Trends in Sexual Assault Against Detainees in US Immigration Detention Centers, 2018-2022.

This study examines sexual assault allegations perpetrated against individuals detained across US Immigration and Customs Enforcement (ICE) detention facilities from 2018 to 2022.

Health and human rights in eastern Myanmar prior to political transition: a population-based assessment using multistaged household cluster sampling.

BACKGROUND: Myanmar/Burma has received increased development and humanitarian assistance since the election in November 2010. Monitoring the impact of foreign assistance and economic development on health and human rights requires knowledge of pre-election conditions. METHODS: From October 2008-January 2009, community-based organizations conducted household surveys using three-stage cluster sampling in Shan, Kayin, Bago, Kayah, Mon and Tanintharyi areas of Myanmar. Data was collected from 5,592 heads of household on household demographics, reproductive health, diarrhea, births, deaths, malaria, and acute malnutrition of children 6-59 months and women aged 15-49 years. A human rights focused survey module evaluated human rights violations (HRVs) experienced by household members during the previous year. RESULTS: Estimated infant and under-five rates were 77 (95% CI 56 to 98) and 139 (95% CI 107 to 171) deaths per 1,000 live births; and the crude mortality rate was 13 (95% CI 11 to 15) deaths per thousand persons. The leading respondent-reported cause of death was malaria, followed by acute respiratory infection and diarrhea, causing 21.2% (95% CI 16.5 to 25.8), 16.6% (95% CI 11.8 to 21.4), and 12.3% (95% CI 8.7 to 15.8), respectively. Over a third of households suffered at least one human rights violation in the preceding year (36.2%; 30.7 to 41.7). Household exposure to forced labor increased risk of death among infants (rate ratio (RR) = 2.2; 95% CI 1.1 to 4.4) and children under five (RR = 2.1; 95% CI 1.3 to 3.6). The proportion of children suffering from moderate to severe acute malnutrition was higher among households that were displaced (prevalence ratio (PR) = 3.3; 95% CI 1.9 to 5.6). CONCLUSIONS: Prior to the 2010 election, populations of eastern Myanmar experienced high rates of disease and death and high rates of HRVs. These population-based data provide a baseline that can be used to monitor national and international efforts to improve the health and human rights situation in the region.

A call for increased transparency and accountability of health care outcomes in US Immigration and Customs Enforcement detention centers.

Concerns over health care in US Immigration and Customs Enforcement (ICE) facilities have grown over the past decade, including reports of medical mismanagement, inadequate mental health care, and inappropriate use of solitary confinement. Despite being a federally funded agency, reporting and accountability of health outcomes in ICE facilities is limited. This manuscript outlines current standards for health in ICE detention, how compliance is evaluated, why this process fails, and how current processes can be improved to achieve transparency and accountability. Ultimately, health metrics must be: 1) frequent; 2) timely; 3) granular; 4) collected by an independent body; and 5) publicly reported. Financial compensation for health service providers must be contingent on meeting these required metrics, with contract termination for persistent violations. Transparent and accountable monitoring systems, as are required in other federally funded healthcare facilities, are essential to accurately measure health outcomes and harms of individuals held in detention.

Deaths in Immigration and Customs Enforcement (ICE) detention: A Fiscal Year (FY) 2021-2023 update.

Background: This study describes the deaths of individuals in Immigration and Customs Enforcement (ICE) detention between FY2021-2023, updating a report from FY2018-2020, which identified an increased death rate amidst the COVID-19 pandemic. Methods: Data was extracted from death reports published online by ICE. Causes of deaths were recorded, and death rates per 100,000 admissions were calculated using population statistics reported by ICE. Reports of individuals released from ICE custody just prior to death were also identified and described. Results: There were 12 deaths reported from FY2021-2023, compared to 38 deaths from FY2018-2020. The death rate per 100,000 admissions in ICE detention was 3.251 in FY2021, 0.939 in FY2022, and 1.457 in FY2023, compared with a pandemic-era high of 10.833 in FY2020. Suicide caused 1 of 12 (8.3%) deaths in FY2021-2023 compared with 9 of 38 (23.7%) deaths in FY2018-2020. COVID-19 was contributory in 3 of 11 (25%) medical deaths in FY2021-2023, compared with 8 of 11 (72.7%) in the COVID-era months of FY2020 (p = 0.030). Overall, 4 of 11 (36.3%) medical deaths in FY2021-2023 resulted from cardiac arrest in detention facilities, compared with 6 of 29 (20.3%) in FY2018-2020. Three deaths of hospitalized individuals released from ICE custody with grave prognoses were identified. Conclusions: The death rate among individuals in ICE custody decreased in FY2021-2023, which may be explained in part by the release of vulnerable individuals following recent federal legal determinations (e.g., Fraihat v. ICE). Identification of medically complex individuals released from ICE custody just prior to death and not reported by ICE indicates that reported deaths underestimate total deaths associated with ICE detention. Attentive monitoring of mortality outcomes following release from ICE custody is warranted.

