Translocations: Migration and Social Change
An Inter-Disciplinary Open Access E-Journal
ISSN Number: 2009-0420
_____________________________________________________________________
HIV and ‘Direct Provision’ – Learning from the Experiences of Asylum Seekers in
Ireland1
Maeve Foreman
School of Social Work and Social Policy, Trinity College Dublin (Email: mforeman@tcd.ie)
_______________________________________________________________________
Abstract
This article explores issues raised by an earlier Irish study conducted with migrants living
with HIV. The latter highlighted the fact that many of those newly diagnosed with HIV in
Ireland are from sub-Saharan African, were in the asylum system when first diagnosed,
and were not accessing available supports. This article discusses the impact the current
policy of holding asylum seekers in ‘direct provision’ accommodation has on best
practice in HIV care and prevention. The challenges facing health care workers providing
HIV care in multicultural Ireland, in a system where immigration policies are known to
inhibit integration into Irish society, are discussed. The article concludes that to provide
adequate support to those living with HIV there may be a need to address the potential
adverse impact of ‘direct provision’ accommodation for asylum seekers.
Key Words: HIV, Asylum Seekers, Direct Provision, Social Work, Ireland
________________________________________________________________________
Introduction
The prominent role that social exclusion and marginalization (play)…has great
significance when considering the design and implementation of HIV/AIDS
prevention programmes. The loneliness, fear and despair expressed…reflect an
overwhelming void of powerlessness and rejection that imbues the lives of many
African migrants (Edubio and Sabanadesan 2001: 89)
This article explores issues raised by an earlier Irish study (Foreman and Hawthorne
2007) conducted with migrants living with HIV; in particular the fact that the majority of
those who are diagnosed HIV positive in Ireland today are from sub-Saharan Africa
(NDSC 2006), that most of those in the study were seeking asylum when they first learnt
of their HIV status, and were not accessing available supports. The possible implications
of this for HIV-testing, care and prevention initiatives with migrants, particularly those
new to Ireland and living in ‘direct provision’, are discussed in the light of research on
the impact of living in ‘direct provision’.
This article is based on a presentation entitled ‘Learning from the experiences of migrants accessing HIV
services in Ireland’ made at the Trinity Immigration Initiative Migration Research Fair, 24 th September,
2007.
1
© 2008 Foreman
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Background
One of many global health issues today is inequality of access to HIV care and treatment.
Almost 40 million people are infected around the world, 60% of whom are in subSaharan Africa. While aid organisations are committed to improving treatment initiatives
in countries most affected by HIV, the fact remains that those infected with HIV in the
developing world are more likely to die of an AIDS related illness than those living in
countries where HIV treatments are freely available (UNAIDS 2007).
Although a relatively small number of migrants coming to Ireland are diagnosed with
HIV infection after arrival (Boyle et al 2007), they do comprise a growing percentage of
those testing positive, presenting new challenges to health services. The largest group
testing HIV positive today are heterosexuals, mostly from Sub-Saharan Africa (SSA)
(Health Protection Surveillance Centre (HPSC) 2007). For example, out of 337 new
infections in 2006, 50% were as a result of heterosexual contact. Of these 62% were from
SSA. This contrasts with the Eighties when intravenous drug users and gay men were the
largest so called ‘at risk groups’ testing positive (National AIDS Strategy Committee
(NASC) 2000; HPSC 2007). When Ireland instituted routine antenatal HIV screening in
1999, maternity hospitals became a major site of first diagnosis for women migrants
(Department of Health and Children 2000). This may go some way to explaining the
disproportionate number of women from African countries testing positive.
Key barriers for migrants accessing health services in Ireland have been identified and
include communication and language difficulties, a lack of understanding of the role of
service providers as well as a lack of understandable information on services (Broderick
2008; Foley Nolan et al 2002; Stewart 2006; Watt and McGaughey 2006). In working
with migrants to overcome such barriers and adhering to complicated HIV drug treatment
regimes, social workers and other health care workers operate within the context of
current immigration rules and regulations. Immigration policies have already been shown
to raise complex practice issues for social workers in Ireland and abroad; e.g. the unequal
treatment of ‘separated children’ within the asylum system regarding care and
accommodation, (Christie 2002a; 2002b, 2003; Fanning and Veale 2001; Fanning 2004)
or unequal access to social welfare services (Fanning and Veale 2004; Humphries 2006).
