BMJ  2003;327:171 (19 July), doi:10.1136/bmj.327.7407.171

reviews

PERSONAL VIEWS

Are HIV positive asylum seekers an unfair burden on the NHS?

The extra burden on the NHS is one of the issues cited in the controversy over the number of asylum seekers entering the United Kingdom. My specialty, which includes care of patients infected with HIV, has seen a considerable increase in the number of new diagnoses of HIV in patients who acquired the virus abroad, such that most new cases in the United Kingdom are now in this category. A major proportion of these patients are asylum seekers, largely from sub-Saharan Africa.

Doctors treating asylum seekers are often required to support applications for exceptional leave to remain in this country, on the grounds that antiretroviral treatment is not widely available (or affordable) in their countries of origin. The growing realisation among doctors and politicians that a sizeable and increasing amount of resources is being taken up in the care of these patients has led to two opposing points of view. The first view is that most of these unfortunate people are fleeing persecution and deserve our full support and care, regardless of the cost to the country. Some holders of this view go further, reasoning that because most of the asylum seekers who reach Britain are resourceful by nature they provide a welcome influx of motivated immigrants. The second view is that most of the HIV positive asylum seekers are either "health tourists" (coming here for treatment they couldn't afford at home) or economic migrants abusing our system, and we shouldn't be using scarce resources on them.

I suspect that although most healthcare professionals who come into contact with this group of patients would admit that both sides of the argument have some truth they largely sympathise with the first point of view. This is probably because, on an individual basis, we see enough evidence of torture and suffering among these people to make the prospect of sending them all home to die of AIDS, if not further persecution, inhumane in the extreme. Naturally, this view overshadows the uncomfortable suspicion that many of the patients we see probably are health tourists or economic migrants.

The first position, however, has several difficulties. It neglects the reality that the cost of caring for these patients is not insubstantial—each additional patient being treated with antiretroviral drugs means two or three fewer hip replacements each year. It also assumes that adequate treatment of HIV infection can be given only in this country. This is probably untrue, as there is growing evidence that patients who are given triple antiretroviral treatment in the developing world, without the sophisticated monitoring we use here, on the whole fare as well as they would in this country. Furthermore, there is the counterargument that the resourceful people who make it to Britain to claim asylum are more useful to the poor African countries they have come from.

Clearly there is a considerable way to go before universal care of all HIV positive patients in the developing world is achieved. Substantially more funding needs to go into increasing access to cheaper antiretroviral drugs, training of HIV specialists, and other support services—all of which will require concerted efforts by governments around the world. The main benefit of such a strategy will be that HIV positive people in poor countries will not face the stark choice of remaining there and dying of AIDS or getting on a plane to Europe. The resources currently used for health care, social security, and asylum applications for those immigrants who have not been persecuted could instead be spent on HIV positive people in the developing countries, where the same amount of money would save many more lives.

Until such universal care is available, HIV specialists have no realistic option—practically or ethically—but to give HIV positive asylum seekers the care they need and to support their applications to remain in Britain. But we should not forget the 30 million or so other people living with HIV in the developing world, most of whom have little immediate hope of being spared from their affliction.

Department of Infection and Travel Medicine, James Cook University Hospital, Middlesbrough davidr.chadwick{at}stees.nhs.uk

CiteULike    Complore    Connotea    Del.icio.us    Digg    Reddit    Technorati    What's this?

Rapid Responses:

Read all Rapid Responses

Disagreement to philosophy of treatment

Vera M Dalley
bmj.com, 22 Jul 2003 [Full text]

Re: Disagreement to philosophy of treatment

Susana Mancero
bmj.com, 23 Jul 2003 [Full text]