Medical Mismanagement in Southern US Immigration and Customs Enforcement Detention Facilities: A Thematic Analysis of Secondary Medical Records.

Detention facilities in the southern US hold a large percentage of individuals detained in the US and have amassed numerous reports of medical mismanagement. The purpose of this study was to evaluate expert declarations of individuals residing in these facilities to assess the appropriateness of medical care provided. We analyzed 38 medical expert declarations from individuals in detention from 2020 to 2021. A thematic analysis was conducted to explore the management of medical conditions. Major themes include inadequate workup, management and treatment of medical conditions, psychiatric conditions, and medical symptoms. Subthemes identified include incorrect workup, failure to refer to a specialist, incorrect medications and/or treatments, missed or incorrect diagnoses, and exacerbation of chronic conditions. This study supports growing evidence of medical mismanagement and neglect of individuals while in immigration detention. Enhanced oversight and accountability around medical care in these facilities is critical to ensure the quality of medical care delivered meets the standard of care.

Emergency Medical Responses at US Immigration and Customs Enforcement Detention Centers in California.

Importance: Knowledge of medical care in US Immigration and Customs Enforcement (ICE) detention centers is limited. Reviews show high rates of preventable deaths while in detention due to substandard medical care within detention centers. Objective: To describe characteristics of medical emergencies at ICE detention centers in California. Design, Setting, and Participants: This cross-sectional study analyzed emergency medical services (EMS)-reported medical emergencies activated through 911 from January 1, 2018, to December 31, 2022, at 3 of the 5 ICE detention centers in California: Adelanto ICE Processing Center, Imperial Regional Detention Facility, and Otay Mesa Detention Center. Exposure: Medical services requiring 911 activation. Main Outcomes and Measures: Data included the number of EMS-reported medical emergencies; ICE-reported medical emergencies; patient age and sex; and medical data in the EMS report, including primary symptom, EMS provider (emergency medical technician or paramedic) impression, vital signs, and interventions performed, using descriptive statistics. Results: In this analysis of 3 detention centers with a mean daily census of 775 (range, 504-1001) individuals per center, there was a median of 68 (IQR, 10-88) EMS-reported emergencies per center per year for a total of 1224 emergencies. The EMS-reported emergencies involved 881 males (72%) and 338 females (28%) with a median age of 39.0 (IQR 30.0-49.0) years. The ratios of female-to-male EMS-reported emergencies were 0.51 (95% CI, 0.31-0.87) at Adelanto, 0.86 (95% CI, 0.31-2.43) at Imperial, and 1.60 (95% CI, 1.40-1.83) at Otay Mesa. Pregnancy-related emergencies accounted for 12.4% (42 of 338) of emergencies in females. A total of 357 individuals (29.2%) had at least 1 abnormal vital sign during their EMS encounter. Psychiatric emergencies comprised 48 EMS responses (3.9%), despite higher rates of ICE-reported psychiatric-related complaints. The median number of monthly EMS-reported emergencies across all 3 centers was 3 (IQR, 0-9) vs 4 ICE-reported emergencies (IQR, 1-15). Conclusions and Relevance: In this study of medical emergencies at 3 of 5 ICE detention facilities in California, there were discrepancies in EMS vs ICE reported emergencies. The data suggested that vulnerable populations, such as pregnant women, had an increased number of medical emergencies, while individuals with psychiatric emergencies accounted for fewer reported emergencies. Based on these findings, emergency medical care provision in ICE detention centers requires increased transparency to ensure appropriate delivery of care.