Medical social workers, as members of multidisciplinary teams, carry both a HIV care
and prevention brief, providing pre and post HIV test counselling and ongoing
psychosocial support to those testing HIV positive and their families (Foreman and
Mulcahy 1997; Foreman 2000; Jones and Foley 2002). In 2003, the social work team in
a Dublin HIV clinic undertook a study with migrants living with HIV as they were not
linking in with support services to the same extent as their Irish counterparts. Using
purposive sampling, questionnaires were completed by 57 migrants living with HIV.
Key issues identified include the fact that the majority (1) were diagnosed while in the
asylum system, (2) had not been offered HIV testing and counselling, (3) were not
accessing HIV support organisations and (4) had difficulties around confidentiality and
disclosure of HIV status to partners (Foreman et al 2004; Foreman and Hawthorne 2007).
This article will explore challenges in HIV care in the context of the current immigration
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policy of holding all asylum seekers in ‘direct provision’, and suggest possible changes in
practice.
Asylum seekers and ‘Direct Provision’
Since 2000, asylum seekers in Ireland are dispersed around the country shortly after
arrival and accommodated in ‘direct provision’ camps or hostels. They share rooms, eat
pre cooked meals with no cooking facilities of their own, and live on 19.10 euros a week,
with 9.60 euros per child. The allowance has stayed at the same rate since its
introduction. They are not allowed to work study or claim benefits, regardless of their
health status (Irish Refugee Council (IRC) 2001, 2004; Quinn and Hughes 2005). The
Social Welfare Act (2003) removed any entitlement asylum seekers had to housing
allowances, and since May 2004 Child Benefit has also been withdrawn, placing them
outside the state welfare system and below the poverty line.
By January 2008 6,799 people seeking asylum (over 20% of them children under the age
of four) were living in a total of 62 accommodation centres, including two reception
centres (Reception and Integration Agency 2008). While this figure includes nine selfcatering units, these are being phased out and all asylum seekers are now placed in direct
provision centres. Only a small percentage are granted refugee status in the first instance
– for the six year period 2000 to 2005, 59% (or 4,022) of those granted asylum were only
successful at the appeal stage. Over 20% have been residing in such centres for two years
or more pending appeal of their cases (Irish Refugee Council 2006).
When dispersal was first introduced, it was envisaged that it might result in
marginalisation of asylum seekers (Fanning and MacEinri 1999). Although the
government has stated that the system of direct provision “is a humane, fair and effective
means of meeting (asylum seekers’) basic needs" (Quinn and Hughes 2005: 10), concern
has been expressed about the legal basis and human rights implications of direct
provision, as well as the long term impact of such segregation (Brady 2002; Collins 2001;
Free Legal Aid Centre 2003; Fanning and Veale 2004; Faughan and Woods 2000; Irish
Refugee Council 2001; King 2004; Stewart 2006).
Social Exclusion
Mullally’s (2001) review of the Irish asylum application process found an emphasis on
security, control and prevention of abuse of the immigration system, rather than on
protection and human rights. The adverse affects of living in direct provision for long
periods on both physical and mental health have been highlighted (Foley Nolan 2002;
Cave et al 2003), with the lack of legal status and enforced unemployment adding to
feelings of marginalisation and lack of belonging (Edubio and Sabanadesan 2001; Cairde
2003; Clarke 2002; Feldman et al 2008; Stewart 2006). This feeling of otherness, when
combined with previous trauma often experienced by those in the asylum system (Boyle
et al 2008; Cave et al 2003; Foley Nolan et al 2002; Stewart 2006), has been shown to
pose severe risks to well being (Sinnerbrink et al 1997; Burnett 2002; Doyal and
Anderson 2005). The HSE psychology service reports that reasons for referral to their
service include experience of violence, torture, sexual abuse, rape and trafficking,
imprisonment and loss of family, and that asylum seekers are at greater risk of psychiatric
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conditions such as depression, psychosis and post-traumatic stress disorder (Boyle et al
2008). Stewart’s (2006) study of the mental health needs of those in direct provision
centres suggest a need to revisit immigration policies in relation to reception of asylum
seekers if social inclusion and integration are to be achieved. Many centres are on the
outskirts of towns adding to a sense of segregation and isolation and Stewart (2006)
stressed the importance of linking with local services and availing of existing community
resources.
