A refugee is a person who ‘owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion is outside the country of his [sic] nationality and is unable or owing to such fear is unwilling to avail himself [sic] of the protection of that country’.[11] An asylum seeker is a person who has applied for protection status and is awaiting a decision on his or her application. Depending on how they arrived in Australia, their date of arrival and their stage in the asylum claim process, asylum seekers may reside in (locked) immigration detention onshore or offshore, in community detention, or be living in the community on a temporary visa.
Asylum seekers receive a health screen including HIV testing in all contexts and a number have been diagnosed with HIV upon arrival.[12] Increasing numbers of asylum seekers with HIV have been reported in Darwin, Northern Territory, since the introduction of HIV screening for those arriving by boat without a visa (from 18 in 2011-2012 to 30 in 2012-2013).[13]
Access to services including Medicare, medicines and work rights varies according to visa status. Importantly, asylum seekers and refugees are eligible for most health and community services in some states and are recognised as a Priority 1 group for community health services. Some states have put in place arrangements to improve access to health services.[14]
Nurses may be involved in the care of HIV-positive refugees and asylum seekers in any setting. While it is important to understand the legal situation around seeking asylum and eligibility, the nurse’s role in keeping with the International Council of Nurses Code of Ethics for Nurses is to advocate and facilitate, support and promote health for all, especially those most vulnerable.[15] In AustralHIV specialist nurses are accessible to asylum seekers and refugees with HIV and early referral to nursing services is advisable, though often overlooked. Refugee health nurses are also involved in caring for people with HIV.
Refugees and asylum seekers in Australia come from a wide range of countries including, but not limited to, Iraq, Iran, China, Afghanistan, Sri Lanka, Sudan, Burma and Sierra Leone. In recent years, greater numbers have arrived from Afghanistan, Iran, Iraq, Sri Lanka and Syria.[16] They may experience specific clinical problems relating to epidemiology in their country of origin. For example, people with HIV from some countries may be prone to reactivation of latent infections not generally screened for in Australian populations such as schistosomiasis and strongyloidiasis.[17] If they are living with HIV, they are more likely to be diagnosed late and with more advanced disease [18] [19] (see Section 2 Late presentation of new HIV diagnosis). Children from refugee backgrounds may be at greater risk of blood-borne viruses transmitted iatrogenically (through blood transfusions and contaminated injections and surrogate breastfeeding or milk banks) so there can be a higher prevalence of HIV in children in Australia who have come from central Asia, Southeast Asia, and Sub-Saharan Africa for example.[20]
Close collaboration with refugee health nurses, social workers, caseworkers and community health, housing and other services is needed to optimise the care of people with HIV who are refugees or asylum seekers. Refugee health clinics are available in most states and territories. See http://refugeehealthaustralia.org/