Rapidly adapted community health strategies to prevent treatment interruption and improve COVID-19 detection for Syrian refugees and the host population with hypertension and diabetes in Jordan.

BACKGROUND: We evaluated community health volunteer (CHV) strategies to prevent non-communicable disease (NCD) care disruption and promote coronavirus disease 2019 (COVID-19) detection among Syrian refugees and vulnerable Jordanians, as the pandemic started. METHODS: Alongside medication delivery, CHVs called patients monthly to assess stockouts and adherence, provide self-management and psychosocial support, and screen and refer for complications and COVID-19 testing. Cohort analysis was undertaken of stockouts, adherence, complications and suspected COVID-19. Multivariable models of disease control assessed predictors and non-inferiority of the strategy pre-/post-initiation. Cost-efficiency and patient/staff interviews assessed implementation. RESULTS: Overall, 1119 patients were monitored over 8 mo. The mean monthly proportion of stockouts was 4.9%. The monthly proportion non-adherent (past 5/30 d) remained below 5%; 204 (18.1%) patients had complications, with 63 requiring secondary care. Mean systolic blood pressure and random blood glucose remained stable. For hypertensive disease control, age 41-65 y (OR 0.46, 95% CI 0.2 to 0.78) and with diabetes (OR 0.73, 95% CI 0.54 to 0.98) had decreased odds, and with baseline control had increased odds (OR 3.08, 95% CI 2.31 to 4.13). Cumulative suspected COVID-19 incidence (2.3/1000 population) was suggestive of ongoing transmission. While cost-efficient (108 US${\$}$/patient/year), funding secondary care was challenging. CONCLUSIONS: During multiple crises, CHVs prevented care disruption and reinforced COVID-19 detection.

Consistency of reports of violence from northern Rakhine state in August 2017.

BACKGROUND: In August 2017, Myanmar's Armed Forces, the Tatmadaw, launched an orchestrated attack on hundreds of Rohingya-majority villages in northern Rakhine state. This study seeks to validate the consistency of previous reports of violence against the Rohingya people in the region carried out by the Tatmadaw, Border Guard Police, and Rakhine villagers in the late summer and early fall of 2017. METHODS: Internal validation data is from a three-armed study. Data analyzed in the external triangulation was sourced through a literature review of known, publicly available surveys and interviews. Both sets of data documented instances of violence against the Rohingya people in northern Rakhine state during the late summer and early fall of 2017. Consistency was evaluated across five indicators of violence: arson, presence of mass graves, reports of sexual violence and human injuries, as well as human fatalities, across 611 locales in northern Rakhine state. Further analysis was conducted to measure consistency of reports by locale and across locales by indicator. RESULTS: Overall, an internal validation of 94 hamlets found that 98% of these locales were consistent across at least four of the five indicators (80% + consistency). Arson and reports of human injuries were the most consistent indicators across locales (100% and 99% consistency, respectively) and sexual violence was the least consistent indicator, with 84% of participating locales exhibiting consistent reports of sexual violence between the qualitative and quantitative data. Similarly, an external validation of 57 locations found that 50 of the 57 locations (88%) were consistent across indicators. Arson was the most consistent across sources (96%), whereas source agreement across locations was the least consistent for reports of sexual violence (58%). CONCLUSION: The government of Myanmar has denied involvement in the 2017 attacks on Rohingya communities in northern Rakhine state and purports that reports of the violence and destruction are overstated. However, consistent reporting from multiple sources on the same locales clearly underscores the veracity of the evidence documented, both by investigative groups and as recounted by Rohingya survivors of violence. It is our hope that this cataloging and comparison of available data, along with this study's assessment of its consistency, will aid ongoing accountability efforts.

Seeking justice amidst chaos: methods to identify and document individuals implicated in crimes against the Rohingya in August 2017.

