The nexus of immigration regulation and health governance: a scoping review of the extent to which right to access healthcare by migrants, refugees and asylum seekers was upheld in the United Kingdom during COVID-19.

OBJECTIVES: Complementing the well-established evidence base on health inequalities experienced by migrants, refugees and asylum seekers in the UK; we examined the extent to which their right to equal non-discriminatory access to health services (promotive, preventive, curative) was upheld during the COVID-19 pandemic. STUDY DESIGN: Arksey and O'Malley's scoping review framework. METHODS: A comprehensive search was conducted on Medline, PubMed, and CINAHL using detailed MESH terms, for literature published between 01 January 2020 and 01 January 2024. The process was supported by a ten-page Google search and hand searching of reference lists. 42 records meeting the inclusion criteria were charted, coded inductively and analysed thematically in an integrated team-based approach. RESULTS: Dissonance between immigration regulation and health governance is illustrated in four themes: Health systems leveraged to (re)enforce the hostile environment; Dissonance between health rights on paper and in practice; Structural failures to overcome communication and digital exclusion; and COVID-19 vaccine (in)equity exacerbated fear, mistrust and exclusion. Migrants, refugees and asylum seekers encountered substantial individual, structural and policy-level barriers to accessing healthcare in the UK during COVID-19. Insecure immigration status, institutional mistrust, data-sharing and charging fears, communication challenges and digital exclusion impacted heavily on their ability to access healthcare in an equitable non-discriminatory manner. CONCLUSIONS: An inclusive and innovative health equity and rights-based responses reaching all migrants, refugees and asylum seekers are warranted if the National Health Service is to live up to its promise of 'leaving no one behind' in post-pandemic and future responses.

Antenatal testing for anaemia, HIV and syphilis in Indonesia - a health systems analysis of low coverage.

BACKGROUND: Adverse pregnancy outcomes can be prevented through the early detection and treatment of anaemia, HIV and syphilis during the antenatal period. Rates of testing for anaemia, HIV and syphilis among women attending antenatal services in Indonesia are low, despite its mandate in national guidelines and international policy. METHODS: Midwife-held antenatal care records for 2015 from 8 villages in 2 sub-districts within Cianjur district were reviewed, alongside the available sub-district Puskesmas (Community Health Centre) maternity and laboratory records. We conducted four focus group discussions with kaders (community health workers) (n = 16) and midwives (n = 9), and 13 semi-structured interviews with laboratory and counselling, public sector maternity and HIV management and relevant non-governmental organisation staff. Participants were recruited from village, sub-district, district and national level as relevant to role. RESULTS: We were unable to find a single recorded result of antenatal testing for HIV, syphilis or anaemia in the village (566 women) or Puskesmas records (2816 women) for 2015. Laboratory records did not specifically identify antenatal women. Participants described conducting and reporting testing in a largely ad hoc manner; relying on referral to health facilities based on clinical suspicion or separate non-maternity voluntary counselling and testing programs. Participants recognized significant systematic challenges with key differences between the more acceptable (and reportedly more often implemented) haemoglobin testing and the less acceptable (and barely implemented) HIV and syphilis testing. However, a clear need for leadership and accountability emerged as an important factor for prioritizing antenatal testing and addressing these testing gaps. CONCLUSIONS: Practical solutions such as revised registers, availability of point-of-care tests and capacity building of field staff will therefore need to be accompanied by both funding and political will to coordinate, prioritize and be accountable for testing in pregnancy.

Realizing the potential for HIV self-testing.

HIV self-testing (HIVST), a process in which an individual performs a HIV rapid diagnostic test and interprets the result in private, is an emerging approach that is well accepted, potentially cost-effective and empowering for those who may not otherwise test. To further explore the potential of HIVST, the Liverpool School of Tropical Medicine and World Health Organization held the first global symposium on the legal, ethical, gender, human rights and public health implications of HIVST. The meeting highlighted the potential of HIVST to increase access to and uptake of HIV testing, and emphasized the need to further develop evidence around the quality of HIVST and linkage to post-test services, and to assess the risks and the benefits associated with scale-up. This special issue of AIDS and Behavior links directly to the symposium and presents some of the latest research and thinking on the scale-up of HIV self-testing.

Acute presentations of HIV are still missed in low prevalence areas.

