Treatment and Prevention of Treatment and Prevention of HIV Amongst Refugees and IDPsHIV Amongst Refugees and IDPs

Rafik Hanna, M.D.Rafik Hanna, M.D.

St. Luke’s Roosevelt Hospital CenterSt. Luke’s Roosevelt Hospital Center

Global Health Fellowship Lecture SeriesGlobal Health Fellowship Lecture Series

UNHCR, WHO, UNAIDS Policy Statement UNHCR, WHO, UNAIDS Policy Statement on HIV Testing and Counseling for on HIV Testing and Counseling for

Refugees and IDPs (2009)Refugees and IDPs (2009)► No mandatory or compulsory HIV testing of persons of No mandatory or compulsory HIV testing of persons of

concern to UNHCR, including children.concern to UNHCR, including children.► Scale up access to HIV testing and counseling.Scale up access to HIV testing and counseling.► All HIV testing and counseling of persons of concern to All HIV testing and counseling of persons of concern to

UNHCR should ensure that confidentiality and informed UNHCR should ensure that confidentiality and informed consent are ensured.consent are ensured.

► Ensure that patients being testing have the same rights as Ensure that patients being testing have the same rights as the citizens of host countries.the citizens of host countries.

► Access to HIV prevention and treatment information in a Access to HIV prevention and treatment information in a language the person can understand.language the person can understand.

► All health care workers conducting HIV testing and counseling All health care workers conducting HIV testing and counseling should be trained to obtain informed consent, ensure should be trained to obtain informed consent, ensure confidentiality, pre-test information and post-test counseling confidentiality, pre-test information and post-test counseling and how to recommend the test. Health care workers and how to recommend the test. Health care workers providing HIV testing and counseling in the context of providing HIV testing and counseling in the context of resettlement should be informed of resettlement criteria in resettlement should be informed of resettlement criteria in relation to HIV so that they can adequately inform applicants.relation to HIV so that they can adequately inform applicants.

► ““In In generalized HIV epidemicsgeneralized HIV epidemics, with a supportive , with a supportive social, policy and legal framework, HIV testing and social, policy and legal framework, HIV testing and counseling should be recommended to all persons of counseling should be recommended to all persons of concern to UNHCR during contact with health care concern to UNHCR during contact with health care providers, in line with the guidance of the country and providers, in line with the guidance of the country and where this is available to the surrounding populations. A where this is available to the surrounding populations. A phased implementation of provider initiated HIV testing phased implementation of provider initiated HIV testing and counseling is recommended.”and counseling is recommended.”

► ““In In concentrated and low level concentrated and low level epidemics, with a epidemics, with a supportive social, policy and legal framework, supportive social, policy and legal framework, recommendationrecommendation of HIV testing and counseling should be of HIV testing and counseling should be considered in sexually transmitted infections services, considered in sexually transmitted infections services, services for most at risk populations, antenatal, childbirth services for most at risk populations, antenatal, childbirth and postpartum health services and tuberculosis and postpartum health services and tuberculosis services, in line with the guidance of the country and services, in line with the guidance of the country and where this is recommended to the surrounding national where this is recommended to the surrounding national populations.”populations.”

UNHCR, WHO, UNAIDS Policy UNHCR, WHO, UNAIDS Policy Statement on HIV Testing and Statement on HIV Testing and

Counseling for Refugees and IDPs Counseling for Refugees and IDPs (2009)(2009)

UNHCR, WHO, UNAIDS Policy Statement UNHCR, WHO, UNAIDS Policy Statement on HIV Testing and Counseling for on HIV Testing and Counseling for

Refugees and IDPs PrecautionsRefugees and IDPs Precautions► Not a priority in the very initial early stages Not a priority in the very initial early stages

of an emergency as it is not a life-saving of an emergency as it is not a life-saving intervention in the immediate term.intervention in the immediate term.

► It becomes an important intervention once It becomes an important intervention once the emergency situation stabilizes.the emergency situation stabilizes.

► Promotion of testing may increase Promotion of testing may increase protection issues for patients found to be protection issues for patients found to be HIV positive.HIV positive.

► Ensuring that laws, policies, and practices Ensuring that laws, policies, and practices regarding HIV and respect for human rights regarding HIV and respect for human rights before integrating provider initiated testing before integrating provider initiated testing and counseling into existing health systems.and counseling into existing health systems.