The fact that the physical and mental health of those living in direct provision is affected
by poverty and social isolation, as well as the lack of family and community supports was
highlighted in submissions to the Irish Health Service Executive’s (HSE) consultation
process to develop their intercultural health strategy (Pillinger 2008; HSE 2008; Combat
Poverty 2007; Cairde 2007; Galway Refugee Support Group 2007, cited in HSE 2008:
27-33).
Not having the right to work, to participate in third level education, to cook
one’s own meals, to appropriate accommodation, especially for families, all
contribute to high levels of poverty, stress, mental illness and poorer health status
among asylum seekers (Combat Poverty in HSE 2008: 2.4)
Nutritional needs are poorly served by direct provision (Corbett 2002; Manandhar et al
2006), and the lack of cooking facilities, overcrowding and sharing accommodation have
all been cited as sources of stress (Cairde 2003; Collins 2001; Comhlamh 2001; King
2004; Stewart 2006). Sharing accommodation can also make it difficult to manage the
various medications that need to be taken with food, and side effects like diarrhoea or
vomiting are hard to manage in hostels with shared toilet facilities.
In the context of a wide-ranging ‘anti-immigrant’ sentiment in Ireland (Feldman 2008) a
recent study indicated that black Africans and asylum seekers are most at risk of racism
in Ireland (McGinnity et al 2006) with up to one third of work permit holders and asylum
seekers in the study reporting race related harassment on the street, on public transport or
at work. Despite all of the above, initiatives in Ireland to promote the integration of
refugees and immigrants do not specifically refer to the social exclusion experienced by
asylum seekers (Interdepartmental Working Group 2003), and Ireland’s lack of a overall
coherent, integration policy has been criticised (Boucher 2008).
HIV and Healthcare in Direct Provision
Some of the social isolation and mental health problems that arise from living in ‘direct
provision’ have been outlined above. For those diagnosed with HIV shortly after arrival
in Ireland the problems are clearly intensified, particularly if coming from a country
where HIV is both a stigmatising and terminal illness. Difficulties in providing
comprehensive health care, including HIV care, to newly arrived migrants within the
current asylum seeking system have been highlighted (Boyle et al 2008). Although the
government’s Reception and Integration Agency (RIA) has been asked by HSE staff to
defer dispersal of asylum seekers to direct provision centres until their health care needs
have been addressed, there is evidence to suggest that this does not always happen (Boyle
et al 2008). Asylum seekers are screened on arrival and those newly diagnosed with HIV
find themselves quickly dispersed to different parts of the country, far from the main HIV
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treatment centres. As a result, the RIA and health care staff are often ‘at loggerheads’,
with the RIA primarily concerned with accommodation and the latter, in the case of those
newly diagnosed with HIV, with HIV care and prevention (Boyle et al 2008: 12).
Follow up, including HIV testing of partners and children, is extremely important.
“Dispersal of clients to other centres before adequate healthcare follow-up at base is a
recurrent problem, begging for a more smooth holistic management approach” (Boyle et
al 2008: 12). Statistics between 2002 and 2007 show that approximately 70% of asylum
seekers take up the offer of health screening for a variety of conditions including HIV.
Local health services are often not consulted in advance about the health needs of
relocated asylum seekers, and fear of disclosure and loss of confidentiality can inhibit the
newly diagnosed asylum seeker from seeking the support they need locally. The lack of
provision of free condoms at ‘direct provision’ centres remains a huge ommission on the
part of the RIA, and one that was raised by the recently launched HIV and AIDS
Education and Prevention Plan (NASC 2008). While some centres have now introduced
condom machines, those living on 19 euro a week cannot easily afford to buy them.