OBJECTIVES: To evaluate missed opportunities and delays in the diagnosis of HIV in a low prevalence setting over a 24 year period. METHODS: Patients with acute presentations of HIV were included in a retrospective note based review. Data were compared from acute presentations in 1985-2001 (88/241 new patients) with 2005-2007 (99/136 new patients). The number of recorded clinical and laboratory clues to infection and subsequent time delays to diagnosis of HIV were evaluated. RESULTS: The findings reflect the shifting demographics of HIV in the UK over the past two decades, exemplified by an eightfold increase in tuberculosis at presentation. Despite recording clinical stigmata of HIV (clues) in the notes, the number of missed clues increased, and many clinicians failed to request HIV testing. The median delay between presentation and diagnosis reduced from 5 to 1 day (p<0.001), and mortality dropped from 14% to 4% among patients presenting with acute symptoms. However, there was still a delay of more than 30 days before diagnosis for almost one in five patients. CONCLUSIONS: Despite some improvement and better awareness, there are still significant delays before hospital doctors consider the diagnosis of HIV for patients in low prevalence areas, even among some patient groups with high risk. Hospitals should consider moving to opt-out routine HIV testing of all medical admissions.

The value of the post-take ward round: are new working patterns compromising junior doctor education?

This prospective observational study assessed the impact of the changes in junior doctors' working hours and waiting-time initiatives on teaching and learning opportunities for junior doctors in acute medicine. An audit cycle of post-take ward rounds including all medical admissions to an urban teaching hospital was conducted. During two seven-day periods in July 2006 and 2008, 317 and 354 patients were admitted respectively. In the two-year interval a number of changes were implemented resulting in a significant increase in patients reviewed by a consultant within 24 hours of admission. Target waiting times were being met but there were many missed learning opportunities for junior staff. Senior doctors continue to perform the majority of post-take reviews in the absence of the doctors who had admitted the patient. Similar patterns are likely to be found in other hospitals attempting to balance training with government targets for waiting times and junior doctors' working hours.

Delivering post-rape care services: Kenya's experience in developing integrated services.

PROBLEM: Comprehensive service delivery models for providing post-rape care are largely from resource-rich countries and do not translate easily to resource-limited settings such as Kenya, despite an identified need and high rates of sexual violence and HIV. APPROACH: Starting in 2002, we undertook to work through existing governmental structures to establish and sustain health sector services for survivors of sexual violence. LOCAL SETTING: In 2003 there was a lack of policy, coordination and service delivery mechanisms for post-rape care services in Kenya. Post-exposure prophylaxis against HIV infection was not offered. RELEVANT CHANGES: A standard of care and a simple post-rape care systems algorithm were designed. A counselling protocol was developed. Targeted training that was knowledge-, skills- and values-based was provided to clinicians, laboratory personnel and trauma counsellors. The standard of care included clinical evaluation and documentation, clinical management, counselling and referral mechanisms. Between early 2004 and the end of 2007, a total of 784 survivors were seen in the three centres at an average cost of US$ 27, with numbers increasing each year. Almost half (43%) of these were children less than 15 years of age. LESSONS LEARNED: This paper describes how multisectoral teams at district level in Kenya agreed that they would provide post-exposure prophylaxis, physical examination, sexually transmitted infection and pregnancy prevention services. These services were provided at casualty departments as well as through voluntary HIV counselling and testing sites. The paper outlines which considerations they took into account, who accessed the services and how the lessons learned were translated into national policy and the scale-up of post-rape care services through the key involvement of the Division of Reproductive Health.

A peer-led HIV counselling and testing programme for the deaf in Kenya.

PURPOSE: To describe and evaluate the establishment of the first VCT services for the Deaf in Africa. METHOD: Operational research methods were used to document programme establishment. The demographics of deaf VCT clients were compared with hearing clients at the same sites as well as where clients had learned of the service, HIV risks, and HIV test results. Univariate and multivariate analyses were used. RESULTS: During the two year period (January 2004 to December 2005) 1709 Deaf and 1649 hearing clients were seen at three Deaf VCT sites. The majority of Deaf clients in this sample learned of the services through the peer education programme. Data indicate that Deaf VCT clients are as much at risk of HIV from sexual transmission as their hearing counterparts and that Deaf persons seeking VCT services have an HIV prevalence of 7%, similar to the national rate of 6.7%. CONCLUSIONS: The Deaf in Kenya are at risk of HIV and there is an urgent need for Deaf-friendly HIV services, supplemented by peer education programmes. This is the first published report describing HIV services run by the Deaf for the Deaf in the developing world.

