Support Services for Immigrant People Living with HIV: Health Care Provider’s Perspective

To evaluate support services for immigrant people living with HIV, a survey was done among HIV care providers of all 27 HIV treatment centers in the Netherlands. Although multiple support services are available, there is a need for additional care in the form of peer support, psychosocial care, and care for refugees and undocumented immigrants in rural areas. With the increase of immigrants in Europe, evaluation of support services in other European countries is recommended. Citation: Been SK, Verbon A (2018) Support Services for Immigrant People Living with HIV: Health Care Provider’s Perspective. J AIDS Clin Res 9: 752. doi: 10.4172/2155-6113.1000752


Introduction
In Europe, migrants are among the key populations disproportionately affected by HIV [1]. This group is a vulnerable population with barriers to optimally access HIV prevention and treatment services, resulting in more late presentation of HIV, less retention in care, and ultimately suboptimal viral suppression rates [2][3][4][5]. In the Netherlands, more than 40% of people living with HIV (PLWH) is of immigrant origin [6]. In 2014, only 70% of the immigrant PLWH (IPLWH) who were diagnosed and linked to care had reached viral suppression (HIV RNA <100 copies/ml) compared to 82% of the Dutch PLWH ( Figure 1).
The availability of medical care and support services is crucial for adequate HIV treatment. According to UNAIDS, these services are important to, among others, support adherence to treatment, enhance prevention and management of HIV-related infections, and to enhance coping with the challenges of living with HIV [7]. Access for IPLWH to these services starts with the awareness of HIV care providers (HCPs) of the available support services. Currently it is unclear which services can be utilized for IPLWH in the HIV treatment centers (HTCs) in the Netherlands, which challenges HCPs encounter, and what is needed to optimize the care for the increasing population of IPLWH in the Netherlands and in Europe. The aim of this study was to evaluate the availability of support services for IPLWH that HCPs working in all Dutch HTCs can refer to.

Participants and data collection
Between April and June 2015, a questionnaire was sent to physicians and nurses from all 27 HTCs in the Netherlands. This questionnaire included items about their view on the care and support services for first and second generation IPLWH offered in both their HTC and nationally. Additionally, HCPs were asked if it was possible to offer additional support services to their patients, like interpreters, legal aid, spiritual aid, health and HIV education, psychological or psychiatric aid, sex counseling, social work, buddy care, and peer support.

Data analyses
Results were analyzed per HTC. If respondents from one HTC gave opposite answers, the result was counted as 'inconclusive' for that center. In addition, a distinction was made between HTCs located in urban and rural areas as refugees are primarily located in the rural areas and immigrants with a residence permit mostly reside in urban areas. Lastly, a comparison was made between HTCs with more and less than 600 PLWH in care.

Results
HCPs from 25 of the 27 HTCs (93%) completed the questionnaire, 13 HTCs were located in urban areas and 12 in rural areas. Thirteen HTCs had more than 600 PLWH in care. HCPs often underestimated the percentage of IPLWH in care, they estimate that 33% (mean, range: 2-60) of the PLWH in clinical care were of immigrant origin. The care provided within the HTC and within the Netherlands was graded as 7.7 and 7.1 (mean) out of 10, respectively ( Table 1). HCPs of 80% of the HTCs (20 HTCs) could refer IPLWH to support services such as interpreters, psychological or psychiatric aid, social work, buddy care, and peer support. In multiple HCPs, no referrals were possible to services like legal aid (32%, 8 HTCs), spiritual aid (28%, 7 HTCs), health and HIV education (44%, 11 HTCs), and sex counseling (24%, 6 HTCs).
Barriers for appropriate care on a patients` level (e.g. language barriers, cultural differences, psychosocial problems, and no show at outpatient clinic appointments) were experienced in 72% of the HTCs (18 HTCs). In 32% of the HTCs (8 HTCs), barriers were experienced on the level of the HTC (e.g. only medically necessary treatment of uninsured patients, and no social workers available in the HTC). On a regional level (province), barriers were experienced in 24% of the HTCs (6 HTCs) (e.g. lack in overview of available support services). HCPs from 48% of the HTCs (12 HTCs) experienced barriers on a national level (e.g. difficulties in continuum of care after replacement of refugees, and complex regulations for asylum seekers and undocumented IPLWH).
Although it is possible to refer patients to psychological and/or psychiatric aid in all HTCs, HCPs from 5 HTCs indicated a need for additional psychosocial care (Table 1). HCPs from 2 HTCs mentioned that IPLWH had barriers such as disclosure concerns and HIV-related stigma that prevented them from using support services.

Urban versus rural areas
In 67% of the 12 HTCs located in rural areas (N=8), respondents missed specific aspects in available care provided to immigrants, compared to only 31% of the 13 urban area HTCs (N=4) ( Table 1). The area of care most frequently missed by HCPs from HTCs in rural areas (50%, N=6) was peer support and/or buddy care. HCPs from 42% of the HTCs located in rural areas (N=5) and 46% of the HTCs located in urban areas (N=6) indicated that they have insufficient insight into the available support services in their region.

Comparison based on the size of the HIV-population
In 58% of the HTCs with <600 patients in care (N=7), respondents missed specific aspects in available care provided to immigrants, compared to 39% of the HTCs with >600 patients in care (N=5) ( Table  1). HCPs from 58% of the HTCs with <600 patients in care (N=7) and 15% of the HTCs with >600 patients in care (N=2) indicated that they have insufficient insight into the available support services in their region.

Asylum seekers and undocumented IPLWH
The most frequently addressed concern on different levels throughout the questionnaire was care for refugees and undocumented IPLWH (Table 1), mentioned by HCPs from 75% of the HTCs located in rural areas (N=9) and 54% of the HTCs located in urban areas (N=7) HCPs indicated that replacements of refugees to other asylum seeker centers throughout the nation are a challenge, hampering adequate HIV care. In addition, only contracted hospitals (15 out of 27 HTCs) are allowed to provide non-emergency HIV-care to refugees and undocumented IPLWH. This may result in loss of patient-provider relationships, subsequently loss of patients retained in care when patients have to relocate, and higher travel costs for this population with minimal financial resources.

Conclusion
In conclusion, our data indicate that there is a need for additional support services for IPLWH such as peer support and/or buddy care, psychosocial care, and specifically for refugees and undocumented IPLWH in HTCs in the Netherlands. The need for these support services is higher in rural areas than in urban areas. Peer and/or buddy support projects from urban areas need to be expanded to rural areas. In addition, a reassessment of the current Dutch policy on HIV care for refugees and undocumented IPLWH, and psychosocial care for all IPLWH should take place, since access to HIV care and support services is not only beneficial for the individual patient but also decreases the risk of transmission. With the increase of immigrants in Europe over the past years, it is important for all European countries to evaluate the specific areas of care provided in and outside HTCs, on a regional and on a national level and these services should be adjusted if needed. The results from this study have been presented at the following meetings: Compliance with Ethical Standards y y The authors declare that they have no conflicts of interest. y y Our study was exempted from a medical ethical review, according to the Dutch Medical Research Involving Human Subjects Act (WMO). Participants were informed beforehand that the results from the survey would be treated anonymously and therefore no identifying information would be published.

Data Availability
The data from the current study are available from the corresponding author on reasonable request.