Those with HIV who are refused asylum can, if they are willing to disclose their HIV
status, apply for temporary ‘leave to remain’ on the humanitarian ground that they need
medical treatment unavailable in their country of origin. This process can take several
years and only a small number are successful - between 2000 and 2005 only 617 people
were given leave to remain for a variety of reasons (Foreman 2003; IRC 2006). The
rights of those granted leave to remain are not defined in Irish law (IRC 2004; Immigrant
Council of Ireland 2006). Interestingly, in some EU countries the numbers getting leave
to remain is far greater than those granted refugee status (IRC 2006).
Those who are HIV positive and clinically well cannot use this legal route, and as a
result, deportations continue to be of major concern to asylum seekers diagnosed with
HIV. In 2004 alone 599 people were deported, eight times the numbers given leave to
remain (75) (IRC 2006). Although there is no way of knowing how many of these might
have been infected with HIV, anecdotally, HIV care agencies have reported that some
asylum seekers on treatment for HIV were deported to South Africa on the grounds that
treatment is now available there, even though they returned to areas where treatment was
inaccessible and unaffordable, and subsequently died.
In October 2006 Ireland introduced a system of ‘subsidiary’ protection for those whose
needs are not covered by refugee conventions to comply with EU regulations (Immigrant
Council of Ireland 2008). In future, this may be a better route for those denied asylum
and in need of HIV treatment not available in their country of origin.
HIV Testing, Support and Stigma
People living with HIV want to be treated equally not differently. Many of the
prejudices towards people living with HIV are as a result of misinformation and
ignorance. The consequence of HIV-related stigma, however, can be catastrophic.
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Prejudice is one of the barriers that prevent people coming forward for HIV
testing. With early testing people can access appropriate treatment and support
and as a result live longer and more productive lives. (Walsh 2007)
HIV has been associated with marginalisation, stigma and discrimination (Ogden and
Nyblade 2005; UNAIDS 2003). There is widespread evidence internationally that the
stigma attached to HIV inhibits those potentially living with HIV from accessing HIV
testing and treatment, limits the availability and accessibility of support and services and
reduces levels of disclosure (Brimlow et al 2003; Cusick and Rhodes 1999; Erwin and
Peters 1999; Herek 1999; Lynch 2000; Parker and Aggleton 2003; UNAIDS 2006).
Rejection, abandonment and isolation resulting from disclosure of HIV status, have all
been documented (Cairde 2003; Serovich 2000) with some African women living in the
UK reporting extreme hostility (Doyal and Anderson 2003; 2005). Not only are people
blamed for becoming infected, they are seen as an infection risk (Herek 1999).
The ongoing stigma towards those living with HIV internationally has been shown to
affect self esteem, mental health, access to care, as well as the actual incidence of HIV
(Brimlow et al 2003), all of which have been highlighted in Ireland by the recent Stamp
Out Stigma campaign2 (www.stampoutstigma.ie). Reducing discrimination and stigma
surrounding HIV is generally accepted as being a key component in the fight to reduce
the incidence of HIV (Ogden and Nyblade 2005). Interestingly, the causes of stigma, the
forms it takes and its consequences, despite minor cultural differences, appear to be
common across cultures (Ogden and Nyblade 2005: 38).
Noel Walsh, chair of the Stamp out Stigma (SOS) campaign in Ireland said at its launch
that “the current climate of fear - of disclosure, of rejection, of discrimination and, in
some cases, of physical violence must end. HIV positive people must be able to live their
lives as fully functioning normal members of society without the fear of stigma and
discrimination.” (www.stampoutstigma.ie)
Research commissioned by SOS indicate that HIV related stigma is a problem in Ireland
– 84% of participants living with HIV felt they were viewed negatively by society. The
research also showed that discrimination came from both friends and the local
community. This was echoed in a survey of the general public with over 50% agreeing
that those living with HIV were viewed negatively, and an alarming 23% would be
concerned about eating a meal prepared by someone with HIV (Stamp out Stigma/Public
Communication Centre 2008).