BACKGROUND: Documenting perpetrators of human rights violations enables effective prosecution and can help prevent future atrocities. Doing so calls for collecting reliable data using verifiable and transparent methodology. We present methods used to document crimes and identify alleged perpetrators implicated in the 2017 attacks against Rohingya civilians in Myanmar. The findings and lessons-learned have relevance to contemporary crises with widespread atrocities. METHODS: A mixed-methods assessment conducted from May to July 2018 included: (1) cross-sectional quantitative surveys among leaders of affected hamlets in northern Rakhine State, (2) qualitative interviews to record hamlet-level accounts, and (3) clinical evaluations of survivors of violence. Survey respondents who reported violence and destruction in each hamlet were asked to identify perpetrators of those acts, including known role or affiliation. The reported names were reviewed for clarity and divergent spellings, repeated references were aggregated, and the names and roles were analyzed and classified by location and affiliation. RESULTS: 143 individuals were implicated in atrocities committed across three Northern Rakhine townships. Each was independently identified by at least three separate survey respondents as directly committing violence or destruction in their hamlet of origin, or as witnessed while fleeing to Bangladesh. Two-thirds (69%) of identified perpetrators were reported by four or more participants and 47% by five or more. Some form of additional identifying information, was provided for 85% of names. The most common affiliations were: Myanmar army (n = 40), Border Guard Police (n = 32), Village Tract Administrators (n = 17), and extremists (n = 25). CONCLUSIONS: The methodology presented here yielded a unique record of individuals purported to have directly committed acts of violence and destruction in Rakhine State in August 2017, forming the most extensive record of individuals implicated in ground-level perpetration of those crimes. This methodology can play a key role in accountability mechanisms for the Rohingya, and in other settings in which perpetrators are many and documentation of their crimes is difficult. The use of survey methods and standardized data collection amongst affected populations to comprehensively characterize crimes committed and to identify individuals implicated in those crimes can serve as a key tool in documentation and an important component of accountability.

Health and human rights in Chin State, Western Burma: a population-based assessment using multistaged household cluster sampling.

BACKGROUND: The Chin State of Burma (also known as Myanmar) is an isolated ethnic minority area with poor health outcomes and reports of food insecurity and human rights violations. We report on a population-based assessment of health and human rights in Chin State. We sought to quantify reported human rights violations in Chin State and associations between these reported violations and health status at the household level. METHODS AND FINDINGS: Multistaged household cluster sampling was done. Heads of household were interviewed on demographics, access to health care, health status, food insecurity, forced displacement, forced labor, and other human rights violations during the preceding 12 months. Ratios of the prevalence of household hunger comparing exposed and unexposed to each reported violation were estimated using binomial regression, and 95% confidence intervals (CIs) were constructed. Multivariate models were done to adjust for possible confounders. Overall, 91.9% of households (95% CI 89.7%-94.1%) reported forced labor in the past 12 months. Forty-three percent of households met FANTA-2 (Food and Nutrition Technical Assistance II project) definitions for moderate to severe household hunger. Common violations reported were food theft, livestock theft or killing, forced displacement, beatings and torture, detentions, disappearances, and religious and ethnic persecution. Self reporting of multiple rights abuses was independently associated with household hunger. CONCLUSIONS: Our findings indicate widespread self-reports of human rights violations. The nature and extent of these violations may warrant investigation by the United Nations or International Criminal Court. Please see later in the article for the Editors' Summary.

Correction: Deaths in Immigration and Customs Enforcement (ICE) detention: FY2018-2020.

[This corrects the article DOI: 10.3934/publichealth.2021006.].

Deaths in Immigration and Customs Enforcement (ICE) detention: FY2018-2020.

BACKGROUND: Many civil liberties organizations have raised concerns that substandard medical care in United States Immigration and Customs Enforcement (ICE) detention facilities have led to preventable deaths. The 2018 Department of Homeland Security Appropriations Bill required ICE to make public all reports regarding in-custody deaths within 90 days beginning in Fiscal Year (FY) 2018. Accordingly, ICE has released death reports following each in-custody death since April of 2018. This study describes characteristics of deaths among individuals in ICE detention following the FY2018 mandate. METHODS: Data was extracted from death reports published by ICE following the FY2018 mandate. Causes of death were categorized as suicide or medical, and medical deaths as COVID-19-related or not. Characteristics were compared between medical and suicide deaths, and among medical deaths between COVID-19-related and non-COVID-19-related deaths. Additionally, death rates per person-year and per 100,000 admissions were calculated for FY2018, 2019, and 2020 using methods from prior work evaluating deaths among detained immigrants in the United States. RESULTS: Since April 2018, 35 individuals have died in ICE detention. The death rate per 100,000 admissions in ICE detention was 2.303 in FY2018, 1.499 in FY2019, and 10.833 in FY2020. Suicide by hanging was identified as the cause of death in 9 (25.7%), and medical causes in the remaining 26 (74.3%). Among 26 deaths attributable to medical causes, 8 (30.8%) were attributed to COVID-19, representing 72.7% of 11 deaths occurring since April 2020. CONCLUSIONS: The death rate among individuals in ICE detention is increasing amidst the COVID-19 pandemic. Potentially preventable causes of death including COVID-19 and suicide contribute to at least half of recent deaths. Findings suggest that individuals detained by ICE may benefit from improved psychiatric care and prevention measures to combat suicide, as well as increased infection control efforts to reduce mortality associated with COVID-19.

