HIV, mental health & refugees - Case Studies by Xavier Pereira

HIV, MENTAL HEALTH & REFUGEES: Case Studies Xavier V Pereira Associate Professor, Psychiatry Director, Health Equity Initiatives 22 November 2011HEALTH EQUITY INITIATIVES

HEALTH EQUITY INITIATIVES (H.E.I) –Health Equity Initiatives (H.E.I.) is a Malaysian NGO established in 2007. –H.E.I. focuses on health rights and health issues of the marginalised. –H.E.I. provides mental health education, assessments and interventions for refugees via their centre based and community mental health programs. –H.E.I. is also involved in research and advocacy.HEALTH EQUITY INITIATIVES

CASE STUDY-1 • Begum (not her real name), a married Rohingya-Myanmar refugee in her early twenties is on treatment for HIV infection at a Malaysian hospital. She has lived in Malaysia for the last 7 years with her husband and 2 children. She claims that none of her family members are HIV positive. • Her HIV status was detected during her first pregnancy, 6 years ago, at a government health clinic. She defaulted follow up and only made contact with the health services (government hospital) for delivery of the baby. • During her second pregnancy one year ago, she was again tested at the health clinic and was confirmed positive for HIV. She was referred to Sungai Buloh Hospital for treatment before delivery in July, 2011. She has been on treatment since August 2011 under the Individual Assistance Desk (IAD) program of UNHCR.HEALTH EQUITY INITIATIVES

CASE STUDY-1 • She stays in Klang and it costs her about RM200.00 each time she has to keep her appointment with the Infectious Disease clinic in Hospital Sg. Buloh. She has to bring her children along with her since she is her children’s sole caretaker. Cost incurred includes travel by taxi and food. The financial burden is heavy and she feels stressed. • The other issue burdening her was the stigma associated with being HIV positive. Those in the community who know her HIV status shun her and refuse the family a place to stay. • She had high scores on all the 3 scales of Stress, Anxiety and Depression on the DASS-21 (Depression, Anxiety and Stress Scale) administered to her.HEALTH EQUITY INITIATIVES

Issues from Case Study-1 ACCESSIBITY to HEALTH CARE 1. There is a lack of recognition of the refugee status in Malaysia • Malaysia has not ratified the 1951 International Convention for Refugees. • Government health centres require official identification for registration, consultation and treatment, and refugees not registered with UNHCR are less able to access government health centres. (Verghis S.E., Pereira X.V., 2009)HEALTH EQUITY INITIATIVES

Issues from Case Study-1 ACCESSIBILITY to HEALTH CARE 2. Refugees are socio-economically burdened • Most refugees arrive in Malaysia with little or nothing • Refugees are not allowed to officially work in Malaysia and earn a living. • Refugees are required to pay foreigner rates at government health centres (RM60.00 per consultation) • In addition there are associated costs of transport, medication and loss of wages.HEALTH EQUITY INITIATIVES

Issues from Case Study-1 PSYCHOLOGICAL DISTRESS and MORBIDITY 1. Refugees have a greater vulnerability to psychological and psychiatric morbidity. (de Vries, 2001; Sultan, A.,& OSullivan, K., 2001; Silove & Steel 2007; Verghis & Pereira 2009) – In Malaysia the contributing factors are the experience of : 1. Loss. 2. Insecurity and Threat. 3. Trauma. (HEI Mental Health Services) – In Malaysia, most common mental health problems among refugees: Depression, Anxiety, Post Traumatic Stress DisorderHEALTH EQUITY INITIATIVES

Issues from Case Study-1 PSYCHOLOGICAL DISTRESS and MORBIDITY 2. Similarly HIV positive status increases the risk of psychiatric morbidity. (Freeman MC et al, 2005) Thus being a refugee with HIV infection greatly increases the risk of psychiatric morbidity.HEALTH EQUITY INITIATIVES

CASE STUDY-2 John (not his real name), a 46 year old refugee from the African continent was referred to the Mental Health Services of Health Equity Initiatives (HEI) because he was experiencing psychological distress. He was seen by a psychiatrist and a clinical psychologist at HEI. John is HIV positive and is receiving treatment at a Malaysian public hospital. He was distressed because during the last consultation he had with a doctor at the infectious diseases clinic he had a rectal examination done on him. He claimed the purpose of the rectal examination was not explained to him by the doctor.HEALTH EQUITY INITIATIVES