WHO Consensus Statement WHO Consensus Statement 2006-20072006-2007

► The minimum requirements and package of The minimum requirements and package of services needed to deliver ARVs for HIV prevention services needed to deliver ARVs for HIV prevention and treatment in emergency settings.and treatment in emergency settings.

► Continuation of ARV therapy for those who were Continuation of ARV therapy for those who were previously on treatment.previously on treatment.

► Initiation of ARVs for those meeting minimal Initiation of ARVs for those meeting minimal requirements.requirements.

► Mother – child prevention for HIV transmissionMother – child prevention for HIV transmission► Availability of PEP for healthcare workers and in Availability of PEP for healthcare workers and in

rape management.rape management.► Setting up of procurement systems that can Setting up of procurement systems that can

respond to urgent ARV supply needs in emergency respond to urgent ARV supply needs in emergency settings, while preventing stock piling and wastage settings, while preventing stock piling and wastage of drugs.of drugs.

Key Considerations Governing the Key Considerations Governing the Provision and Use of ARVs in UNHCR Provision and Use of ARVs in UNHCR

OperationsOperations► Refugees often live for years in relatively stable Refugees often live for years in relatively stable

settingssettings in their host country. By the end of 2003, in their host country. By the end of 2003, refugee populations remained in their host country refugee populations remained in their host country for an average of 17 years.for an average of 17 years.

► A minority of refugees in numerous countries are A minority of refugees in numerous countries are already finding their own innovative ways to begin already finding their own innovative ways to begin ARVs.ARVs.

► The increase of ARV resistanceThe increase of ARV resistance by stopping and then by stopping and then re-starting the therapy in a controlled fashion is not re-starting the therapy in a controlled fashion is not considered to be more of a risk for populations that considered to be more of a risk for populations that have been displaced by conflict than other have been displaced by conflict than other populations. The largest threat to developing ARV populations. The largest threat to developing ARV resistance remains persons taking ARVs in an resistance remains persons taking ARVs in an incorrect manner; this threat is no larger for forcibly incorrect manner; this threat is no larger for forcibly displaced populations than other populations (?)displaced populations than other populations (?)

Principles Governing the Provision and Principles Governing the Provision and Use of ARVs in UNHCR OperationsUse of ARVs in UNHCR Operations

► Planning for and including HIV in the earliest possible Planning for and including HIV in the earliest possible stages of an emergency response is necessary.stages of an emergency response is necessary.

► Continuity of ART.Continuity of ART.► Refugees should receive equivalent services as those Refugees should receive equivalent services as those

available in the surrounding community.available in the surrounding community.► Interventions are to be initiated only where and once Interventions are to be initiated only where and once

the minimum criteria to implement such activities are the minimum criteria to implement such activities are met.met.

► Diagnostic and treatment protocols should follow those Diagnostic and treatment protocols should follow those of the host communityof the host community unless they are ineffective.unless they are ineffective.

► Sustainability of ART (minimum of one year).Sustainability of ART (minimum of one year).► ““Pilot” programs should be implemented in line with Pilot” programs should be implemented in line with

national policies.national policies.

Post-exposure ProphylaxisPost-exposure Prophylaxis

► 28-day course of ARVs that reduces the 28-day course of ARVs that reduces the likelihood of transmission after exposure to likelihood of transmission after exposure to an HIV-positive source.an HIV-positive source.

► Part of the response to rape and part of Part of the response to rape and part of sexual and gender-based violence programs.sexual and gender-based violence programs.

► Used within 72-hours following non-Used within 72-hours following non-occupational exposure to HIV (usually sexual), occupational exposure to HIV (usually sexual), following host country or UN guidelines.following host country or UN guidelines.

► All occupational (e.g. needle stick) exposure All occupational (e.g. needle stick) exposure in line with the UN and NGO occupational in line with the UN and NGO occupational guidelines for provision of PEP.guidelines for provision of PEP.

Prevention of Mother-to-Child Prevention of Mother-to-Child Transmission (PTMCT)Transmission (PTMCT)

► PMTCT programs should be implemented for refugees as soon as PMTCT programs should be implemented for refugees as soon as feasible.feasible.

► In cases of repatriation to sites with unknown or poor access to ARVs, In cases of repatriation to sites with unknown or poor access to ARVs, similar to treatment for tuberculosis, the pregnant woman and her family similar to treatment for tuberculosis, the pregnant woman and her family should be advised to delay repatriation until after delivery in order to should be advised to delay repatriation until after delivery in order to complete PMTCT.complete PMTCT.