Continued Trauma: A Thematic Analysis of the Asylum-Seeking Experience Under the Migrant Protection Protocols.

Introduction: The Migrant Protection Protocols (MPP) required asylum seekers presenting to the U.S. southern border to wait in Mexico while seeking asylum. Currently, there is a lack of understanding of the MPP's potential harm to an already highly traumatized population. We sought to understand health impacts of this policy, including exposure to continued trauma. Methods: The University of Southern California (USC)'s Keck Human Rights Clinic analyzed de-identified legal declarations and forensic medical affidavits of 11 asylum seekers subjected to MPP. A deductive, thematic analysis was performed to understand the health impact and traumas experienced, and instances of each subtheme were counted by utilizing content analysis methodology. Results: Case analysis identified a total of 36 subthemes. Trauma subthemes included physical assault, psychological abuse, violence against family/friends, witnessed violence, sexual violence, and escalation. Perpetrator subthemes included gang, paramilitary, intimate partner, family, state, and unknown/other. Stress subthemes included despondency and social isolation. Security subthemes included reach of perpetrator, impunity of perpetrator, continued fear of persecution, fear of return, lack of safety, and reliance on strangers. Social determinants of health subthemes included tenuous housing, financial support, food insecurity, health care access, access to employment, and hazardous conditions. Psychological sequelae included anxiety, depressive, post-trauma, and suicidality; physical sequelae included dental, neurological, and dermatological sequelae. Conclusion: The MPP caused harm among these 11 cases evaluated. Harm resulted from continued trauma, worsening social determinants of health, and continued presence of fear and insecurity. The MPP may increase the risk of re-traumatization as well as detract from asylum seekers' ability to heal from pre-migration trauma.

Characteristics of Deaths Among Individuals in US Immigration and Customs Enforcement Detention Facilities, 2011-2018.

Importance: Concerns have been raised that substandard medical care has contributed to deaths in US Immigration and Customs Enforcement (ICE) detention facilities. After each in-custody death, ICE produces detainee death reviews, which describe the circumstances of the death and determine whether ICE Performance-Based National Detention Standards (PBNDS) were violated. Objective: To describe factors associated with deaths in ICE detention facilities. Design, Setting, and Participants: This case series used data extracted from detainee death reviews of deaths among individuals detained in ICE facilities for whom these reviews were available from January 2011 to December 2018. Exposures: All individuals were in the custody of ICE at the time of death. Main Outcomes and Measures: Data including demographic information, medical histories, recorded medical data, and reported violations of PBNDS were systematically extracted and summarized. Results: Among 71 individuals who died in an ICE detention facility during the study period, detainee death reviews were available for 55 (77.5%). Most were male (47 [85.5%]), and the mean (SD) age at death was 42.7 (11.5) years. Individuals resided in the US for a mean (SD) of 15.8 (13.2) years before detention and were in ICE custody for a median of 39 days (interquartile range, 9-76 days) before death. Most had low burdens of preexisting disease, with 18 (32.7%) having a Charlson Comorbidity Index score of 0 and 15 (27.3%) having a score of 1 or 2. A total of 47 deaths (85.5%) were attributed to medical causes and 8 (14.5%) to suicide. Markedly abnormal vital signs were documented in the death reviews before 29 of 47 deaths from medical causes (61.7%), and 21 of these 29 deaths (72.4%) were preceded by abnormal vital signs during 2 or more encounters with ICE personnel before death or terminal hospital transfer. Overall, 43 detainee death reviews (78.2%) identified PBNDS violations related to medical care, with a mean (SD) of 3.2 (3.0) deficiencies per detainee death review. Conclusions and Relevance: In this case series, deaths in ICE detention facilities from 2011 to 2018 occurred primarily among young men with low burdens of preexisting disease. Markedly abnormal vital signs preceded death or hospital transfer for most nonsuicide deaths. The PBNDS were violated in most detainee death reviews. These results suggest that additional oversight and external evaluation of practices related to medical and psychiatric care within ICE facilities are needed.