CASE STUDY-2 On assessment John complained of poor sleep, decreased appetite, low mood, poor concentration and recurrent negative thoughts. He also said he was irritable and had lost interest in normal pleasurable activities (anhedonia). He had recurrent thoughts that the doctor perceived him to be a ‘faggot’ or homosexual and thus had carried out a rectal examination on him. During the assessment John repeatedly said that he was married and had three children. This was interpreted as an attempt to refute the assumption that the doctor who examined him had perceived him to be a ‘faggot’.HEALTH EQUITY INITIATIVES

Issues from Case Study-2 INFORMED CONSENT and COUNSELLING • All migrant workers/expatriate professionals are screened for infectious diseases as per Malaysian immigration rules. • There are reports that the 3 Cs – Consent, Counselling and Confidentiality – are not practiced. • This case study reveals that informed consent and counselling should also precede physical examination especially invasive examinations like rectal and vaginal examination in HIV positive individualsHEALTH EQUITY INITIATIVES

Issues from Case Study-2 ADHERENCE to TREATMENT • Evidence indicates that mental health morbidity detrimentally affects adherence to treatment in HIV infected persons. ( Mellins CA et al , 2003) • The patient in the case study was apprehensive about returning for treatment. • The IAD (Individual Assistance Desk) of UNHCR has an Adherence Support Program for HIV positive refugees on treatment in Sg. Buloh Hospital. Adherence to treatment has increased from about 25% in 2007 to about 85% in 2011 through this program. • UNHCR has 12 trained refugee Adherence Support Workers (ASWs) for this program.HEALTH EQUITY INITIATIVES

The WAY FORWARD – Collaborative effort - HEI, IAD and Infectious Diseases Unit of SBH to deal with mental health issues of HIV positive refugees. – Rapid appraisal of mental health of HIV +ve refugees using the DASS-21 – Training of ASWs of UNHCR in mental health – Provision by HEI of counselling, psychological and psychiatric services for HIV +ve refugees.HEALTH EQUITY INITIATIVES

RECOMMENDATIONS 1. Malaysia to ratify the 1951 International Convention for Refugees. 2. Align the medical consultation fees for refugees in Malaysian public health centres with that paid by Malaysian patients. 3. Allow refugees to work in order for them to cover their health care costs. 4. Train health care professionals and health workers to detect mental health problems in HIV +ve patients.HEALTH EQUITY INITIATIVES

REFERENCES 1. De Vries, J. (2001). Mental health issues in Tamil refugees and displaced persons. Counselling implications. [doi: DOI: 10.1016/S0738- 3991(99)00120-2]. Patient Education and Counseling, 42(1), 15-24. 2. Freeman MC, Patel V et al. Integrating mental health in global initiatives for HIV/AIDS. British Journal of Psychiatry (2005), 187, 1-3. 3. Mellins CA et al. Longitudinal Study of Mental Health and Psychosocial Predictors of Medical Treatment Adherence in Mothers Living with HIV Disease. AIDS PATIENT CARE and STDs (2003) Volume 17, Number 8, 407-420. 4. Silove D, Austin P, Steel Z. No Refuge from Terror: The Impact of Detention on the Mental Health of Trauma-affected Refugees Seeking Asylum in Australia. Transcultural Psychiatry. 2007 September 1, 2007;44(3):359-93. 5. Sultan A, OSullivan K. Psychological disturbances in asylum seekers held in long term detention: A participant–observer account. Medical Journal of Australia. 2001;175:593–6. 6. Verghis S, Pereira XV. ‘Health concerns of refugees and asylum seekers in Malaysia’. Paper presented at: Roundtable on Developing a Comprehensive Policy Framework for Refugees and Asylum Seekers. Kuala Lumpur: Bar Council Malaysia; 2009 June 23,HEALTH EQUITY INITIATIVES

THANK YOUHEALTH EQUITY INITIATIVES

HIV, mental health & refugees - Case Studies by Xavier Pereira

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