► If PTMCT programs exist in areas of return, cross-border programs If PTMCT programs exist in areas of return, cross-border programs should be established to coordinate PTMCT follow-up and referrals for should be established to coordinate PTMCT follow-up and referrals for those pregnant women who have been diagnosed early in pregnancy those pregnant women who have been diagnosed early in pregnancy and who insist upon repatriation, in order to ensure they and their and who insist upon repatriation, in order to ensure they and their newborns receive appropriate care, treatment and follow-up.newborns receive appropriate care, treatment and follow-up.

► PMTCT programs should be as comprehensive as possible and at a PMTCT programs should be as comprehensive as possible and at a minimum include comprehensive maternal-child healthcare; counseling minimum include comprehensive maternal-child healthcare; counseling and testing services; counseling and support about safe infant feeding and testing services; counseling and support about safe infant feeding practices, optimal obstetrical care practices; short-course ARVs for HIV practices, optimal obstetrical care practices; short-course ARVs for HIV infected pregnant women and newborn; family planning counseling and infected pregnant women and newborn; family planning counseling and services linked to voluntary counseling and testing. Such programs must services linked to voluntary counseling and testing. Such programs must follow international standards and norms.follow international standards and norms.

► Other components of PMTCT, such as long term ART and care of the Other components of PMTCT, such as long term ART and care of the mother should be considered in all PMTCT programs.mother should be considered in all PMTCT programs.

Provision of ARTProvision of ART

1.1. For refugees, who had been on ART in their country of origin For refugees, who had been on ART in their country of origin prior to flight, every effort should be made to secure prompt prior to flight, every effort should be made to secure prompt continuation of treatment:continuation of treatment:

► If ART is available in the area/district where the refugee stays, If ART is available in the area/district where the refugee stays, the refugee should be referred to the existing facilities the refugee should be referred to the existing facilities without delay in order to continue ART.without delay in order to continue ART.

► If ART is not available in the area/district, action should be If ART is not available in the area/district, action should be taken without delay to either move the refugee and his/her taken without delay to either move the refugee and his/her family to a suitable location where treatment is possible or to family to a suitable location where treatment is possible or to bring services to the concerned area in a concerted effort bring services to the concerned area in a concerted effort involving UNHCR, the HIV UN Theme Group (of which UNHCR involving UNHCR, the HIV UN Theme Group (of which UNHCR is a member), the host Government, and NGOs.is a member), the host Government, and NGOs.

Provision of ARTProvision of ART

2. For refugees, who did not receive ART 2. For refugees, who did not receive ART prior to their flight, at a minimum, ART prior to their flight, at a minimum, ART should be provided when such should be provided when such treatment is available to surrounding treatment is available to surrounding populations.populations.

Provision of ARTProvision of ART3. In situations where voluntary repatriation is considered imminent the 3. In situations where voluntary repatriation is considered imminent the following considerations should govern the decision to commence ART:following considerations should govern the decision to commence ART:► ART is a lifesaving treatment and should be considered for refugees ART is a lifesaving treatment and should be considered for refugees

regardless of whether repatriation is imminent.regardless of whether repatriation is imminent.► If ART is already available in the country of origin and accessible upon If ART is already available in the country of origin and accessible upon

return, there is no reason to abstain from or delay the start of ART. return, there is no reason to abstain from or delay the start of ART. However, measures to secure the continuity of treatment of returnees However, measures to secure the continuity of treatment of returnees under ART must form an integral component of the planning of the under ART must form an integral component of the planning of the repatriation operation.repatriation operation.

► It must be agreed that in exercise of their freedom of movement, returnees It must be agreed that in exercise of their freedom of movement, returnees should be allowed and assisted to return to areas where continuation of ART should be allowed and assisted to return to areas where continuation of ART can be secured.can be secured.

► UNHCR with UN HIV Theme Group, NGOs, and governments must work to UNHCR with UN HIV Theme Group, NGOs, and governments must work to ensure that there is good communication and strong linkages with national ensure that there is good communication and strong linkages with national programs in both countries (or with other organizations if governments are programs in both countries (or with other organizations if governments are not providing ART to these populations). These interventions should not providing ART to these populations). These interventions should preferably be an integral part of the health systems and not be parallel preferably be an integral part of the health systems and not be parallel programs.programs.

► Issues such as ART protocols, adherence and other key factors need to be Issues such as ART protocols, adherence and other key factors need to be considered beforehand, hence the need for regional/subregional initiatives considered beforehand, hence the need for regional/subregional initiatives that can harmonize drug and treatment protocols.that can harmonize drug and treatment protocols.