Cytomegalovirus retinitis in the absence of HIV or immunosuppression.

PURPOSE: Cytomegalovirus (CMV) retinitis classically occurs in advanced human immunodeficiencyvirus (HIV) infection but is rare in other forms of immunosuppression. The authors report a case of CMV retinitis in an HIV-negative man with idiopathic CD4 lymphocytopenia (ICL). This is the first such case to be confirmed by polymerase chain reaction (PCR) of aqueous humor. METHODS: Case report. RESULTS: A 69-year-old retired Chinese seaman presented with gradual visual deterioration. He was a diet controlled diabetic on regular steroids for presumed asthma. Examination showed no diabetic eye disease but confirmed acute retinal necrosis (ARN). Anterior chamber tapping of the aqueous humor was PCR positive for CMV. HIV antibody and RNA tests were negative but his full blood count revealed lymphocytopenia, with a low CD4+ subset. He responded to a 3-week course of intravenous ganciclovir therapy followed by suppressiveoral valganciclovir. CONCLUSIONS: CMV is associated with sight-threatening retinitis in HIV infection at CD4+ counts below 50 cells/microL and in transplant recipients or heavily immunosuppressed patients. Systemic steroids are a risk factor for clinical disease in these groups. It is extremely rare to report CMV eye disease in previously healthy individuals. This case illustrates that the condition does occur in association with ICL. Corticosteroids may be implicated in disease reactivation. Molecular METHODS are necessary to confirm the diagnosis.

Potential for abuse in the VCT counselling room: service provider's perceptions in Kenya.

The rapid scale-up of HIV counselling and testing programmes in Kenya has led to quality concerns, including the potential for abuse within the private, confidential setting of client-initiated voluntary counselling and testing (VCT). A qualitative study was conducted in three provinces of Kenya, involving 26 VCT service providers and 13 key informants. First and second hand accounts of emotional, physical and sexual abuse emerged in all three study sites in spite of measures to mitigate such occurrences. Whilst uncommon, abuse was perceived by service providers to be serious and sufficiently widespread to raise significant concerns. Abuse occurred client to counsellor, from counsellor to client and from counsellor to counsellor. In all cases the person suffering the abuse was female. While the potential for abuse was demonstrated in VCT sites, we argue that experiences of abuse are not confined to VCT and are largely shaped by gender and power relations within the Kenyan cultural context. The international impetus for scale-up of HIV services provides an urgent rationale for the need to address and highlight these difficult issues at multiple levels. International guidelines, policy and methods need adapting in recognition of the potential for abuse. Systems for investigating and deregistering counsellors have been developed in Kenya but require formalizing. Institutions providing VCT should consider unlocked doors, semi-opaque windows and the use of 'mystery clients' as a quality assurance measure.

Working with risk: occupational safety issues among healthcare workers in Kenya.

The objective of this study was to explore knowledge of, attitudes towards and practice of post-exposure prophylaxis (PEP) among healthcare workers (HCWs) in the Thika district, Kenya. We used site and population-based surveys, qualitative interviews and operational research with 650 staff at risk of needlestick injuries (NSIs). Research was conducted over a 5-year period in five phases: (1) a bio-safety assessment; (2) a staff survey: serum drawn for anonymous HIV testing; (3) interventions: biosafety measures, antiretrovirals for PEP and hepatitis B vaccine; (4) a repeat survey to assess uptake and acceptability of interventions; in-depth group and individual interviews were conducted; and (5) health system monitoring outside a research setting. The main outcome measures were bio-safety standards in clinical areas, knowledge, attitudes and practice as regards to PEP, HIV-sero-prevalence in healthcare workers, uptake of interventions, reasons for poor uptake elucidated and sustainability indicators. Results showed that HCWs had the same HIV sero-prevalence as the general population but were at risk from poor bio-safety. The incidence of NSIs was 0.97 per healthcare worker per year. Twenty-one percent had had an HIV test in the last year. After one year there was a significant drop in the number of NSIs (OR: 0.4; CI: 0.3-0.6; p<0.001) and a significant increase in the number of HCWs accessing HIV testing (OR: 1.55; CI: 1.2-2.1; p=0.003). In comparison to uptake of hepatitis B vaccination (88% of those requiring vaccine) the uptake of PEP was low (4% of those who had NSIs). In-depth interviews revealed this was due to HCWs fear of HIV testing and their perception of NSIs as low risk. We concluded that Bio-safety remains the most significant intervention through reducing the number of NSIs. Post-exposure prophylaxis can be made readily available in a Kenyan district. However, where HIV testing remains stigmatised uptake will be limited - particularly in the initial phases of a programme.

