Supplementary memorandum by Terrence Higgins
Trust (HA 14A)
THT DIRECT REGARDING
THT Direct is a nationally available phone lime
for anything related to HIV which receives on average around 600
calls a week. These are on a wide range of matters and, while
data is collected systematically, when the system was set up eligibility
enquiries were so infrequent that they did not merit a data category
of their own. Thus, they are usually a subset of immigration enquiries
and are not collected independently.
Anecdotally, staff and volunteers estimate that
enquiries about eligibility for NHS services have gone from around
one to two a week (a year ago), to one to two each day (currently);
a sevenfold increase. They state that, in general, the majority
of these enquiries relate to whether someone will be entitled
to NHS services, rather than from people who have already been
refused them, and are within a wider range of enquiries rather
than being the sole reason for callingThey also state that
a substantial number of these calls are from people who are eligible
for NHS services, but who are afraid to approach services directly
because they do not want the shame of being refused.
Although there has not been time to do a comparative
overview of other developed countries, and no accurate table of
requirements currently exists, enquiries have established that
the UK's nearest neighbour on the European mainland, France, has
a much more liberal eligibility requirement than the UK for health
services. In France, since 1997, all health services are available
free to anyone who can show that they have been living within
French territories or dependencies for the past three months and
where someone has a serious health condition for which treatments
are not available in their country of origin, they cannot be deported
back to there. Therefore, if anyone with HIV was intending to
migrate to Europe in seek of HIV services, they would be substantially
better off going to France than to the UK. There is no evidence
to show that this has, in fact, occurred because most people immigrating
who subsequently approach the NHS for HIV-related services are
unaware of their HIV status upon entry (THT/GHT 2003).
Appended please find the overview of this piece
of research, which also may be of use to the Committee in its
RECENT MIGRANTS USING HIV SERVICES IN ENGLAND
Policy, Campaigns and Research Division at Terrence
Higgins Trust, October 2003.
Data supplied by Terrence Higgins Trust (THT) and
George House Trust (GHT).
This snapshot, undertaken in October 2003, used
basic, anonymised information from recent users of THT and GHT
services who are also adult migrants to the UK. It aimed to map:
when they were diagnosed with HIV;
under what circumstances that diagnosis
The records of 60 recent users of services were
examined by the following agencies: Lighthouse Kings (part of
THT) in South London (14), George House Trust in Manchester (24),
Terrence Higgins Trust in the West Midlands (22). The identifying
factors for selecting records were that they should be of the
most recently presenting migrants with HIV who had asked for support
and who had provided enough information about their circumstances
for staff to be able to complete the survey with confidence.
In all, 17 different countries were represented,
15 of them African. Of the 60 people whose case notes were revisited,
just over 50% (31) were of Zimbabwean origin. One in 12 (five)
was from Uganda. Only 7% (four) were not from Africa, of whom
three were Jamaican and one Afghani.
Just over 18% (11) had arrived in the UK before
2000. Ten entered in 2000, nine entered in 2001 and 20 (33%) entered
in 2002. Only five had arrived in the first nine months of the
current year, 2003. Five people did not have dates of entry in
their case notes. The numbers appear to rise in 2002 and then
return to a steady level, and this may be explained in part by
the preponderance of Zimbabweans. 2002 was a particularly turbulent
year in Zimbabwe, with many people fleeing persecution and others
taking advantage of work or study opportunities to stay away from
the violence and intimidation in their home country. Other data
on migrants and people seeking asylum in 2002 confirms an across-the-board
rise in the number of Zimbabweans entering the UK in that year.
Method of entry
Despite many suppositions to the contrary, only
13 (22%) in all were recorded as having entered the UK to seek
asylum. Almost half of these were Zimbabwean (6), with others
being from Uganda, the Congo, Sierra Leone and Afghanistanall
areas of acknowledged political turbulence within the last few
years. Another 12 (20%) had entered to study. A similar number,
13 (22%) had entered as visitors for unspecified reasons, with
a further seven (12%) coming to join family already here. Others
had come on work visas, to join the army or to get married. Method
of entry to the UK was not known in 11 (18%) cases, but this was
incomplete data records on the part of the responding agencies
rather than failure to disclose. Most HIV support agencies only
collect data necessary to respond to someone's support needs and
reason for original entry to the UK may not have been relevant
to these in all cases.