Provision of ARTProvision of ART4. 4. If ART is not and cannot promptly be made available within theIf ART is not and cannot promptly be made available within the country of origin upon return, the refugee should be informed about country of origin upon return, the refugee should be informed about this fact and receive comprehensive counseling on the medical this fact and receive comprehensive counseling on the medical situation and on the options available for him or her, including on the situation and on the options available for him or her, including on the possibilities to (temporarily) remain in the country of asylum, thereby possibilities to (temporarily) remain in the country of asylum, thereby allowing him or her to make an informed decision:allowing him or her to make an informed decision:

► If a refugee does not wish to repatriate because lifesaving medicine is not If a refugee does not wish to repatriate because lifesaving medicine is not available upon return, UNHCR, respecting the voluntary nature of repatriation, available upon return, UNHCR, respecting the voluntary nature of repatriation, cannot actively be engaged in returning the individual and must take the cannot actively be engaged in returning the individual and must take the utmost efforts to advocate for this person to be permitted to stay in the utmost efforts to advocate for this person to be permitted to stay in the country of asylum on humanitarian grounds until sufficient medical services country of asylum on humanitarian grounds until sufficient medical services will be established in the country of origin.will be established in the country of origin.

► During that time, UNHCR, UN HIV theme Group, and other organizations During that time, UNHCR, UN HIV theme Group, and other organizations should advocate for and aid in the coordination of ART to be available in the should advocate for and aid in the coordination of ART to be available in the country of origin and in particular in areas to where the repatriates return.country of origin and in particular in areas to where the repatriates return.

Provision of ARTProvision of ART

5. Where a refugee is already on ART and 5. Where a refugee is already on ART and insists on voluntary repatriation, insists on voluntary repatriation, although ART is not and cannot promptly although ART is not and cannot promptly be made available upon return within the be made available upon return within the country of origin, proper counseling must country of origin, proper counseling must ensure that the refugee fully understands ensure that the refugee fully understands the medical consequences of the medical consequences of discontinuing the treatment. This discontinuing the treatment. This counseling and the informed decision of counseling and the informed decision of the refugee must be properly the refugee must be properly documented.documented.

WHO Clinical Staging of HIVWHO Clinical Staging of HIV

►Staging is based on clinical findings Staging is based on clinical findings that guide the diagnosis, evaluation, that guide the diagnosis, evaluation, and management of HIV/AIDS.and management of HIV/AIDS.

►Does not require a CD4 count or VL.Does not require a CD4 count or VL.►Used to determine eligibility for ARV Used to determine eligibility for ARV

therapy in settings where CD4 testing therapy in settings where CD4 testing is not available.is not available.

►Used for Used for ≥≥15 years of age.15 years of age.►Last revised in 2007.Last revised in 2007.

WHO Clinical Staging of HIVWHO Clinical Staging of HIV

► Primary HIV infection (asymptomatic or Primary HIV infection (asymptomatic or acute retroviral syndrome)acute retroviral syndrome)

1.1. Clinical Stage I: asymptomatic or persistent Clinical Stage I: asymptomatic or persistent generalized lymphadenopathy.generalized lymphadenopathy.

2. Clinical Stage II: moderate unexplained 2. Clinical Stage II: moderate unexplained weight loss (<10% of presumed or weight loss (<10% of presumed or measured body weight), recurrent measured body weight), recurrent respiratory infections (sinusitis, tonsillitis, respiratory infections (sinusitis, tonsillitis, otitis media, and pharyngitis), herpes otitis media, and pharyngitis), herpes zoster, angular cheilitis, recurrent oral zoster, angular cheilitis, recurrent oral ulceration, papular pruritic eruptions, ulceration, papular pruritic eruptions, seborrheic dermatitis, fungal nail infections. seborrheic dermatitis, fungal nail infections.