The politics of TB: TB control services need tailoring for new arrivals, not vice versa.

High rates of TB amongst new arrivals to the UK require flexible, innovative responses that go beyond traditional biomedical models and take into account the needs of these heterogeneous groups. This article explores the merging of public health and human rights based approaches to TB control in response to the challenge of increasing rates of TB amongst new arrivals in the UK.

Engendering health sector responses to sexual violence and HIV in Kenya: results of a qualitative study.

In Kenya many people who have been affected by sexual violence turn to the health sector for clinical treatment and preventive therapies. This interface provides a vital opportunity to impact on the dual epidemics of HIV and sexual violence. Despite this, the uptake of post-rape care services in health facilities is low and health care providers felt ill-prepared to deal with the consequences of sexual violence. A qualitative study was conducted to better understand the reasons for the low uptake of services and to establish perceptions of sexual violence in Kenya. Thirty-four key informants were interviewed and sixteen focus group discussions with women and men were held in three districts in Kenya. Blurred boundaries between forced and consensual sex emerged. Important implications for the delivery of HIV post exposure prophylaxis (PEP) after sexual violence include the need for gender-aware patient-centred training for health providers and for HIV PEP interventions to strengthen on-going HIV-prevention counselling efforts. Further research needs to determine the feasibility of on-going risk reduction measures in the context of PEP delivery.

The clinical impact of nucleic acid amplification tests on the diagnosis and management of tuberculosis in a British hospital.

BACKGROUND: Nucleic acid amplification tests (NAAT) based on PCR provide rapid identification of Mycobacterium tuberculosis and the detection of rifampicin resistance. Indications for their use in clinical samples are now included in British tuberculosis guidelines. METHODS: A retrospective audit of patients with suspected mycobacterial infection in a Liverpool hospital between 2002 and 2006. Documentation of the impact of NAAT usage in acid fast bacillus (AFB) microscopy positive samples on clinical practice and the influence of a multidisciplinary group on their appropriate use, compared with British guidelines. RESULTS: Mycobacteria were seen or isolated from 282 patients and identified as M tuberculosis in 181 (64%). NAAT were indicated in 87/123 AFB positive samples and performed in 51 (59%). M tuberculosis was confirmed or excluded by this method in 86% of tested samples within 2 weeks, compared with 7% identified using standard methods. The appropriate use of NAAT increased significantly over the study period. The NAAT result had a clinical impact in 20/51 (39%) tested patients. Culture results suggest the potential for a direct clinical impact in 8/36 (22%) patients in which it was indicated but not sent and 5/36 (14%) patients for whom it was not indicated. Patients managed by the multidisciplinary group had a higher rate of HIV testing and appropriate use of NAAT. CONCLUSIONS: There were significant clinical benefits from the use of nucleic acid amplification tests in this low prevalence setting. Our data suggest that there would be additional benefit from their use with all AFB smear positive clinical samples.

HIV voluntary counselling and testing for African communities in London: learning from experiences in Kenya.

OBJECTIVES: To explore the feasibility and acceptability of translating a successful voluntary counselling and testing (VCT) service model from Kenya to African communities in London. METHODS: Qualitative study with focus group discussions and a structured workshop with key informants. Five focus group discussions were conducted in London with 42 participants from 14 African countries between August 2006 and January 2007. A workshop was held with 28 key informants. Transcripts from the group discussions and workshop were analysed for recurrent themes. RESULTS: Participants indicated that a community-based HIV VCT service would be acceptable to African communities in London, but also identified barriers to uptake: HIV-related stigma, concerns about confidentiality, and doubts about the ability of community-based services to maintain professional standards of care. Workshop participants highlighted three key requirements to ensure feasibility: (a) efficient referrals to sexual health services for the newly diagnosed; (b) a locally appropriate testing algorithm and quality assurance scheme; (c) a training programme for VCT counsellors. CONCLUSIONS: Offering community-based VCT with rapid HIV tests appears feasible within a UK context and acceptable to African communities in London, provided that clients' confidentiality is ensured and appropriate support is given to the newly diagnosed. However, the persistence of concerns related to HIV-related stigma among African communities suggests that routine opt-out testing in healthcare settings may also constitute an effective approach to reducing the proportion of late diagnoses in this group. HIV service models and programmes from Africa constitute a valuable knowledge base for innovative interventions in other settings, including developed countries.

