______

Asylum seekers living with HIV in Israel

Facts about Asylum seekers living with HIV in Israel

According to data from the Population and Immigration Authority, there are currently 38,540 asylum seekers in Israel; the vast majority of them (92%) is from Eritrea and Sudan. Israel applies a policy of "temporary group protection", which consists of non-deportation, to them, while leaving them without a clear status and without access to basic civil rights. The National Health Insurance Law does not apply to them and they do not have access to public health services, except in cases of extreme emergencies. According to the Ministry of Health, there are approximately 600-800 HIV-positive people living in Israel, and in our assessment, most of them are asylum seekers.

For many years, asylum seekers and undocumented migrants with HIV/AIDS have been deprived from receiving anti-retroviral (ART) treatment in Israel. Such treatment is pertinent for the health of people living with HIV (PLHIV). In January 2014, the Ministry of Health (MoH) initiated the Community Antiretroviral Therapy Program for HIV-positive immigrants without medical insurance. This initiative has brought together government agencies, AIDS clinics, NGOs and pharmaceutical companies to make the treatment accessible for people with no status and no health insurance through AIDS clinics in hospitals. In October 2016, MoH promulgated new regulations on this matter, which redefined and expanded the program. Since then, the "National Program for the Prevention of HIV and Treatment of HIV-Positive Migrants" is funded exclusively by the MoH, and managed by the Department of Tuberculosis and AIDS. The medical treatment is provided in eight AIDS clinics, located in hospitals throughout the country.

The new MoH policy is a significant step forward in protecting the right to life and health of asylum seekers and migrants in Israel. The MoH no longer leaves the care of asylum seekers and undocumented immigrants with HIV-positive status in the hands of non-governmental organizations, and stopped relying on the kindness of pharmaceutical companies. In addition, the treatment offered to them is part of the public AIDS Centers, which is a crucial step towards equating the treatment of people without status to the treatment provided to Israeli residents. Nevertheless, the current program has some significant flaws, enumerated below.

No ART treatment to PLHIV with "high" CD4 levels

The new MoH policy provides that only immigrants/ asylum seekers with CD4 levels below 500 would qualify for ART treatment. This does not meet the WHO protocol on the matter, which stipulates that ART treatment should be provided for all PWHIV, without any restrictions based on CD4 level. The Israeli legislature also deleted such a restriction following the recommendation of the 2016 National Health Basket Committee. Hence, no such restriction applies to Israeli citizens covered by the National Health Insurance Act. There is a significant number of asylum seekers and migrants who do not obtain ART treatment due to the low CD4level condition. They basically wait for their CD4 level to fall down in order to get treated.

It should be emphasized that early treatment is significant not only for the HIV positive person him/herself, but also to halt the spread of the virus, as studies unequivocally show that the risk that an HIV positive person to infect another person via unprotected sex is practically non-existent once the HIV positive person is under consistent ART treatment. Hence, by not providing early treatment, the Israeli governmental puts the public, and especially immigrant groups, at risk of further HIV infection.

          No adequate treatment to PLHIV with resistances or allergies

Drugs provided under the are "old- generation" drugs. These drugs often cause serious side effects, which can lead to non-adherence to the treatment, leading to deterioration in health and potentially also to resistance to the ART regimen. Patients who have already developed resistance may not be able to receive effective treatment because the drugs offered by the MoH program are often times the ones they have already developed resistance to, and the newer drugs, which could be helpful for them, are not included in the program. Under these conditions, the lives of these patients are at serious risk. In addition, several AIDS clinics reported, that when they needed to switch an ART treatment for a patient, and contracted MoH for approval of such change, they were turned down, without further explanation. IATF has also appealed to MoH on that matter (in a joint letter with ASSAF – AID organization for Refugees and Asylum Seekers), and have yet to receive a formal written answer. However, the Director of TB and AIDS department in MoH communicated to IATF Director six months ago, that this matter is on his agenda, and that he will attempt to secure funds from the Ministry in order to include newer ART regimens in the MoH program.  

No holistic medical treatment to PLHIV

PLHIV, who have not been properly treated for long periods of time, often suffer from co-morbidities. Many of them already developed other diseases, such as cancer, due to their weak immune system. However, since they are status-less, they are not entitled to services under the National Health Insurance Law, and therefore remain without any proper medical treatment for their medical condition. The MoH program covers, at most, ART treatment, but does not offer comprehensive treatment of the patients' medical problems. Hence, treatment remains partial and incomplete.

Diagnostic tests, biopsies, mammography, PET SCAN, MRI and other important tests are all lacking in the MoH program, as are cancer treatments for PLHIV diagnosed with various types of cancer. Mental illness, various kidney or gastrointestinal problems, skin problems and gynecological problems, just to specify several other medical conditions that are quite prevalent among the population under discussion, are also left untreated.   

As mentioned above, many of the PLHIV who lack civil status and medical insurance in Israel are asylum seekers. Many of them suffer post-trauma from persecution in their countries of origin or from human trafficking in their journey to ISrael (mostly in the Sinai desert), and they often have no support from their families or the community. Asylum seekers and undocumented immigrants with HIV often also suffer from social isolation and internalized stigmatization as well as stigmatization by the community. All of this adds to their vulnerability and propensity to suffer from poor mental health.

In light of the aforementioned, we believe that the MoH should abolish the numerical restriction and offer ART treatment to all asylum seeker/ undocumented immigrant who are HIV positive, regardless of their levels of CD4; offer newer drugs for patients with significant side effects/ allergies/ resistances; and allow participants in the program to obtain complete medical treatment, when needed, beyond mere ART treatment.

The National Program for HIV Prevention and Treatment of HIV Positive Asylum seeker/undocumented immigrant, funded and supervised by the Ministry of Health, is a significant and important program that can affect and even save lives of hundreds of HIV-positive people. Thus, the Ministry of Health must continue its positive trend, beginning in 2014, and introduce all the necessary changes in the program, in order to provide full and appropriate treatment to all HIV positive asylum seekers and long-staying immigrants in Israel.