WHO Clinical Staging of HIVWHO Clinical Staging of HIV

3.3. Clinical Stage III: Clinical Stage III: unexplained severe weight loss (>10% of presumed unexplained severe weight loss (>10% of presumed

or measured body weight), unexplained chronic or measured body weight), unexplained chronic diarrhea for >1 month, unexplained persistent fever diarrhea for >1 month, unexplained persistent fever for >1 month (>37.6ºC, intermittent or constant), for >1 month (>37.6ºC, intermittent or constant), persistent oral candidiasis (thrush), oral hairy persistent oral candidiasis (thrush), oral hairy leukoplakia, pulmonary tuberculosis (current), severe leukoplakia, pulmonary tuberculosis (current), severe presumed bacterial infections (e.g., pneumonia, presumed bacterial infections (e.g., pneumonia, empyema, pyomyositis, bone or joint infection, empyema, pyomyositis, bone or joint infection, meningitis, bacteremia), acute necrotizing ulcerative meningitis, bacteremia), acute necrotizing ulcerative stomatitis, gingivitis, or periodontitis unexplained stomatitis, gingivitis, or periodontitis unexplained anemia (hemoglobin <8 g/dL), neutropenia anemia (hemoglobin <8 g/dL), neutropenia (neutrophils <500 cells/µL), chronic (neutrophils <500 cells/µL), chronic thrombocytopenia (platelets <50,000 cells/µL).thrombocytopenia (platelets <50,000 cells/µL).

WHO Clinical Staging of HIVWHO Clinical Staging of HIV4.4. Clinical Stage IVClinical Stage IV: : HIV wasting syndrome, as defined by the CDC (see HIV wasting syndrome, as defined by the CDC (see Table 1Table 1, above), , above),

ppneumocystisneumocystis pneumonia, recurrent severe bacterial pneumonia, pneumonia, recurrent severe bacterial pneumonia, chronic herpes simplex infection (orolabial, genital, or anorectal site chronic herpes simplex infection (orolabial, genital, or anorectal site for >1 month or visceral herpes at any site), esophageal candidiasis for >1 month or visceral herpes at any site), esophageal candidiasis (or candidiasis of trachea, bronchi, or lungs), extrapulmonary (or candidiasis of trachea, bronchi, or lungs), extrapulmonary tuberculosis, Kaposi sarcoma, cytomegalovirus infection (retinitis or tuberculosis, Kaposi sarcoma, cytomegalovirus infection (retinitis or infection of other organs), central nervous system toxoplasmosis, HIV infection of other organs), central nervous system toxoplasmosis, HIV encephalopathy, cryptococcosis, extrapulmonary (including encephalopathy, cryptococcosis, extrapulmonary (including meningitis), disseminated nontuberculosis mycobacteria infection, meningitis), disseminated nontuberculosis mycobacteria infection, progressive multifocal leukoencephalopathy, candida of the trachea, progressive multifocal leukoencephalopathy, candida of the trachea, bronchi, or lungs, chronic cryptosporidiosis (with diarrhea), chronic bronchi, or lungs, chronic cryptosporidiosis (with diarrhea), chronic isosporiasis, disseminated mycosis (e.g., histoplasmosis, isosporiasis, disseminated mycosis (e.g., histoplasmosis, coccidioidomycosis, penicilliosis), recurrent nontyphoidal coccidioidomycosis, penicilliosis), recurrent nontyphoidal SalmonellaSalmonella bacteremia, lymphoma (cerebral or B-cell non-Hodgkin), invasive bacteremia, lymphoma (cerebral or B-cell non-Hodgkin), invasive cervical carcinoma, atypical disseminated leishmaniasis, cervical carcinoma, atypical disseminated leishmaniasis, symptomatic HIV-associated nephropathy, symptomatic HIV-symptomatic HIV-associated nephropathy, symptomatic HIV-associated cardiomyopathy, reactivation of American associated cardiomyopathy, reactivation of American trypanosomiasis (meningoencephalitis or myocarditis)trypanosomiasis (meningoencephalitis or myocarditis)

WHO Clinical Staging of HIVWHO Clinical Staging of HIV

► 2010 – Stage IV: treat; Stage III: treat; stage II: treat 2010 – Stage IV: treat; Stage III: treat; stage II: treat if symptomatic; stage I: do not treat. If known CD4 if symptomatic; stage I: do not treat. If known CD4 < 350: treat.< 350: treat.

► Validation of World Health Organization HIV/AIDS Validation of World Health Organization HIV/AIDS Clinical Staging in Predicting Initiation of Clinical Staging in Predicting Initiation of Antiretroviral Therapy and Clinical Predictors of Low Antiretroviral Therapy and Clinical Predictors of Low CD4 Cell Count in Uganda. Baveewo S, Ssali F, CD4 Cell Count in Uganda. Baveewo S, Ssali F, Karamagi C, Kalyango JN, Hahn JA, et al. 2011 PLoS Karamagi C, Kalyango JN, Hahn JA, et al. 2011 PLoS ONE 6(5): e19089. ONE 6(5): e19089. doi:10.1371/journal.pone.0019089 doi:10.1371/journal.pone.0019089

► Previous sensitivities in Uganda at CD4 of 200 was Previous sensitivities in Uganda at CD4 of 200 was 51-52% and specificity was 68-88%.51-52% and specificity was 68-88%.