Ciprofloxacin treatment of bacterial peritonitis associated with chronic ambulatory peritoneal dialysis caused by Neisseria cinerea.

Bacterial peritonitis is a well-recognized complication of chronic ambulatory peritoneal dialysis (CAPD) in patients with end-stage renal failure. We present a case of peritonitis due to an unusual pathogen, Neisseria cinerea, unresponsive to the standard intraperitoneal (i.p.) vancomycin and gentamicin, which responded rapidly to oral ciprofloxacin.

Susceptibility of healthcare workers in Kenya to hepatitis B: new strategies for facilitating vaccination uptake.

Hepatitis B virus (HBV) infection is preventable, yet many healthcare workers (HCWs) in resource-poor countries remain at risk. The aims of this study were to evaluate the susceptibility of HCWs in a Kenyan district to HBV infection, and the feasibility of expanding the Extended Programme of Immunization (EPI) for infants to incorporate hepatitis B vaccination of HCWs. HCWs in Thika district, Kenya were invited to complete an interviewer-administered questionnaire about their immunization status and exposure to blood or body fluids. Participants were asked to provide a blood sample to assess natural or vaccine-induced protection against HBV. All non-immune HCWs were offered hepatitis B vaccination. Thirty percent (168/554) of HCWs reported one or more needlestick injuries (NSIs) in the previous year, with an annual incidence of 0.97 NSIs/HCW/year. Only 12.8% (71/554) of HCWs had received vaccination previously and none had been screened for immunity or for hepatitis B surface antigen. In total, 407 staff provided blood samples; 41% were HBV core antibody, 4% expressed hepatitis B surface antibody from previous vaccination, and 55% were unprotected. Two hundred and twenty-two staff were eligible for vaccine delivered through the EPI infrastructure. Self-motivated uptake of a full course of vaccine was 92% in the smaller health centres and 44% in the district hospital. This study demonstrates the importance of hepatitis B vaccination of HCWs in parts of Africa where high exposure rates are combined with low levels of vaccine coverage. High rates of vaccination can be achieved using childhood immunization systems for the distribution of vaccine to HCWs.

Piloting post-exposure prophylaxis in Kenya raises specific concerns for the management of childhood rape.

Thika District, Kenya, is the site of an operational research study on the provision of comprehensive post-rape care, including the free provision of HIV post-exposure prophylaxis (PEP). It is a typical rural Kenyan district in terms of resources and patient throughput. The high rate of children attending for post-rape services was unexpected and had significant programming implications. An age-disaggregated analysis of existing quantitative data from the first 8 months of service provision was conducted. Ninety-four case records were reviewed, of whom 48 (51%) were in the age range 1.5-17 years inclusive. All three cases of male rape were in children. Children were more likely to know their assailant than adults and were more likely to be HIV-negative at baseline. The majority (86%) of children presented in time for PEP, with adherence and completion rates similar to adults but lower rates of 6-week follow-up. The use of weight bands to determine drug dosages greatly simplified the appropriate and early administration of paediatric PEP. The high rates of childhood rape and demand for post-rape services were an enormous challenge for service providers and policy-makers.

Using gender analysis to build voluntary counselling and testing responses in Kenya.

The rapid expansion of voluntary counselling and testing (VCT) for HIV in sub-Saharan Africa has led to concerns over the quality and equity of the services. Kenya has seen an unprecedented scale-up of VCT, and valuable lessons have been learnt at national as well as at district and community levels. We combined quantitative and qualitative research methodology and showed how the results of gender analysis can be used to develop equity in VCT scale-up. A gender-disaggregated analysis of VCT client data was conducted for the first 8 months of 2003. These quantitative data revealed that despite an increased vulnerability to HIV, women are underrepresented in VCT sites in all settings in Kenya. Our data also showed that women were also less likely to use condoms or to take home condoms after a VCT visit than their male counterparts. Further exploration through in-depth qualitative work with women and men allowed a better understanding of the reasons behind gender differences in Kenyan VCT sites and helped to develop strategies to address gender inequity. We conclude that there is an ongoing need to mainstream gender in monitoring and evaluation strategies to ensure services meet the needs and priorities of all groups.