1. HIV, MENTAL HEALTH &
REFUGEES: Case Studies
Xavier V Pereira
Associate Professor, Psychiatry
Director, Health Equity Initiatives
22 November 2011
HEALTH EQUITY INITIATIVES

2. HEALTH EQUITY INITIATIVES (H.E.I)
–Health Equity Initiatives (H.E.I.) is a Malaysian
NGO established in 2007.
–H.E.I. focuses on health rights and health
issues of the marginalised.
–H.E.I. provides mental health education,
assessments and interventions for refugees via
their centre based and community mental
health programs.
–H.E.I. is also involved in research and
advocacy.
HEALTH EQUITY INITIATIVES

3. CASE STUDY-1
• Begum (not her real name), a married Rohingya-Myanmar
refugee in her early twenties is on treatment for HIV infection
at a Malaysian hospital. She has lived in Malaysia for the last
7 years with her husband and 2 children. She claims that
none of her family members are HIV positive.
• Her HIV status was detected during her first pregnancy, 6
years ago, at a government health clinic. She defaulted follow
up and only made contact with the health services
(government hospital) for delivery of the baby.
• During her second pregnancy one year ago, she was again
tested at the health clinic and was confirmed positive for HIV.
She was referred to Sungai Buloh Hospital for treatment
before delivery in July, 2011. She has been on treatment
since August 2011 under the Individual Assistance Desk (IAD)
program of UNHCR.
HEALTH EQUITY INITIATIVES

4. CASE STUDY-1
• She stays in Klang and it costs her about RM200.00 each
time she has to keep her appointment with the Infectious
Disease clinic in Hospital Sg. Buloh. She has to bring her
children along with her since she is her children’s sole
caretaker. Cost incurred includes travel by taxi and food. The
financial burden is heavy and she feels stressed.
• The other issue burdening her was the stigma associated with
being HIV positive. Those in the community who know her
HIV status shun her and refuse the family a place to stay.
• She had high scores on all the 3 scales of Stress, Anxiety and
Depression on the DASS-21 (Depression, Anxiety and Stress
Scale) administered to her.
HEALTH EQUITY INITIATIVES

5. Issues from Case Study-1
ACCESSIBITY to HEALTH CARE
1. There is a lack of recognition of the refugee
status in Malaysia
• Malaysia has not ratified the 1951 International
Convention for Refugees.
• Government health centres require official
identification for registration, consultation and
treatment, and refugees not registered with UNHCR
are less able to access government health centres.
(Verghis S.E., Pereira X.V., 2009)
HEALTH EQUITY INITIATIVES

6. Issues from Case Study-1
ACCESSIBILITY to HEALTH CARE
2. Refugees are socio-economically burdened
• Most refugees arrive in Malaysia with little or
nothing
• Refugees are not allowed to officially work in
Malaysia and earn a living.
• Refugees are required to pay foreigner rates at
government health centres (RM60.00 per
consultation)
• In addition there are associated costs of transport,
medication and loss of wages.
HEALTH EQUITY INITIATIVES

7. Issues from Case Study-1
PSYCHOLOGICAL DISTRESS and MORBIDITY
1. Refugees have a greater vulnerability to
psychological and psychiatric morbidity.
(de Vries, 2001; Sultan, A.,& O'Sullivan, K., 2001; Silove & Steel
2007; Verghis & Pereira 2009)
– In Malaysia the contributing factors are the
experience of : 1. Loss. 2. Insecurity and
Threat. 3. Trauma.
(HEI Mental Health Services)
– In Malaysia, most common mental health
problems among refugees: Depression,
Anxiety, Post Traumatic Stress Disorder
HEALTH EQUITY INITIATIVES

8. Issues from Case Study-1
PSYCHOLOGICAL DISTRESS and MORBIDITY
2. Similarly HIV positive status increases the risk
of psychiatric morbidity. (Freeman MC et al,
2005)
Thus being a refugee with HIV infection greatly
increases the risk of psychiatric morbidity.
HEALTH EQUITY INITIATIVES

9. CASE STUDY-2
John (not his real name), a 46 year old refugee
from the African continent was referred to the
Mental Health Services of Health Equity
Initiatives (HEI) because he was experiencing
psychological distress. He was seen by a
psychiatrist and a clinical psychologist at HEI.
John is HIV positive and is receiving treatment
at a Malaysian public hospital. He was
distressed because during the last consultation
he had with a doctor at the infectious diseases
clinic he had a rectal examination done on him.
He claimed the purpose of the rectal
examination was not explained to him by the
doctor.
HEALTH EQUITY INITIATIVES

