Securing HIV treatment and care for undocumented migrants in England Falling Through the Cracks, 23 July, 13.00-14.00 Securing HIV treatment and care for undocumented migrants in England Abstract #WEPDD0201 NAT is a UK NGO working exclusively on HIV policy and campaigns work. I’m Policy & Campaigns Manager at NAT and today I will be talking about our campaign for free HIV treatment and care for undocumented migrants in England. Sarah Radcliffe Policy & Campaigns Manager, NAT, UK

Background Some migrants ineligible for free NHS care Treatment access Background Some migrants ineligible for free NHS care 2004: crackdown on unlawful residence HIV the only communicable disease/STI for which charges were not waived Public narrative of NHS ‘health tourism’ The first things you need to know are that Healthcare is a devolved matter in the UK, meaning that England, Scotland, Wales and Northern Ireland each run their own National Health Service. The NHS is free at the point of use. It is not an insurance or contributory-based system – it is funded by general taxation. Asylum seekers and migrants living in England are generally eligible for free care on the same basis as other residents. But a small group of often vulnerable migrants are charged. This includes short-term visitors but also anyone living in the UK without papers. This means refused asylum seekers and undocumented migrants. This has been the case particularly since 2004. NHS charging rules included public health exemptions for treatment for STIs and serious communicable diseases – except for HIV. HIV testing was free, but undocumented migrants would be billed for any treatment they needed at the cost of 1,000s of pounds. The charging regime is generally supported by a public narrative of ‘health tourism’. As the NHS is a universally free service to residents, the suggestion is that migrants come to the UK with the specific intention of accessing expensive healthcare for free. This argument is used by Government and the media alike and has some currency within the health service also.

Strategies Developing evidence base Cost & public health arguments Treatment access Strategies Developing evidence base Cost & public health arguments Human rights case Broad coalition of support Parliamentary engagement Incremental changes NAT campaigned for eight years against HIV treatment charges. We used the following strategies: We developed our own evidence base to challenge unfounded claims that people living with HIV came to the UK as health tourists. Our report The Myth of HIV Health Tourism used government surveillence data to show, amongst other things, that people were diagnosed an average of 4 years after arrival in the UK. We used real-life case studies to show the deterrent effect that treatment charges had on testing and entry to care, the human impact of this and the additional costs to the NHS. For example, chargeable migrants would avoid contact with NHS services until seriously ill and then arrive at Accident and Emergency needing costly treatment. The NHS must provide treatment in such an emergency situation and the costs far outweigh the cost of routine HIV treatment (which the patient will eventually need). We used emerging studies on treatment as prevention to show that failure to test and treat migrants would lead to new infections which could have been prevented. Throughout our campaign, we referred back to the human rights of the migrants affected by charging – though these unfortunately did not have as great an impact as we would have liked. Crucial to our success in making these arguments was that we cultivated a broad coalition of supporters –who were making the same points. This included the British HIV Association, the professional association of HIV doctors, individual clinicians, HIV support organisations, migrant and refugee groups. As well as making submissions to formal Government consultations on NHS charging, we took every opportunity to engage with parliamentarians and especially parliamentary committees including the Joint Committee on Human Rights and the Health Select Committee.

Outcomes Amendment to Health & Social Care Act 2012 Treatment access Outcomes Amendment to Health & Social Care Act 2012 New public health evidence (HPTN052) Implemented October 2012 Scotland followed suit in May 2014 UK remains a ‘hostile environment’ for undocumented migrants– but it is possible! Finally, we achieved a change in charging rules via an amendment to the Government’s Health and Social Care Act 2012. This was not the most obvious place for such a policy change, which may have been part of the success – it became a public health issue, not a migration one. The amendment which NAT drafted was tabled by Lord Norman Fowler, former Secretary of State who oversaw the UK’s Government response to the AIDS crisis at the beginning of the epidemic. The clincher in terms of winning the argument in 2012 was the findings of the HPTN952 trial, which was the evidence the Department of Health needed to exempt HIV treatment and care on public health grounds. The exemption came into effect in October 2012. Scotland has brought in equivalent rule-changes and Northern Ireland and Wales have committed to the same. In 2013 the Home Secretary announced the intention to make the Uk a ‘hostile environment’ for undocumented migrants. If anything public attitudes have got worse. But the NAT campaign shows that it is possible to improve HIV care for vulnerable migrants even in a political environment such as this.

Thank you sarah.radcliffe@nat.org.uk www.nat.org.uk @NAT_AIDS_Trust Treatment access Thank you sarah.radcliffe@nat.org.uk www.nat.org.uk @NAT_AIDS_Trust