, refused asylum seekers, undocumented migrants and visa overstayers have no longer been entitled to HIV treatment and care from the National Health Service (NHS) in England, although treatment for all other infectious diseases and sexually transmitted infections continues to be free to everyone on public health grounds irrespective of residency status. (The NHS in Scotland and Wales have different policies.)

Earlier this year, a High Court ruling resulted in HIV-positive refused asylum seekers being entitled to free HIV treatment and care for as long as they remained in the UK. But the judge refused a claim that there was a human right to NHS treatment, saying that any discrimination in the rules was justifiable so as to discourage ‘health tourism’.

Yet a new NAT report that “separates facts and evidence around migration from fears and misinformation”, argues that there is no evidence to demonstrate that HIV health tourism to the UK exists. Allegations of ‘HIV health tourism’, says the report, “make a serious charge against the integrity and truthfulness of many HIV-positive migrants to the UK, effectively alleging that stated reasons for migration to the UK are at best a pretext and at worst totally untrue. Given the discrimination and marginalisation experienced by many migrants we must question very carefully any claim which might add to social hostility”.

The report also notes, “the claim of health tourism has been central to the Government’s policy of charging refused asylum seekers and other migrants without lawful residency status for healthcare. The Government argues that free NHS care for those without what they deem to be a legitimate reason to migrate to the UK acts as a ‘pull factor’, encouraging illegal immigration and discouraging refused asylum seekers from leaving. Charges for NHS care for certain categories of migrant were introduced to end the ‘pull’ of free NHS care and address the so-called problem of ‘health tourism’.

“Is there really evidence of HIV health tourism which would justify on grounds of immigration policy the singling out of HIV for NHS charges alone amongst all serious or sexually transmitted infections?” asks NAT. Over the course of twelve pages, the paper robustly argues that there is no evidence to demonstrate that ‘HIV health tourism’ is “a significant or real motivation for migration to the UK” and considerable evidence to demonstrate otherwise, “in particular the lower rates of HIV prevalence compared with country of origin, the long average delays [an average of five years] between arrival in the UK and accessing HIV testing and care, and the evidence available on the actual motivations of migrants coming to the UK”.

Dr Le Feuvre, a Kent GP, told the conference that NAT’s conclusions match his own experience. “We had tens of thousands of [refugees and asylum seekers] coming through East Kent in the last ten years. I only personally remember one person amongst those tens of thousands who seemed to be coming here for medical treatment and the majority of people diagnosed with HIV, and who left the [Dover Induction Centre], left with it being diagnosed after their arrival and not before.”

One of the paper’s recommendations is that “since the provision of free HIV treatment has no bearing on migration trends, the basis for the Government’s policy of charging for HIV treatment is wholly undermined. It has been demonstrated elsewhere that the policy actually increases costs to the NHS and endangers public health. The Government must review its policy on NHS charging so as to exempt HIV treatment from charges.”

The impact of this policy was brought into sharp focus at the BHIVA conference by Professor Jane Anderson of Homerton University Hospital, east London, who provided a case study to illustrate the desperation faced by HIV-positive undocumented migrants in England. She told the conference about a 35 year-old East African woman who was refused a prescription by a medical team outside of London when she had only three days supply of antiretrovirals left and no means to return to her country of origin. “We gave her an immediate prescription for antiretroviral drugs...and gave her a travelcard from our charitable fund so she could get food and support from other charitable sources,” she said.

She argued that HIV care in the UK should be for everyone. She noted that the new UK HIV testing guidelines, which include a list of ‘indicator diseases’ prompting the offer of opt-out testing “is only ethically acceptable if positive individuals are immediately linked into appropriate HIV treatment and care. Yet,” she asked, “we are meant to send them to a place where they’re going to get a big bill. Is this appropriate practice?”

Adam Hundt, a human rights lawyer provided an overview of the complex rules and regulations governing access to secondary NHS treatment and care, which he described as “a bit of a minefield”. He noted that there are situations, people, and diseases exempted from the charging regulations including treatment given at an emergency department, 34 infectious diseases (including TB and viral hepatitis) and all sexually transmitted infections apart from HIV which he said, “is a policy decision”.

There is also an exemption for continuing a course of treatment, including treatment for HIV, as long as someone has lawfully entered the UK. “Unhelpfully,” he noted, “there’s no definition of what ‘a course of treatment’ is.” The Government recently clarified that ‘treatment’ does not necessarily mean antiretroviral therapy, but in fact, can mean continued monitoring of immune and clinical status due to an HIV diagnosis.

He noted that there is also much confusion amongst clinicians over what constitutes ‘immediately necessary treatment’ which should be provided to anyone regardless of their ability to pay. “It basically specifies that if someone requires treatment because their condition is life threatening, or because if treatment is not given immediately it will become life threatening, or because permanent and serious damage would be caused by any delay then they must be given treatment regardless of whether they can pay or not and then be charged for it later,” he said.

Dr Ian Williams, BHIVA’s Chair, recently wrote to the Department of Health to argue that HIV care should be considered immediately necessary in the same way as maternity care. “I think the most important thing to remember,” noted Mr Hundt, “is that it’s a matter of clinical judgment which should not be second-guessed by administrative staff.”

In the discussion that followed, Prof. Anderson pointed out the paradox of one Government department, the Department for International Development, supporting universal access to HIV treatment and care overseas, but another two Government departments, the Department of Health and the Home Office “denying that care free here and also sending people back through various legislation and legal decisions to places where there’s no care. Why can’t we have domestic policies that are the same as foreign policy?” she asked.