These findings indicate that there is no identifiable
single way in which people subsequently diagnosed with HIV are
entering the UK; rather, the picture is a complex and diverse
one. It strongly suggests that making testing a condition of work
visas (a common move amongst industrial countries to quiet popular
fears about HIV and migration) would have very little impact upon
the issue. It is also clear that the commonly made link between
asylum and HIV is a tenuous one.
Five people were diagnosed with HIV before 2001,
with a further four diagnosed in 2001. Ten people were diagnosed
in 2002, with the vast majority, 41 (68%) diagnosed only recently,
in 2003. To some extent, this may reflect the fact that recently
diagnosed people may be those most likely to access community
services, but it also reflects the pattern of diagnoses amongst
African immigrants to the UK and recent testing campaigns targeted
at those communities. There is also a likely link to the rising
efficiency of antenatal testing, through which an increasing number
of heterosexual women with HIV are being identified.
In order to examine the contention that people
are entering the UK with the specific intention of obtaining treatment,
two other pieces of data were examined; length of time between
arrival in the UK and diagnosis, and circumstances of diagnosis.
Only five people (8%) were diagnosed within three months of entry
to the UK. The most common timespan between entry and diagnosis
was 10 to 12 months, with 14 people (23%) diagnosed at this time.
In all, at least 45 (75%) waited more than nine months to test
after their entry. One third of people in the cases examined (20)
had tested more than 18 months after entry. In six cases (10%),
it was not possible to determine the length of time between entry
and testing due to missing data.
This data militates against the argument that
people are coming to the UK in order to obtain treatment. Were
this the case, one would expect to see a far swifter progression
in the overall data from arrival to testing, rather than three
quarters of people testing after nine months or more. This view
is strengthened by the final category of data collected below.
Possibly the most interesting data was on how
people came to be tested, This data, was available for all 60
people, as something highly likely to have been, relevant to the
reasons they initially sought help from the organisation. By far
the most common reason given for testing was the onset of symptomatic
HIV, with 35 people (58%) testing when they became actively unwell.
Almost half of these people (27% in all) fell severely ill before
diagnosis, as measured by CD4 counts, emergency admission to hospital,
or conditions such as TB. Ten women were diagnosed antenatally
(17%) through routine offers of testing to all pregnant women.
Another nine (15%) tested only after the death or diagnosis of
a partner. Only two people reported being diagnosed prior to entering
the UK, and only one person (less than 2% of the sample) was diagnosed
as the result of an unprompted visit to a GUM clinic. Other ways
in which people came to test included testing following sexual
assault, army medical and a medical for a visa.
This data shows that people discovered their
HIV status by a wide range of methods common amongst those who
are unaware that they have HIV. More than a quarter became severely
ill before being diagnosed with HIV, some having presented at
hospital with mystery symptoms a number of times or succumbing
to life-threatening conditions before HIV was suspected; not the
mark of people undertaking "treatment tourism". In only
one case out of the 60 examined had someone attended at a GUM
clinic for sexual health screening without an obvious external
trigger, the action most likely by someone who might be already
aware of their HIV status and wanting to access services for it.
Obviously, this is a relatively small sample
and there is a need for further investigation of a wider cohort.
However, it is clear that the picture is a far more complex one
than most coverage of the issue has suggested.
People with HIV arrive in the UK
in a wide range of ways for many reasons.
Many are diagnosed in a manner that
contraindicates any previous knowledge of their condition.
The majority do not obtain a diagnosis
early upon arrival in the UK, but in the course of ordinary living
over an extended period of time.
Many are spurred to test by the onset
of ill-health associated with relatively, late stage HIV.
Terrence Higgins Trust would welcome further
factual investigation of this issue, in order to conduct the debate
about migration, treatment tourism and sexual health in a more
constructive and rational manner.