Mapping factors associated with deaths in immigration detention in the United States, 2011-2018: A thematic analysis.

Background: Climate change, poverty, and violence increasingly drive migration to the United States. United States Immigration and Customs Enforcement (ICE) detain some individuals while awaiting determination of immigration status or potential deportation. Over the last two decades, more than 200 individuals died in ICE detention. In this study, we aim to identify systemic issues related to deaths of individuals in ICE detention to potentially mitigate further harm. Methods: The ICE Office of Detention Oversight conducts investigations after each death in detention, producing a report called a "Detainee Death Review". To identify systemic issues in these deaths, we used thematic analysis to review 55 Detainee Death Reviews available between 2011 and 2018. Findings: We identified 3 major themes of pervasive issues-Detainee Not Patient, System Over Patient, and Grossly Substandard Care- and 11 subthemes. Subthemes of culture of shortcuts, delays in care, and poor care delivered were present in the vast majority of cases. Subthemes bias and discrimination, language injustice, falsification of and inconsistencies between records and reports, willful indifference, security over health, communication breakdown, inadequate resources, failure of protective mechanisms, missing/ignoring red flags, and failure of emergency response were also prominent. Interpretation: This study identified underlying systems issues within the medical care provided in ICE detention. While there are issues with language services, discrimination, and inadequate response to medical emergencies, the greatest issue is the lack of independent, external review. Greater transparency is required, so that adherence to basic standards of care for individuals in ICE detention can be better evaluated. Funding: Haas Jr. Fund and the University of Southern California's Equity Research Institute.

Integrating community health volunteers into non-communicable disease management among Syrian refugees in Jordan: a causal loop analysis.

OBJECTIVES: Globally, there is emerging evidence on the use of community health workers and volunteers in low-income and middle-income settings for the management of non-communicable diseases (NCDs), provision of out-of-clinic screening, linkage with health services, promotion of adherence, and counselling on lifestyle and dietary changes. Little guidance exists on the role of this workforce in supporting NCD care for refugees who lack access to continuous care in their host country. The goals of this work were to evaluate the current roles of community health volunteers (CHVs) in the management of diabetes and hypertension (HTN) among Syrian refugees and to suggest improvements to the current primary care model using community health strategies. SETTING AND PARTICIPANTS: A participatory, multistakeholder causal loop analysis workshop with representatives from the Ministry of Health of Jordan, non-governmental organisations, United Nations agencies, CHVs and refugee patients was conducted in June 2019 in Amman, Jordan. PRIMARY OUTCOME: This causal loop analysis workshop was used to collaboratively develop a causal loop diagram and CHV strategies designed to improve the health of Syrian refugees with diabetes and HTN living in Jordan. RESULTS: During the causal loop analysis workshop, participants collaboratively identified and mapped how CHVs might improve care among diagnosed patients. Possibilities identified included the following: providing psychosocial support and foundational education on their conditions, strengthening self-management of complications (eg, foot checks), and monitoring patients for adherence to medications and collection of basic health monitoring data. Elderly refugees with restricted mobility and/or uncontrolled disease were identified as a key population where CHVs could provide home-based blood glucose and blood pressure measurement and targeted health education to provide more precise monitoring. CONCLUSIONS: CHV programmes were cited as a key strategy to implement secondary prevention of morbidity and mortality among Syrian refugees, particularly those at high risk of decompensation.

A cohort study to assess a communication intervention to improve linkage to HIV care in Nakivale Refugee Settlement, Uganda.