WHO Clinical Staging of HIVWHO Clinical Staging of HIV

WHO 2010 Recommendations WHO 2010 Recommendations on ARV Therapyon ARV Therapy

WHO 2010 Recommendations WHO 2010 Recommendations on ARV Therapyon ARV Therapy

WHO 2010 Recommendations WHO 2010 Recommendations on ARV Therapyon ARV Therapy

HIV Treatment and the HIV Treatment and the Challenge of IDPs if Movement is Challenge of IDPs if Movement is

ImminentImminent► ART is a long-term life-saving measure and ART is a long-term life-saving measure and

should still be evaluated.should still be evaluated.► Displaced persons may be returning to areas Displaced persons may be returning to areas

where HIV care is stronger or weaker or even where HIV care is stronger or weaker or even non-existent.non-existent.

► Staging of the disease and anticipated Staging of the disease and anticipated availability at the site being travelled to availability at the site being travelled to should guide the urgency of therapy should guide the urgency of therapy initiation.initiation.

► If patients have advanced clinical disease If patients have advanced clinical disease (severe AIDS-defining illness or CD4<50), (severe AIDS-defining illness or CD4<50), patients should be advised to delay their patients should be advised to delay their departure and ART commenced immediately.departure and ART commenced immediately.

HIV Treatment and the HIV Treatment and the Challenge of IDPs if Movement is Challenge of IDPs if Movement is

ImminentImminent► If the patient is WHO Class III and healthy or with a good known If the patient is WHO Class III and healthy or with a good known

CD4 and:CD4 and:1.1. treatment is available at the site being travelled totreatment is available at the site being travelled to, then , then

initiation of treatment may occur at either location.initiation of treatment may occur at either location.2.2. treatment is not available at the site being travelled to, ttreatment is not available at the site being travelled to, the he

displaced person should be encouraged to remain where they displaced person should be encouraged to remain where they are and initiate ART for at least 3 months to monitor potential are and initiate ART for at least 3 months to monitor potential side-effects and adherence, and subsequently be provided side-effects and adherence, and subsequently be provided with a stock of medication for 3-6 months if possible.with a stock of medication for 3-6 months if possible.

3.3. individuals insist on leaving immediately or in the near future,individuals insist on leaving immediately or in the near future, then the options include a) leaving with no ART, b) initiation of then the options include a) leaving with no ART, b) initiation of ART for a short period prior to leaving together with additional ART for a short period prior to leaving together with additional ART stock, or c) leaving with a supply to be initiated at the site ART stock, or c) leaving with a supply to be initiated at the site being travelled to (with referral letters and extensive pre-being travelled to (with referral letters and extensive pre-adherence counseling).adherence counseling).*The guidelines group believed option a to be better for most *The guidelines group believed option a to be better for most individuals going to areas of limited care and options b or c for individuals going to areas of limited care and options b or c for individuals going to areas of adequate care.individuals going to areas of adequate care.

HIV Treatment and the HIV Treatment and the Challenge of IDPs if Movement is Challenge of IDPs if Movement is

ImminentImminent► There may be additional reasons for delaying treatment There may be additional reasons for delaying treatment

initiation, other than those previously listed, such as patient initiation, other than those previously listed, such as patient readiness, practical considerations (such as side effects readiness, practical considerations (such as side effects during travel and reintegration), concurrent medical during travel and reintegration), concurrent medical conditions that may worsen on ART (e.g. immune conditions that may worsen on ART (e.g. immune reconstitution diseases may present catastrophically and the reconstitution diseases may present catastrophically and the receiving site may not have the resources to manage them), receiving site may not have the resources to manage them), and other considerations. The risks and benefits of deferring and other considerations. The risks and benefits of deferring treatment must be carefully weighed against immediate treatment must be carefully weighed against immediate initiation; options should be discussed with the patient, initiation; options should be discussed with the patient, including delaying departure.including delaying departure.

► This decision-making may require significant ART expertise, This decision-making may require significant ART expertise, and the health worker should consult if not confident that and the health worker should consult if not confident that s/he has the expertise to give adequate counsel.s/he has the expertise to give adequate counsel.

