title: Is forced migration a barrier to treatment success? Similar HIV treatment outcomes among refugees and a surrounding host community in Kuala Lumpur, Malaysia.
abstract: In response to an absence of studies among refugees and host communities accessing highly active antiretroviral therapy (HAART) in urban settings, our objective was to compare adherence and virological outcomes among clients attending a public clinic in Kuala Lumpur, Malaysia. A cross-sectional survey was conducted among adult clients (≥18 years). Data sources included a structured questionnaire that measured self-reported adherence, a pharmacy-based measure of HAART prescription refills over the previous 24 months, and HIV viral loads. The primary outcome was unsuppressed viral load (≥40 copies/mL). Among a sample of 153 refugees and 148 host community clients, refugees were younger (median age 35 [interquartile range, IQR 31, 39] vs 40 years [IQR 35, 48], p < 0.001), more likely to be female (36 vs 21 %, p = 0.004), and to have been on HAART for less time (61 [IQR 35, 108] vs 153 weeks [IQR 63, 298]; p < 0.001). Among all clients, similar proportions of refugee and host clients were <95 % adherent to pharmacy refills (26 vs 34 %, p = 0.15). When restricting to clients on treatment for ≥25 weeks, similar proportions from each group were not virologically suppressed (19 % of refugees vs 16 % of host clients, p = 0.54). Refugee status was not independently associated with the outcome (adjusted odds ratio, aOR = 1.28, 95 % CI 0.52, 3.14). Overall, the proportions of refugee and host community clients with unsuppressed viral loads and sub-optimal adherence were similar, supporting the idea that refugees in protracted asylum situations are able to sustain good treatment outcomes and should explicitly be included in the HIV strategic plans of host countries with a view to expanding access in accordance with national guidelines for HAART.
authors.affiliation: MRC Tropical Epidemiology Group, Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK, joshua.mendelsohn@lshtm.ac.uk.
authors.forename: Joshua B
authors.initials: JB
authors.lastname: Mendelsohn
authors.forename: Marian
authors.initials: M
authors.lastname: Schilperoord
authors.forename: Paul
authors.initials: P
authors.lastname: Spiegel
authors.forename: Susheela
authors.initials: S
authors.lastname: Balasundaram
authors.forename: Anuradha
authors.initials: A
authors.lastname: Radhakrishnan
authors.forename: Christopher K C
authors.initials: CK
authors.lastname: Lee
authors.forename: Natasha
authors.initials: N
authors.lastname: Larke
authors.forename: Alison D
authors.initials: AD
authors.lastname: Grant
authors.forename: Egbert
authors.initials: E
authors.lastname: Sondorp
authors.forename: David A
authors.initials: DA
authors.lastname: Ross
mesh_terms: D000293:Adolescent; D000328:Adult; D023241:Antiretroviral Therapy, Highly Active; D018791:CD4 Lymphocyte Count; D003430:Cross-Sectional Studies; D004641:Emigration and Immigration; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000821:virology*; D006801:Humans; D008296:Malaysia; D015999:Multivariate Analysis; D010349:Patient Compliance; D012036:Refugees; D012959:Socioeconomic Factors; D016896:Treatment Outcome; D019562:Viral Load / Q000187:drug effects