10. CASE STUDY-2
On assessment John complained of poor sleep,
decreased appetite, low mood, poor
concentration and recurrent negative thoughts.
He also said he was irritable and had lost
interest in normal pleasurable activities
(anhedonia). He had recurrent thoughts that
the doctor perceived him to be a ‘faggot’ or
homosexual and thus had carried out a rectal
examination on him. During the assessment
John repeatedly said that he was married and
had three children. This was interpreted as an
attempt to refute the assumption that the doctor
who examined him had perceived him to be a
‘faggot’.
HEALTH EQUITY INITIATIVES

11. Issues from Case Study-2
INFORMED CONSENT and COUNSELLING
• All migrant workers/expatriate professionals are
screened for infectious diseases as per Malaysian
immigration rules.
• There are reports that the 3 Cs – Consent,
Counselling and Confidentiality – are not practiced.
• This case study reveals that informed consent and
counselling should also precede physical
examination especially invasive examinations like
rectal and vaginal examination in HIV positive
individuals
HEALTH EQUITY INITIATIVES

12. Issues from Case Study-2
ADHERENCE to TREATMENT
• Evidence indicates that mental health morbidity
detrimentally affects adherence to treatment in HIV
infected persons. ( Mellins CA et al , 2003)
• The patient in the case study was apprehensive about
returning for treatment.
• The IAD (Individual Assistance Desk) of UNHCR has an
Adherence Support Program for HIV positive refugees
on treatment in Sg. Buloh Hospital. Adherence to
treatment has increased from about 25% in 2007 to
about 85% in 2011 through this program.
• UNHCR has 12 trained refugee Adherence Support
Workers (ASWs) for this program.
HEALTH EQUITY INITIATIVES

13. The WAY FORWARD
– Collaborative effort - HEI, IAD and Infectious
Diseases Unit of SBH to deal with mental
health issues of HIV positive refugees.
– Rapid appraisal of mental health of HIV +ve
refugees using the DASS-21
– Training of ASWs of UNHCR in mental health
– Provision by HEI of counselling, psychological
and psychiatric services for HIV +ve refugees.
HEALTH EQUITY INITIATIVES

14. RECOMMENDATIONS
1. Malaysia to ratify the 1951 International
Convention for Refugees.
2. Align the medical consultation fees for
refugees in Malaysian public health centres
with that paid by Malaysian patients.
3. Allow refugees to work in order for them to
cover their health care costs.
4. Train health care professionals and health
workers to detect mental health problems in
HIV +ve patients.
HEALTH EQUITY INITIATIVES

15. REFERENCES
1. De Vries, J. (2001). Mental health issues in Tamil refugees and displaced
persons. Counselling implications. [doi: DOI: 10.1016/S0738-
3991(99)00120-2]. Patient Education and Counseling, 42(1), 15-24.
2. Freeman MC, Patel V et al. Integrating mental health in global initiatives for
HIV/AIDS. British Journal of Psychiatry (2005), 187, 1-3.
3. Mellins CA et al. Longitudinal Study of Mental Health and Psychosocial
Predictors of Medical Treatment Adherence in Mothers Living with HIV
Disease. AIDS PATIENT CARE and STDs (2003) Volume 17, Number 8,
407-420.
4. Silove D, Austin P, Steel Z. No Refuge from Terror: The Impact of
Detention on the Mental Health of Trauma-affected Refugees Seeking
Asylum in Australia. Transcultural Psychiatry. 2007 September 1,
2007;44(3):359-93.
5. Sultan A, O'Sullivan K. Psychological disturbances in asylum seekers held
in long term detention: A participant–observer account. Medical Journal of
Australia. 2001;175:593–6.
6. Verghis S, Pereira XV. ‘Health concerns of refugees and asylum seekers
in Malaysia’. Paper presented at: Roundtable on Developing a
Comprehensive Policy Framework for Refugees and Asylum Seekers.
Kuala Lumpur: Bar Council Malaysia; 2009 June 23,
HEALTH EQUITY INITIATIVES

16. THANK YOU
HEALTH EQUITY INITIATIVES