► Choice of regimen: In general, try to match the regimen to Choice of regimen: In general, try to match the regimen to the one the individual is most likely to be on over the next the one the individual is most likely to be on over the next year (try wherever possible to match the regimen to that year (try wherever possible to match the regimen to that available in the area the person is going to).available in the area the person is going to).

HIV Treatment and the HIV Treatment and the Challenge of IDPsChallenge of IDPs

Treatment for Patients on Treatment for Patients on Previous ARTsPrevious ARTs

► A repeat HIV test to confirm their infection.A repeat HIV test to confirm their infection.► If the individual is currently on ART, continue If the individual is currently on ART, continue

treatment with no interruption.treatment with no interruption.► If possible, a viral load and CD4 count should be done If possible, a viral load and CD4 count should be done

at the time of the first visit. If the VL is raised at the time of the first visit. If the VL is raised (according to the national protocol), adherence (according to the national protocol), adherence intensification is usually warranted. Expert opinion intensification is usually warranted. Expert opinion should be sought before ordering resistance testing, should be sought before ordering resistance testing, if available.if available.

► If there has been a treatment interruption, try to If there has been a treatment interruption, try to restart treatment as soon as possible, after careful restart treatment as soon as possible, after careful assessment of the reasons for the interruption. The assessment of the reasons for the interruption. The VL may be high if the interruption is significant.VL may be high if the interruption is significant.

► Adherence counseling and support should be Adherence counseling and support should be undertaken in light of the new circumstances.undertaken in light of the new circumstances.

Treatment for Patients on Treatment for Patients on Previous ARTsPrevious ARTs

► If on the same regimen as national program, then If on the same regimen as national program, then continue same regimen.continue same regimen.

► If currently on a different regimen from the national If currently on a different regimen from the national program, continue with the current regimen if the program, continue with the current regimen if the national program supports this different regimen.national program supports this different regimen.

► If the national program does not support the If the national program does not support the current regimen, then decide based on the history current regimen, then decide based on the history of side effects and co-morbidities, history of of side effects and co-morbidities, history of treatment or clinical failure, use of concomitant treatment or clinical failure, use of concomitant medication.medication.

► If patient on previous unknown regimen or poor If patient on previous unknown regimen or poor known history, then initiate on the national known history, then initiate on the national guidelines first-line therapy and follow closely. guidelines first-line therapy and follow closely. Check a VL in 6 weeks if possible.Check a VL in 6 weeks if possible.

Treatment for Patients on ARTs Treatment for Patients on ARTs and Contingency Planningand Contingency Planning

► Though not less likely to be adherent when on Though not less likely to be adherent when on medications, displaced persons are at a greater risk medications, displaced persons are at a greater risk of treatment interruption.of treatment interruption.

► Provisions of personal ART stocks.Provisions of personal ART stocks.► Patients should have in their position a personal HIV Patients should have in their position a personal HIV

treatment card (drugs, labs, toxicities, illness treatment card (drugs, labs, toxicities, illness history).history).

► If on an NNRTI regimen (which have a long half-life) If on an NNRTI regimen (which have a long half-life) and treatment is stopped with no possibility of and treatment is stopped with no possibility of immediate restocking of drugs, consider “covering immediate restocking of drugs, consider “covering the tail” (the long half-life of NNRTIs) by continuing the tail” (the long half-life of NNRTIs) by continuing dual nucleosides for a week after stopping the dual nucleosides for a week after stopping the NNRTI, to prevent possible NNRTI resistance.NNRTI, to prevent possible NNRTI resistance.

ART Specific ChallengesART Specific Challenges► Some ARVs (e.g. ritonivir) require refrigeration.Some ARVs (e.g. ritonivir) require refrigeration.► Some ARVs require food intake for optimal absorption. Many regimens Some ARVs require food intake for optimal absorption. Many regimens

require twice daily dosing. Displaced persons may not have sufficient require twice daily dosing. Displaced persons may not have sufficient food available and should be told to take their medications despite lack food available and should be told to take their medications despite lack of food, and warned of possible increased GI side-effects.of food, and warned of possible increased GI side-effects.

► If the ART choice requires more frequent monitoring, consider the ease If the ART choice requires more frequent monitoring, consider the ease and cost of access to the displaced person.and cost of access to the displaced person.

► ARVs requiring reconstitution (some pediatric formulations) depend on ARVs requiring reconstitution (some pediatric formulations) depend on access to clean water, which may not be easily available to displaced access to clean water, which may not be easily available to displaced persons.persons.