Although the Equality Status Act 2000 can be used to pursue cases of HIV-related
discrimination in service provision, the resulting loss of confidentiality has precluded any
cases being brought to date. “The stigma surrounding HIV serves to fuel discrimination
2
Stamp out Stigma, a national education and awareness campaign launched on 1 stDecember, 2007, was
established by a multi-stakeholder forum of statutory and voluntary agency workers and people living with
HIV, including migrants, to tackle public perception and attitudes. It received an initial budget of €300,000
from the State.
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in that it acts as a deterrent to mounting a legal challenge” (Montgomery 2007: 1). In
Cairde’s (2003) study of minority ethnic women living with HIV in Ireland there was
also evidence of discrimination within migrant communities towards those with HIV. As
many in Irish society view asylum seekers negatively (Fanning 2002; Guerin 2002;
Lentin et al 2002; Know Racism 2003), to receive a diagnosis of HIV while an asylum
seeker carries a ‘double negativity’ effect, indicating the additional importance of HIV
care and support for this group.
Although HIV counselling is generally accepted as an important tool in both behaviour
change and disclosure for those who are at risk of, or infected, with HIV (National AIDS
Strategy Committee 2000; UNAIDS 2004), in Foreman and Hawthorne (2007) the
majority of participants had either not received pre test counselling prior to receiving a
positive result or immediate post-test counselling having been told they were HIV
positive.
Disclosure of HIV Status
It is generally accepted that good social support networks can result in better mental and
physical health (Vaux 1988; Onwumere et al 2002; Reilly and Woo 2004) protecting
migrants from adaptation stress and improving coping abilities (Folkman and Moskowitz
2000). A clear link has also been shown between positive social support networks, low
risk sexual behaviour and disclosure of HIV status (Reilly and Woo 2004). Disclosure is
considered good for mental and physical health as it can increase social support and
coping abilities, decrease anxiety and depression, and reduce isolation and high risk
sexual behaviour (Cusick and Rhodes 1999; Reilly and Woo 2004; Serovich et al 2001).
A key issue to emerge in Foreman and Hawthorne (2007) was the impact that stigma and
discrimination within migrants’ own communities had on disclosure of HIV status and
accessing support. While the majority had informed current partners of their HIV status,
most had not disclosed to ex partners. As a result some current or ex partners of
practically all study participants lacked information that they may be at risk of HIV and
should consider testing. Fear of blame, violence, discrimination, loss of family,
relationship or marriage job, fear of the wider community discovering their HIV status
and resulting loss of confidentiality, social isolation and lack of support were all factors
in non-disclosure, factors also evidenced in other studies (Cairde 2003; Doyal and
Anderson 2003; Hackl et al 1997; Ogden and Nyblade 2005; Serovich 2000; Simoni et al
1995, 2000; Zierler 2000).
In Foreman and Hawthorne (2007) studies show that more than half of those who had
been in Ireland for less than one year were not getting the support they needed. Those
who felt supported had been able to disclose their status to partners, generally considered
a first step in both HIV prevention and breaking often self-imposed isolation (Miller and
Madge 1996). The added burden of living in direct provision, with its lack of privacy and
lack of freedom of movement e.g. to travel to sources of support, would appear to have
an impact on levels of HIV disclosure. This in turn has implications for HIV prevention.
Migrants reported a lack of knowledge of support organisations and how to access them
(Foreman and Hawthorne 2007). However, even those who were more aware of the
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availability of voluntary support organisations were reluctant to use them. Reasons cited
included fears of stigma, difficulties in adjustment to a new diagnosis and feelings of
social exclusion, resulting in an assumption that HIV services used by indigenous Irish
were not for them.
Migrants clearly need more help in accessing existing support services, and seeing them
as both available and relevant to their needs. The way information is currently provided –
i.e. primarily through leaflets and booklets - and the relevance of existing support
organisations to this group, need to be explored. For those newly diagnosed while in
reception centres, a quick dispersal (Boyle et al 2008) can mean missing out on hospital
appointments with social workers and essential introductions to support organisations. It
is important to state, however, that once migrants found their way to voluntary
organisations, these were found to be helpful and a good source of support (Foreman and
Hawthorne 2007).
