Is forced displacement a barrier to acceptable outcomes among refugees on antiretroviral therapy? : a field-study in Malaysia and Kenya

Abstract

In response to a major gap in evidence regarding treatment outcomes among asylum-based refugees. the primary objective of the thesis was to investigate adherence to highly active antiretroviral therapy (HAART) and virological outcomes among refugees and to compare these outcomes with local host communities in one urban, Southeast Asia setting (Sungai Buloh, Kuala Lumpur, Malaysia) and one remote sub-Saharan refugee camp (Kakuma. Kenya) setting. Given limited resources for expanding treatment, questions have been raised as to whether refugees can achieve sufficient levels of adherence and viral suppression to justify sustaining and expanding access. Data sources included a structured questionnaire with self-reported adherence measures, a pharmacy-based prescription refill measure, HIV viral loads, and indepth interviews. Analyses made use of quantitative and qualitative approaches. The thesis begins by presenting the rationale, aims, research questions, and a description of preparatory work. Paper One presents the results of a systematic review of the literature on adherence to HAART and treatment outcomes among conflict-affected and forcibly displaced populations. finding only 17 reports, five of which included less than <100 clients, adherence estimates in the range of 87-99.5%, and good treatment outcomes. Papers Two and Three present the quantitative findings from both settings, finding no differences in outcomes between refugees and the host community in either setting, but a large difference between the settings. In Malaysia, 83% of clients on HAART for 2:25 weeks were suppressed while only II % were suppressed in Kenya. Female sex, longer time from HIV diagnosis to HAART start, and optimal adherence pharmacy refill schedule were protective in the Malaysian setting while temporary migration for 2: I month (in the previous year) and 2: I hour average transit time to clinic were independent risk factors. Larger household sizes were protective in the Kenyan setting. Paper Four offers an account of patient experiences based on the qualitative findings from both settings, and suggests that systemic barriers and resilient strategies were prevalent in both settings; however. intensive systemic barriers appeared to overwhelm personal resilience in the camp setting. Paper Five positions the work in the context of previous and future research and makes recommendations for programs and policy. The thesis concludes by suggesting that. just as good treatment outcomes were shown to be achievable in a range of forcibly displaced groups. asylum-based refugees were also capable of treatment success and maintain outcomes similar to those of the host communities. There is a clear public health and humanitarian interest in guaranteeing access to ART, promoting optimal adherence. and sustaining viral suppression in all who are in need of treatment. When problems in achieving and sustaining viral suppression occurred, they were not typically due to previous forced displacement, or refugee status itself. Overall, refugees ought to have equal access to HIV treatment based on the principles of fairness, human rights, and individual and population-based public health benefits. Since HIV-positive individuals on HAART with good adherence will rarely transmit HIV to their sexual partners, it is in the enlightened self-interest of host country governments to support HIV programs that serve HIV -positive refugees and host clients equally.