While there is no evidence to support the claim that refugee populations have an increased prevalence of HIV, it is true that refugees are inherently more vulnerable to HIV – due to social instability, loss of relatives and breadwinners, increased risk of sexual assault or involvement in commercial sexual activities, as well as a lack of resources and services in education and health.
Before the 1990s, there was little focus on the risks of HIV/AIDS within refugee populations due to the fear that highlighting these risks would cause governments to resist accepting refugees. As countries began to consider the necessity to test refugees for HIV before allowing international travel and resettlement, UNHCR strove to protect refugees against expulsion due to their HIV status by publishing its Policy Guidelines Regarding Refugee Protection and Assistance and Acquired Immune Deficiency Syndrome (AIDS). Since then UNHCR has continued to publish guidelines and strategic plans promoting the rights of refugees with regard to HIV and AIDS, including discouraging the use of mandatory testing.
According to the 1951 Refugee Convention, host countries are required to provide non-discriminatory social and medical assistance to refugees equal to that for nationals. However, countries already overburdened with HIV/AIDS within their own population are usually unwilling to provide additional services for refugees and seldom include refugees in their National AIDS policies.
Stigma and misconceptions
As of March 2007, there were some 39,400 refugees and persons of concern registered with UNHCR in Cairo. Among those, Sudanese, Iraqis and Somalis constitute the vast majority (93%), with other nationalities representing the remaining 7%. Refugees enjoy very few socio-economic rights in Egypt and therefore depend mainly on UNHCR and other NGO partners for assistance – and, in the crowded urban areas of Cairo and Alexandria, compete with local Egyptians for limited resources.
Refugees are impeded not only by the lack of medical services, but also by the intense stigma and discrimination associated with HIV/AIDS within both the Egyptian and refugee populations. Egypt’s estimated low HIV prevalence can be attributed to the strong underlying cultural and religious values within society. As a result there is a lack of awareness about the disease and vast misconceptions with regard to modes of transmission and ways of prevention. It is commonly held that those with HIV must be promiscuous or drug-users and that HIV is a disease brought in by foreigners. As a result, HIV/AIDS is a highly stigmatised disease.
Before 2004, most HIV cases were reported as a result of the mandatory testing of blood donors, foreigners residing for more than six months and nationals applying for work permits to work abroad. While voluntary testing was available, those who tested positive were reported to the Ministry of Health and Population (MOHP), thereby greatly discouraging the use of such services. In addition, foreigners found to be HIV-positive were deported within 48 hours in order to try to contain the extent of the virus in Egypt.
In March 2004, following discussions with UNHCR, MOHP’s National AIDS Programme (NAP) exempted any registered refugee or person under protection of UNHCR from this same threat – but non-registered refugees found to be HIV-positive still have no protection from deportation. As a result, many organisations, including AMERA, encourage refugees to keep their HIV status confidential.
Only in the past three years has the Ministry of Health and Population (MOHP), with the support of Family Health International, developed a system of voluntary confidential counselling and testing (VCCT) and established national guidelines and a monitoring and evaluation plan. There are currently 14 VCCT sites, nine managed by the MOHP, plus nine UNFPA-funded mobile VCCT vans to provide access to people in remote areas. All VCCTs provide anonymous testing; while seropositive cases are reported to the Ministry for statistical and epidemiological purposes, no identifying information is provided.
Unfortunately, as foreigners are not allowed access to national HIV/AIDS services, refugees are left to depend on local NGOs and organizations – such as Refuge Egypt, which introduced a VCCT service at their clinic in 2003.While anyone who comes to Refuge Egypt can access VCCT, the organisation mainly targets high-risk groups within their family planning, antenatal and TB clinics. For HIV-positive pregnant mothers, they help prevent transmission to the baby through caesarean sections and by providing milk formula to prevent transmission through breastfeeding. Anyone living with HIV/AIDS is also eligible for food packages and can obtain house visits from the clinic doctors. Refuge Egypt is the only organisation offering pre- and post-test counselling.
Caritas, another implementing partner of UNHCR, performs confidential HIV testing for refugees on request and also provides support and counselling on how to handle life with HIV. Similarly, AMERA, an independent NGO offering legal support to refugees in Egypt, provides psychosocial support services for seropositive refugees. Since 2005, MOHP’s NAP has allowed refugees to be treated at Abbassia Fever Hospital for HIV-related illnesses or infections necessitating hospitalisation – but fear of deportation still prevents many from attending.
|In 2007, an Ethiopian refugee called on Dr Harrell-Bond, founder of AMERA, to explain that he – an HIV-positive refugee – had been referred to the Abbassia Fever Hospital but was afraid to go. He believed he would be locked in and never allowed to leave. The next day, a medical intern escorted him to Abbassia but he refused to go in. He said that his friends would instead collect money for him to return to his country where he could get medicine. His condition was such, however, that it is unlikely that he would survive any delay.
Despite these initiatives, refugees have no access to anti-retrovirals to prevent the onset of AIDS. While Refuge Egypt does have preventative anti-retrovirals such as post-exposure prophylaxis (PEP) for rape victims and single doses of ARVs to prevent mother-to-child transmission, there are no long-term therapeutic ARVs, leaving very limited options for treatment apart from treating any infections that may arise.
Recently however, the Global Fund for AIDS, Tuberculosis, Malaria (GFATM) provided funding for around 20 refugees to receive ARVs over a period of 5 years at Refuge Egypt starting in the fall of 2008. The Ministry of Health, with UNHCR support, has started training doctors in HIV awareness, VCCT, prevention of mother-to-child transmission, PEP, emergency contraception and case detection of STIs and HIV-related illnesses.
The situation has improved over the last three years as the Egyptian government has begun to extend their services to registered refugees, coupled with the new ARV programme at Refuge Egypt. These examples of integration of refugees into national HIV/AIDS services are key to helping HIV-positive refugees in Cairo, not only for the refugee population but also to help strengthen Egypt’s prevention efforts.
However education is vital in order to attempt to remove the stigma and discrimination surrounding not only HIV/AIDS but also refugees. The secrecy that is created by advising refugees to reveal their HIV status only to their immediate family and doctor unfortunately only continues to stigmatise the disease. This reinforces discrimination within the community and forces the disease underground, affecting prevention efforts. It is only through education and outreach programmes that awareness can be raised and misconceptions dispelled to promote a better understanding of the situation.
Anna Popinchalk (firstname.lastname@example.org) is a student at Macalester College in St. Paul, Minnesota, who worked as an intern for Dr. Harrell-Bond in Cairo in 2007. The author thanks UNAIDS, Caritas, Family Health International, Refuge Egypt and AMERA for their assistance.
 These numbers exclude the hundreds of thousands of ‘closed files’, not to mention the thousands of Palestinians residing in Egypt. UNAIDS, UNHCR. Report on Project: HIV/AIDS prevention and impact mitigation among refugees in Greater Cairo, Egypt. January 2006