Learning from others - examples of good policy and practice
“HIV prevention needs to be addressed concurrently with issues of immigration, housing
and general health” (Health Education Research Unit HERU 1996: 2). An assessment of
HIV prevention intervention with refugees and asylum seekers in the UK, a country with
a long history of immigration from African countries, supported the general principles of
good practice in health promotion with this group, i.e. “involve communities, focus
interventions, address stigma and discrimination, address confidentiality, support
community and organisation development” (HERU 1996: 2). HERU also identified the
importance of managing information about HIV infection in this group to avoid further
discrimination, and of developing strategic responses based on consultation with refugees
and asylum seeker groups. The importance of contextualising HIV prevention as just one
element of health care was also highlighted.
More recently, Sigma Research was commissioned by the National African HIV
Prevention Programme (NAHIP) to assess HIV prevention need among Africans in
England (Dodds et al 2007). More than 4000 Africans took part, of whom over 15% were
HIV positive. The report identified key areas for HIV prevention, including the need to
address knowledge gaps regarding HIV testing and HIV treatments, as well as to inform
people on how immigration policy interacts with HIV. Two thirds of respondents were
unaware that one in twenty Africans living in England has HIV, and prevention initiatives
are needed to increase African’s perceived proximity to HIV in Europe. They also
identified the need to increase people’s ability and motivation to use condoms or, in the
case of women, to influence their partners to use them.
Statutory Services
Recent positive developments in Ireland include the Irish Health Service Executive’s
(HSE) Intercultural Strategy in Health (HSE 2008), the strategy of the Education and
Prevention Sub Committee of the National AIDS Strategy Committee (2008), and the
NCCRI’s (2007) Guide to Improving Government Service Provision to Minority Ethnic
Groups. Despite a lack of clear policies and resources to ensure competence in working
with diverse cultures until relatively recently (Eastern Regional Health Authority 2004;
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Pillinger 2008; HSE 2008), positive images and experiences of health care providers
experienced by migrants have emerged (Cairde 2003; Foreman and Hawthorne 2007).
However, problems concerning lack of interpreters have also come to light. For example,
in Foreman and Hawthorne (2007) some participants had been asked to translate for other
patients, or had to rely on children or other members of their families to interpret for
them. While translation services are available in some hospital settings, difficulties arose
through using interpreters who had not been trained to work in highly sensitive health
care areas, thus risking further alienating asylum seekers and fuelling the negative
psycho-social impact of a diagnosis of HIV.
The need for culturally appropriate health and social services, including access to
translation services and information in different languages, as well as involvement of
service users in service plans is acknowledged by the Social Inclusion Service 3 within the
HSE (ERHA 2004; Nurse 2006; Pillinger 2008). Initiatives within the HSE have
improved information, translation and interpretation services for minority ethnic users of
health services, but they remained fragmented (Nurse 2006). With the population
expected to rise to 5 million by 2030, up to 18% of whom may be foreign born, the HSE
recognises the need for a culturally competent health service (Nurse 2006) and recently
launched its National Intercultural Health Strategy 2007-2012 (HSE 20084). The
consultation report advocated a culturally sensitive, accessible service with an emphasis
on staff training.
The National AIDS Strategy HIV Education and Prevention Plan 2008-2012 (2008)
stressed the importance of targeting prevention efforts to specific groups. In particular, it
emphasised the need to do this with those from countries where HIV is endemic, and
identified refugees and asylum seekers as an ‘at risk’ population, particularly because of
unequal health outcomes for minority ethnic groups. It acknowledged the increase in
funding to improve access to services by providing staff training. The fact that an agreed
ethnic identifier is now included in the health sector is also an important development.