► Lack of lab access should not exclude ART for patients. If the ART Lack of lab access should not exclude ART for patients. If the ART choice requires more frequent monitoring, consider ease and cost of choice requires more frequent monitoring, consider ease and cost of access. For example, a nevirapine regimen should ideally have liver access. For example, a nevirapine regimen should ideally have liver function monitoring in the initiation phase, which may increase the function monitoring in the initiation phase, which may increase the frequency and cost of visits. However, in many cases, nevirapine is frequency and cost of visits. However, in many cases, nevirapine is the only NNRTI available, and no liver function testing is available, in the only NNRTI available, and no liver function testing is available, in which case the drug should be initiated with extensive patient which case the drug should be initiated with extensive patient counseling.counseling.

► Syrup formulations are often difficult to carry and require a lot of Syrup formulations are often difficult to carry and require a lot of space.space.

Evidence Based Guidelines for Evidence Based Guidelines for Immigrants and RefugeesImmigrants and Refugees

Canadian Medical Association JournalCanadian Medical Association Journal►Screen for HIV, with informed consent, Screen for HIV, with informed consent,

all adolescents and adults from all adolescents and adults from countries where HIV is prevalent (> countries where HIV is prevalent (> 1%) – Sub-Saharan Africa and parts of 1%) – Sub-Saharan Africa and parts of the Caribbean the Caribbean (The HIV infection rate is about 12.6 times higher (The HIV infection rate is about 12.6 times higher among immigrants and refugees from countries where HIV is endemic than it is among immigrants and refugees from countries where HIV is endemic than it is in the Canadian-born population.)in the Canadian-born population.)

►The decision to screen men and women The decision to screen men and women is based on the dramatic reduction in is based on the dramatic reduction in mortality with ARV (triple) therapy.mortality with ARV (triple) therapy.

BibliographyBibliography► UNHCR/WHO/UNAIDS Policy Statement on HIV Testing and Counselling in UNHCR/WHO/UNAIDS Policy Statement on HIV Testing and Counselling in

Health Facilities for Refugees, Internally Displaced Persons and other Persons Health Facilities for Refugees, Internally Displaced Persons and other Persons of Concern to UNHCR 2009.of Concern to UNHCR 2009.

► WHO Consensus Statement – Delivering Antiretroviral Drugs in Emergencies: WHO Consensus Statement – Delivering Antiretroviral Drugs in Emergencies: Neglected but Feasible 9/20/2006.Neglected but Feasible 9/20/2006.

► UNHCR Antiretroviral Medication Policy for Refugees January, 2007.UNHCR Antiretroviral Medication Policy for Refugees January, 2007.► WHO Case Definitions of HIV For Surveillance and Revised Clinical Staging and WHO Case Definitions of HIV For Surveillance and Revised Clinical Staging and

Immunological Classification of HIV-Related Disease in Adults and ChildrenImmunological Classification of HIV-Related Disease in Adults and Children► WHO Antiretroviral Therapy For HIV Infection in Adults and Adolescents 2006 WHO Antiretroviral Therapy For HIV Infection in Adults and Adolescents 2006

Revision.Revision.► WHO Antiretroviral Therapy For HIV Infection in Adults and Adolescents 2010 WHO Antiretroviral Therapy For HIV Infection in Adults and Adolescents 2010

Revision.Revision.► UNHCR Clinical Guidelines For Antiretroviral Therapy Management For UNHCR Clinical Guidelines For Antiretroviral Therapy Management For

Displaced Populations 2007.Displaced Populations 2007.► Validation of World Health Organization HIV/AIDS Clinical Staging in Predicting Validation of World Health Organization HIV/AIDS Clinical Staging in Predicting

Initiation of Antiretroviral Therapy and Clinical Predictors of Low CD4 Cell Initiation of Antiretroviral Therapy and Clinical Predictors of Low CD4 Cell Count in Uganda. Baveewo S, Ssali F, Karamagi C, Kalyango JN, Hahn JA, et al. Count in Uganda. Baveewo S, Ssali F, Karamagi C, Kalyango JN, Hahn JA, et al. 2011 PLoS ONE 6(5): e19089. doi:10.1371/journal.pone.0019089 2011 PLoS ONE 6(5): e19089. doi:10.1371/journal.pone.0019089

► Evidence Based Clinical Guidelines for Immigrants and Refugees. Evidence Based Clinical Guidelines for Immigrants and Refugees. www.cmaj.ca on July 27, 2011. P.35-37www.cmaj.ca on July 27, 2011. P.35-37