Antiretroviral therapy for refugees and internally displaced persons: a call for equity.

Available evidence suggests that refugees and internally displaced persons (IDPs) in stable settings can sustain high levels of adherence and viral suppression. Moral, legal, and public health principles and recent evidence strongly suggest that refugees and IDPs should have equitable access to HIV treatment and support. Exclusion of refugees and IDPs from HIV National Strategic Plans suggests that they may not be included in future national funding proposals to major donors. Levels of viral suppression among refugees and nationals documented in a stable refugee camp suggest that some settings require more intensive support for all population groups. Detailed recommendations are provided for refugees and IDPs accessing antiretroviral therapy in stable settings

Six rapid assessments of alcohol and other substance use in populations displaced by conflict

BACKGROUND: Substance use among populations displaced by conflict is a neglected area of public health. Alcohol, khat, benzodiazepine, opiate, and other substance use have been documented among a range of displaced populations, with wide-reaching health and social impacts. Changing agendas in humanitarian response-including increased prominence of mental health and chronic illness-have so far failed to be translated into meaningful interventions for substance use. METHODS: Studies were conducted from 2006 to 2008 in six different settings of protracted displacement, three in Africa (Kenya, Liberia, northern Uganda) and three in Asia (Iran, Pakistan, and Thailand). We used intervention-oriented qualitative Rapid Assessment and Response methods, adapted from two decades of experience among non-displaced populations. The main sources of data were individual and group interviews conducted with a culturally representative (non-probabilistic) sample of community members and service providers. RESULTS: Widespread use of alcohol, particularly artisanally-produced alcohol, in Kenya, Liberia, Uganda, and Thailand, and opiates in Iran and Pakistan was believed by participants to be linked to a range of health, social and protection problems, including illness, injury (intentional and unintentional), gender-based violence, risky behaviour for HIV and other sexually transmitted infection and blood-borne virus transmission, as well as detrimental effects to household economy. Displacement experiences, including dispossession, livelihood restriction, hopelessness and uncertain future may make communities particularly vulnerable to substance use and its impact, and changing social norms and networks (including the surrounding population) may result in changed - and potentially more harmful-patterns of use. Limited access to services, including health services, and exclusion from relevant host population programmes, may exacerbate the harmful consequences. CONCLUSIONS: The six studies show the feasibility and value of conducting rapid assessments in displaced populations. One outcome of these studies is the development of a UNHCR/WHO field guide on rapid assessment of alcohol and other substance use among conflict-affected populations. More work is required on gathering population-based epidemiological data, and much more experience is required on delivering effective interventions. Presentation of these findings should contribute to increased awareness, improved response, and more vigorous debate around this important but neglected area

Low levels of viral suppression among refugees and host nationals accessing antiretroviral therapy in a Kenyan refugee camp.

BACKGROUND: Refugees and host nationals who accessed antiretroviral therapy (ART) in a remote refugee camp in Kakuma, Kenya (2011-2013) were compared on outcome measures that included viral suppression and adherence to ART. METHODS: This study used a repeated cross-sectional design (Round One and Round Two). All adults (≥18 years) receiving care from the refugee camp clinic and taking antiretroviral therapy (ART) for ≥30 days were invited to participate. Adherence was measured by self-report and monthly pharmacy refills. Whole blood was measured on dried blood spots. HIV-1 RNA was quantified and treatment failures were submitted for drug resistance testing. A remedial intervention was implemented in response to baseline testing. The primary outcome was viral load <5000 copies/mL. The two study rounds took place in 2011-2013. RESULTS: Among eligible adults, 86% (73/85) of refugees and 84% (86/102) of Kenyan host nationals participated in the Round One survey; 60% (44/73) and 58% (50/86) of Round One participants were recruited for Round Two follow-up viral load testing. In Round One, refugees were older than host nationals (median age 36 years, interquartile range, IQR 31, 41 vs 32 years, IQR 27, 38); the groups had similar time on ART (median 147 weeks, IQR 38, 64 vs 139 weeks, IQR 39, 225). There was weak evidence for a difference between proportions of refugees and host nationals who were virologically suppressed (<5000 copies/mL) after 25 weeks on ART (58% vs 43%, p = 0.10) and no difference in the proportions suppressed at Round Two (74% vs 70%, p = 0.66). Mean adherence within each group in Round One was similar. Refugee status was not associated with viral suppression in multivariable analysis (adjusted odds ratio: 1.69, 95% CI 0.79, 3.57; p = 0.17). Among those not suppressed at either timepoint, 69% (9/13) exhibited resistance mutations. CONCLUSIONS: Virologic outcomes among refugees and host nationals were similar but unacceptably low. Slight improvements were observed after a remedial intervention. Virologic monitoring was important for identifying an underperforming ART program in a remote facility that serves refugees alongside host nationals. This work highlights the importance of careful laboratory monitoring of vulnerable populations accessing ART in remote settings

If You Could Only Choose Five Psychotropic Medicines: Updating the Interagency Emergency Health Kit

Mark van Ommeren and colleagues describe how they chose five psychotropic medicines to add to the Interagency Emergency Health Kit, which is a box with medicines and medical supplies designed to help people in major humanitarian emergencies

Education: critical to HIV prevention and mitigation

Good-quality protective formal and non-formal education can provide the knowledge and skills for the prevention of HIV and protection from the impact of AIDS

Funding for reproductive health in conflict and post-conflict countries: a familiar story of inequity and insufficient data.

Paul Spiegel and colleagues discuss a new study that examines funding for sexual and reproductive health programs in conflict-affected low-income countries

Bounded agency in humanitarian settings: a qualitative study of adherence to antiretroviral therapy among refugees situated in Kenya and Malaysia.

HIV-positive refugees confront a variety of challenges in accessing and adhering to antiretroviral therapy (ART) and attaining durable viral suppression; however, there is little understanding of what these challenges are, how they are navigated, or how they may differ across humanitarian settings. We sought to document and examine accounts of the threats, barriers and facilitators experienced in relation to HIV treatment and care and to conduct comparisons across settings. We conducted semi-structured interviews among a purposive sample of 14 refugees attending a public, urban HIV clinic in Kuala Lumpur, Malaysia (July-September 2010), and 12 refugees attending a camp-based HIV clinic in Kakuma, Kenya (February-March 2011). We used framework methods and between-case comparison to analyze and interpret the data, identifying social and environmental factors that influenced adherence. The multiple issues that threatened adherence to antiretroviral therapy or precipitated actual adherence lapses clustered into three themes: "migration", "insecurity", and "resilience". The migration theme included issues related to crossing borders and integrating into treatment systems upon arrival in a host country. Challenges related to crossing borders were reported in both settings, but threats pertaining to integration into, and navigation of, a new health system were exclusive to the Malaysian setting. The insecurity theme included food insecurity, which was most commonly reported in the Kenyan setting; health systems insecurity, reported in both settings; and emotional insecurity, which was most common in the Kenyan setting. Resilient processes were reported in both settings. We drew on the concept of "bounded agency" to argue that, despite evidence of personal and community resilience, these processes were sometimes insufficient for overcoming social and environmental barriers to adherence. In general, interventions might aim to bolster individuals' range of action with targeted support that bolsters resilient processes. Specific interventions are needed to address locally-based food and health system insecurities