Key principles informing the action plan include working in partnership with target
population groups and greater involvement of people living with HIV. Its call for
improved coordination to strengthen the development of HIV prevention activities is
particularly needed in this area. Key action areas identified include education and
awareness raising specific to the needs of minority ethnic communities, sensitive to
issues of gender, ethnicity and religion. Free condoms in reception centres and hostels,
support for peer led interventions, increased access to screening and testing, capacity
building of those from countries where HIV is endemic to enable them to act as their own
3
Social Inclusion services target Homeless people, Minority Ethnic Communities; Asylum Seekers;
Refugees; Migrant Workers; Travellers; Illicit Drug Users, the Lesbian, Gay, Bisexual, Transsexual/
Transgender communities, people with problematic/dependent alcohol use and people living with
HIV/AIDS (www.hse.ie). The main policy and legislation underpinning Social Inclusion include Quality &
Fairness (the National Health Strategy); Towards 2016 Partnership Agreement; National Anti Poverty
Strategy, Homelessness - An Integrated Strategy; National Drugs Strategy; National Travellers’ Strategy;
Equality legislation; and Planning for Diversity - the National Action Plan Against Racism (NPAR) 20052008
4
The commitment to developing this strategy was made in Planning for Diversity, the National Action Plan
against Racism 2005-2008 (Dept. of Justice, Equality and Law Reform).
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advocates are all raised within the strategy. The strategy is aspirational - most of these
actions require the HSE to take on lead responsibility, in partnership with relevant
statutory agencies and civil society.
The Guide to Improving Government Service Provision to Minority Ethnic Groups
(NCCRI 2007) highlights key considerations for service providers to improve state
services to minority ethnic groups, an initiative that followed on from a cross-border
research project (Watt and McGaughey 2006). The guidelines suggest clear anti-racist
and intercultural policies including staff training, access to interpreters, data collection
and analysis to ensure consistent ethnic/equality monitoring. The importance of
consultation, with a view to mainstreaming or targeting services, is stressed.
Civil Society
In Ireland, voluntary organisations like Cairde, Dublin AIDS Alliance and Open Heart
House have already been putting some of the above strategies into practice. Cairde 5,
adopting a community development approach, is working with migrant communities to
develop their own advocacy groups on health matters, including HIV.
Dublin AIDS Alliance’s6 initiative with ethnic minority target groups highlighted some
of the language and cultural barriers they experienced accessing HIV information and
support services (Broderick 2008). Using innovative outreach methods to access hard to
reach populations, they held focus groups with several nationalities, including English
and French speaking groups for people from African countries. The focus groups
highlighted a lack of knowledge on how HIV status would affect legal status, and the
need for accurate information on how to access services, resulting in the development of
sexual health information booklets in several languages (Dublin AIDS Alliance 2007).
Faith has been identified as an important source of support for those living with HIV
(Biggar et al 1999; Kamya 2000; Dibelius 2001; Reilly and Woo 2004, Foreman and
Hawthorne 2007), suggesting the importance of including churches in HIV prevention
and care initiatives. Irish HIV support organisation Open Heart House (OHH)7, which
provides peer support to challenge the social stigma and isolation of HIV, developed a
minority ethnic advisory committee. Its brief includes increasing the membership base
and to facilitate engaging more effectively with community and church leaders to develop
supportive collaborative relationships (OHH 2008). There are many new churches
established in Ireland catering for the needs of immigrant communities (Irish Council of
Churches 2003) who could help combat the fear of refection and moral judgement that
inhibits migrants accessing their own communities for support (Doyal and Anderson
2003, 2005; Cairde 2003; Chandran 2005; Segujja 2005). Currently 20% of OHH
5
Cairde is a community development organisation working to tackle health inequalities among ethnic
minority communities by improving ethnic minority access to health services and ethnic minority
participation in health planning and delivery (www.cairde.ie).
6
Dublin AIDS Alliance is a voluntary organisation working to improve conditions for people living with,
or affected by, HIV/AIDS (DAA 2008)
7
Open Heart House is a member-led organisation and is the largest peer support network of HIV positive
people living in Ireland
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members are from minority ethnic backgrounds and members of SPECTRA United, a bimonthly social gathering at OHH have spoken out on radio about living with HIV in
Ireland. A nominated group member has also sat on the National AIDS Strategy
Committee (NASC) since March 2006. Other examples of good practice include a recent
partnership between OHH and Balseskin reception centre, with members of OHH
offering peer support to newly diagnosed HIV positive asylum seekers.
