MAKE UP MARCH 2007

Countries in southern Africa host a variety of displaced
populations: refugees and asylum seekers who have fled
conflict or persecution in their country; internally displaced
persons who are still within their country; and economic
migrants moving in search of employment. Regardless of the
reason for displacement, all persons have the right to the
‘highest attainable standard of health’,1 including HIV-related
care. However, the displaced person’s ability to access care can
be fraught with challenges. They often do not speak the
language in the area to which they have moved. They might
not be familiar with local systems or services. They may have
knowledge gaps, particularly related to HIV and AIDS, and have
specific support needs owing to lack of traditional community
and family support structures. But one of the greatest barriers
to access to care is one that can easily be surmounted:
reluctance on the part of health professionals, from nurses to
clinicians, to make the extra effort necessary to deliver services
to such individuals.

The reasons for this reluctance are varied. Certain myths about
displaced persons persist, such as the belief that they are more
likely to engage in high-risk behaviour, or that they are too
mobile to adhere to antiretroviral therapy (ART) and therefore
pose a risk of developing resistance. None of the available
evidence supports these perceptions; on the contrary, the
evidence we have for refugee populations, for example,
demonstrates fewer risky behaviours in comparison with the
host community.2,3 However, every situation is context-specific
and must be evaluated as such.

By the end of 2003, refugee populations remained in their host
country for an average of 17 years.4 Furthermore, behavioural
surveillance surveys show a high level of interaction between
refugee and host communities; clearly the exclusion of
displaced persons from local HIV and AIDS-related services is
detrimental to efforts in HIV prevention, care and treatment to
both displaced persons and the surrounding host com-
munities.5

According to the World Health Organization (WHO), the largest
threat for developing resistance to ART is persons taking their
medications in an incorrect manner;6 this threat is no larger
for displaced populations than for other populations.

Differing treatment regimens and treatment interruption
between area of origin and area of displacement may also pose
a challenge to clinicians. However, clear guidance on this issue
has been developed through a consultative process led by the

Southern African HIV Clinicians Society and UNHCR (included
in this issue of the journal).

Lack of awareness of the rights of displaced persons, together
with xenophobia, can lead health professionals to deny care. In
a survey conducted among urban refugees in South Africa in
2003,7 30% of respondents who had been denied emergency
medical care, which is guaranteed to everyone under the
national Constitution, reported that the denial came directly
from a doctor or a nurse. The reasons given varied, but many
practitioners showed a lack of familiarity with refugee rights,
as well as a belief that such services were ‘only provided to
South Africans’.

In fact, the HIV care needs of displaced persons are, for the
most part, not different to those of local patients; a bit of
empathy and creativity will go a long way towards finding
ways of providing the same quality of services to these
populations. In a number of countries in the southern African
region, creative approaches to some of these challenges have
already been employed. In Botswana and South Africa, local
non-governmental organisations (NGOs) maintain a roster of
trained interpreters to help with communication and
adherence support. In Mozambique and Namibia, UNHCR and
its NGO partners provide support for transport from refugee
camps to the nearest ART site. UNHCR has also produced or
translated existing HIV information materials into local
refugee and migrant languages. These materials are a very
effective means of educating patients, whether dealing with
prevention, care or treatment. The only problem was language,
which again, with a bit of initiative, has been quite easily
overcome.

DISPLACED PERSONS AND HIV CARE:
CHALLENGES AND SOLUTIONS

Laurie Bruns, MS

Paul Spiegel, MD MPH

United Nations High Commissioner for Refugees

Clinic in Zambia serving refugees and locals, 2006 (J Redden,
UNHCR).

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WHO, together with UNHCR, UNICEF and other international
organisations, recently held an expert consultation on
delivering antiretrovirals in emergencies. In the consensus
statement from this meeting, they conclude:

‘That emergencies … should not affect one’s access to HIV
services and that the provision of such services is not only

feasible, but an inalienable human right and a public health
necessity.’8

HIV knows no borders, nor individuals. Addressing the HIV-
related needs of displaced persons in an equitable, non-
discriminatory manner is a critical intervention in the fight
against HIV and AIDS, particularly in sub-Saharan Africa.

REFERENCES

1. International Convenant on Economic, Social and Cultural Rights (ICESCR).
2. UNHCR. HIV and AIDS Behavioural Surveillance Survey, Marratane Refugee

Camp, Mozambique. November 2005.
3. Spiegel, PB. HIV/AIDS among conflict-affected and displaced populations:

dispelling myths and taking action. Disasters 2004; 28(3): 322-339.
4. UNAIDS, UNHCR. Strategies to Support the HIV-related Needs of Refugees and

Host Populations. Geneva: UNAIDS Best Practice Collection, 2005.
5. UNHCR. Antiretroviral Medication Policy for Refugees. Geneva, January 2007.
6. WHO. HIV drug resistance. Geneva, 2006. http://www.who.int/hiv/drug

resistance/en/
7. Japan International Cooperation Agency (JICA) & UNHCR. National Refugee

Baseline Survey: Final Report. November 2003.
8. WHO, UNAIDS, UNHCR, UNICEF, Medecins sans Frontieres, et al. Consensus

statement: Delivering Antiretroviral Drugs in Emergencies: Neglected but
Feasible. 2006.

Displaced boy, Luena, Angola, 2006 (J Redden, UNHCR).

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