Communication interventions to enhance linkage to HIV care have been successful in sub-Saharan Africa but have not been assessed among refugees. Refugees and Ugandan nationals participating in HIV testing in Nakivale Refugee Settlement were offered weekly phone call and short message service (SMS) reminders. We assessed linkage to care and predictors of linkage within 90 days of testing, comparing Intervention participants to those unwilling or ineligible to participate (Non-Intervention). Of 208 individuals diagnosed with HIV, 101 (49%) participated in the intervention. No difference existed between Intervention and Non-intervention groups in linkage to care (73 [72%] vs. 76 [71%], p = 0.88). Excluding those who linked prior to receipt of intervention, the intervention improved linkage (69 [68%] vs. 50 [47%], p = 0.002). Participants were more likely to link if they were older (aOR 2.39 [1.31, 4.37], p = 0.005) or Ugandan nationals (aOR 3.76 [1.12, 12.66], p = 0.033). Although the communication intervention did not significantly improve linkage to HIV care, the linkage was improved when excluding those with same-day linkage. Excluding participants without a phone was a significant limitation; these data are meant to inform more rigorous designs moving forward. Innovative methods to improve linkage to HIV care for this vulnerable population are urgently needed.

Access to Care and Prevalence of Hypertension and Diabetes Among Syrian Refugees in Northern Jordan.

Importance: The management of noncommunicable diseases in humanitarian crises has been slow to progress from episodic care. Understanding disease burden and access to care among crisis-affected populations can inform more comprehensive management. Objective: To estimate the prevalence of hypertension and diabetes with biological measures and to evaluate access to care among Syrian refugees in northern Jordan. Design, Setting, and Participants: This cross-sectional study was undertaken from March 25 to April 26, 2019, in the districts of Ramtha and Mafraq, Jordan. Seventy clusters of 15 households were randomly sampled, and chain referral was used to sample Syrian households, representative of 59 617 Syrian refugees. Adults were screened and interviewed about their access to care. Data analysis was performed from May to September 2019. Exposures: Primary care delivered through a humanitarian organization since 2012. Main Outcomes and Measures: The main outcomes were self-reported prevalence of hypertension and diabetes among adults aged 18 years or older and biologically based prevalence among adults aged 30 years or older. The secondary outcome was access to care during the past month among adults aged 18 years or older with a diagnosis of hypertension or diabetes. Results: In 1022 randomly sampled households, 2798 adults aged 18 years or older, including 275 with self-reported diagnoses (mean [SD] age, 56.5 [13.2] years; 174 women [63.3%]), and 915 adults aged 30 years or older (608 women [66.5%]; mean [SD] age, 46.0 [12.8] years) were screened for diabetes and hypertension. Among adults aged 18 years or older, the self-reported prevalence was 17.2% (95% CI, 15.9%-18.6%) for hypertension, 9.8% (95% CI, 8.6%-11.1%) for diabetes, and 7.3% (95% CI, 6.3%-8.5%) for both conditions. Among adults aged 30 years or older, the biologically based prevalence was 39.5% (95% CI, 36.4%-42.6%) for hypertension, 19.3% (95% CI, 16.7%-22.1%) for diabetes, and 13.5% (95% CI, 11.4%-15.9%) for both conditions. Adjusted for age and sex, prevalence for all conditions increased with age, and women had a higher prevalence of diabetes than men (adjusted prevalence ratio, 1.3%; 95% CI, 1.0%-1.7%), although the difference was not significant. Complications (57.4%; 95% CI, 51.5%-63.1%) and obese or overweight status (82.8%; 95% CI, 79.7%-85.5%) were highly prevalent. Among adults aged 30 years or older with known diagnoses, 94.1% (95% CI, 90.9%-96.2%) currently took medication. Among adults aged 18 years or older with known diagnoses, 26.8% (95% CI, 21.3%-33.1%) missed a medication dose in the past week, and 49.1% (95% CI, 43.3%-54.9%) sought care in the last month. Conclusions and Relevance: During this protracted crisis, obtaining care for noncommunicable diseases was feasible, as demonstrated by biologically based prevalence that was only moderately higher than self-reported prevalence. The high prevalence of complications and obese or overweight status, however, suggest inadequate management. Programs should focus on reinforcing adherence and secondary prevention to minimize severe morbidity.