Conclusion
This article set out to look at possible implications for asylum seekers being diagnosed
HIV positive while living in ‘direct provision’ and the impact that this might have on
HIV care and prevention. The contradictory objectives and practices of immigration and
integration policies, one of which is the system of differential immigration statuses, are
problematic (Feldman et al 2008), and asylum seekers would appear to have the lowest
status of all. Indications are that living in ‘direct provision’ can heighten social exclusion
which militates against best practice in HIV care and prevention, and that a more
proactive, targeted service is needed to meet the HIV prevention and care needs of
migrants, particularly those living in the asylum system.
It is important to note that issues facing those newly diagnosed with HIV within the
asylum system cannot be seen in isolation from issues facing all migrants living with
HIV. While those living in ‘direct provision’ face additional hardships (King 2004;
Stewart 2006) all migrants, particularly those from SSA, face potential barriers in
accessing HIV testing, treatment and care because of racism, lack of integration and
discrimination and stigma within their own communities (Cairde 2003; Hawthorne and
Foreman 2007; Boyle et al 2008).
There is clearly a need for better interagency cooperation between the RIA, the HSE and
civil society if the issues raised in this article are to be addressed. The recommendations
emerging from this discussion echo demands of those currently employed to provide
health care to asylum seekers (Boyle et al 2006; Foreman and Hawthorne 2007). The
need for information and education at point of entry on all aspects of health care
including the benefits of testing for HIV, as well as the need for reassurance about the
implications of a HIV positive result for those seeing asylum has already been raised
(Boyle et al 2008; Dodds et al 2007) and is reinforced by this review, as is the continuing
need for improved channels of communication. Newly diagnosed migrants need easy
access to verbal as well as written information on HIV, in both a form and language that
is accessible (Broderick 2008), and this discussion has highlighted the need for
interpreters trained in sensitive health issues. Foreman and Hawthorne (2007) raised the
importance of easy access to confidential HIV testing with routine counselling, and this
discussion has also highlighted the importance of linking newly diagnosed asylum
seekers with local community based support services.
Several Irish studies mentioned have argued for an improvement in accommodation for
asylum seekers with access to education, training and employment to address the bioTranslocations
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psychosocial impact of living in ‘direct provision’, lessen social exclusion and improve
integration (Cave et al 2003; Fanning and Veale 2004; Stewart 2006). This review
reiterates this as well as indicating the importance of self catering accommodation for
those living with a stigmatising condition like HIV.
We need to develop ways of ensuring ongoing consultation with migrants affected by
HIV to ensure that services are not just available but also accessible and acceptable. The
inclusion of a migrant on the Care and Management Committee of NASC is a small
beginning in this direction. We also need to work in partnership with migrant groups to
challenge the stigma and discrimination that inhibits those living with HIV from
disclosing their HIV status and accessing necessary supports.
Recent initiatives such as the HSE’s intercultural health strategy and NASC’s education
and prevention strategy, while they are to be welcomed, need to be properly resourced if
they are to have any impact. Civil society is already actively working in this area and
properly funded are in a position to further this essential work. However, those working
in the area of HIV care support and prevention in both statutory and voluntary agencies
cannot do it alone. Immigration policies that promote integration for asylum seekers,
especially for those in the system for six months or more, are needed to help create the
necessary conditions to both prevent the spread of HIV as well as care for those most
affected. The use of ‘subsidiary protection’ (IMC 2008) to avoid deportations of asylum
seekers in need of HIV treatment needs to be explored.
In the meantime, it is hoped that the contribution of social workers and other health care
workers in HIV clinics, together with organisations like Cairde, Dublin AIDS Alliance,
Open Heart House and other migrant led organisations, will go some way towards
alleviating the enormous isolation and stress of those being diagnosed HIV positive
within the current asylum system of ‘direct provision’.
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Testing,
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