In Minnesota, during the period prior to the cessation of the waiver requirement, HIV-infected refugees arrived in Minnesota at varying stages from asymptomatic infection to advanced disease. A majority had no prior record of ART; coinfections detected at post-arrival domestic health screening were common; and three AIDS-related deaths occurred. Two HIV-infected refugee women were pregnant at arrival, and 20 became pregnant after arrival, thus requiring specialized care to prevent mother-to-child HIV transmission. These findings reinforce the importance of providing information regarding HIV-infection to refugee populations [8
]. In addition, these data may serve as useful baseline comparison for the evaluation of changing practices and guidelines of HIV-testing.
Before 2010, documentation of HIV infection through the waiver program was the primary means of identifying HIV-infected refugees prior to arrival. The impact of the 2009 rule change on refugee health, particularly those who are HIV-positive, is unknown. Because early identification and appropriate initiation of therapy for HIV is associated with decreased morbidity and improved overall survival [11
], collaboration between refugee health programs and HIV counseling and testing services will be of increased importance. Current CDC guidelines recommend HIV screening in health-care settings for all persons aged 13–64 years, including refugees [3
]. Voluntary screening is encouraged by CDC for all refugees on arrival, when counseling and referrals for care, treatment, and preventive services are available [6
]. These changes are in accordance with the United Nations High Commissioner for Refugees (UNHCR), WHO, and United Nations Program on HIV/AIDS recommendations regarding HIV testing and counseling in health facilities for refugees, internally displaced persons, and other persons of concern to UNCHR [12
Identifying health needs and providing care to resettled refugees fits within the framework of upholding health as a human right. Data regarding HIV prevalence and risks for acquiring HIV infection among refugee populations are sparse [13
], and testing might not be available before arrival. After the change from required HIV testing, timely and accurate HIV diagnosis and treatment is of increased importance. Therefore, the arrival refugee medical examination provides an optimal opportunity to identify HIV infection among refugees and provide treatment. Coinfections are common and morbidity likely can be reduced with earlier diagnosis and treatment of HIV infection. As illustrated by the frequency of pregnancy among this population, the early identification of HIV after arrival can also reduce the likelihood of perinatal HIV transmission. Continued collaboration between public health agencies and health care providers will be necessary to follow and assess refugees’ health status, including HIV infection, in Minnesota and throughout the United States.
Similar to other reports investigating the health of HIV-infected refugees, coinfections were commonly detected [7
]. The high prevalence of TB among refugees described in this analysis is expected, considering that TB is a common coinfection among HIV-infected persons and in sub-Saharan Africa [17
]. Knowing a patient’s HIV status may influence clinicians suspicion and approach to TB infection and disease diagnosis. Moving forward, with the rule change, clinicians will not have the advantage of knowing the HIV status prior to arrival, making post-arrival screening important in detecting both HIV and TB disease.
During the period covered by chart reviews, US immigrant and refugee TB screening requirements were updated from 1991 requirements. In 1991, the requirements included a chest radiograph and three sputum samples (acid-fast–bacilli stain only) for disease detection. In 2007, these technical instructions were updated to require screening to include mycobacterial culture and completion of directly observed therapy before US arrival for anyone with TB disease [19
]. These data indicate that a substantial proportion (52%) of those with LTBI detected during their domestic health assessment did not complete treatment or treatment outcome was missing; LTBI patients do not have access to directly observed therapy making it challenging for public health and/or health care providers to monitor their treatment through completion. Linguistic or socio-cultural barriers and loss to follow-up due to out-migration are additional challenges that can disrupt LTBI treatment adherence. LTBI and treatment completion are not reportable to the TB surveillance or refugee health programs, which may have led to underreporting of treatment outcomes. In recent years, the refugee health program at the Minnesota Department of Health has improved its processes to actively track LTBI treatment outcomes. For refugees arriving from 2008 to 2010, the program has seen an increase in the proportion of refugees who follow LTBI treatment through to completion, due in part to improved tracking and reporting; 78% of all refugees who completed LTBI treatment, compared to only 48% during 2000–2007. However, this is still inadequate, particularly for those with HIV infection where the TB reactivation rate is excessive.
These data, based on medical chart review of resettled refugees, provide a unique summary of the health status of HIV-infected refugees during a period when HIV-infection status was known before US arrival. However, this study has certain limitations. As a retrospective medical chart review, certain clinical details might not be recorded in medical charts; others might have been missed during the process of chart abstraction; and patients might have sought health care elsewhere from the site of medical chart abstraction. To maintain a simplified data collection tool, certain details (e.g., the date that ART was prescribed) and treatment rationale were not ascertained. This review did not include psychosocial components, as others have included [16
]. Despite these limitations, our findings provide additional information given the limited data that exist regarding HIV-infection among refugee populations and can serve as useful baseline comparisons in lieu of changing practices and guidelines of HIV-testing and availability of ART. To complement medical chart abstractions, future evaluations of health status of HIV-infected refugee populations should include culturally appropriate patient interviews to better understand their knowledge, attitudes, and beliefs regarding HIV/AIDS testing and care.
In Minnesota, evaluating the health of all refugees through a health screening assessment, regardless of HIV-infection status is a routine MDH activity, provides a means for determining care and prevention needs, and includes constant interaction within MDH programs (e.g., TB prevention services follow-up). During 2000–2007, the refugee health screening rate was 94.8% of 29,182 eligible resettled refugees. Refugees are ineligible if they move out of state or to an unknown location or have incorrect contact information. In lieu of the waiver program, routine HIV screening is the most efficient way to detect HIV infection and provide appropriate and timely care.