HIV entry barriers and why they are stupid

A letter to my MP, who cosponsored a recent amendment to the Immigration Bill

Here in the United Kingdom, our Parliament is currently debating an Immigration Bill. It left the House of Commons last week, but not before a group of 18 Conservative MPs attempted to amend the bill to prevent the entry into the UK of people infected with HIV or hepatitis B by adding the following clause:

NC21: Immigration permission: prescribed pathogens
(1) The Secretary of State may by order provide that persons who apply for immigration permission must demonstrate that they are not carriers of any of the prescribed pathogens listed in subsection (2).
(2) The prescribed pathogens are—
(a) Hepatitis B;
(b) HIV (Human Immunodeficiency Virus);
(c) such other pathogens as the Secretary of State may prescribe by order under this section.

A small handful of countries in the world disallow entry to individuals infected with HIV, though the trend is for these immigration barriers to be withdrawn, with the repeal of the US entry bar being announced by President Obama in 2009. The list of countries that bar all entry to people with HIV is not exactly a list of liberal democracies.

Travel restrictions for people with HIV, as at February 2014.
Red indicates no entry; orange and yellow are restrictions for short- and long-term visitors respectively;
green indicates no restriction; grey indicates missing or unclear data. Source: www.hivrestrictions.org; created by myself.

As my own MP was one of the cosponsors of the amendment, I figured I should write to him, in an attempt to educate him further; the letter — slightly reformatted for the benefit of Medium — is below.

Mr Lord,

I was disappointed and alarmed to see that, in last week’s debates considering the Immigration Bill, you were a signatory to amendment NC21, entitled “Immigration permission: prescribed pathogens”, which sought to restrict entry to the UK by anyone carrying any one of a list of pathogens, starting with HIV and hepatitis B.

I’d be very interested to understand your rationale for supporting such a measure.

In particular, I’d be happy to walk you through the evidence from organisations working in the area of HIV and AIDS, who unanimously condemn such entry restrictions.

In 1984, in the Siracusa Principles on the Limitation and Derogation of Provisions in the International Covenant on Civil and Political Rights (UN document E/CN.4/1984/4), the UK was among nation states agreeing that exercises of national sovereignty — including immigration and visa restrictions — were bound by human rights, including non-discrimination. Under the Siracusa Principles, limitations of these human rights by nation states must be accompanied by evidence that the limitations are necessary, effective and are the least-restrictive means possible.

Even in 1988, before the advent of highly-active antiretroviral therapy (HAART), the World Health Organization took the position that

since HIV infection is already present in every region and in virtually every major city in the world, even total exclusion of all travellers (foreigners and citizens travelling abroad) cannot prevent the introduction and spread of HIV.[1]

The WHO added that

HIV screening of international travellers would be ineffective, impractical and wasteful”, continuing: “Rather than screening international travellers, resources must be applied to preventing HIV transmission among each population, based on information and education, and with the support of health and social services.[1]

Eight years later, the UN General Assembly adopted resolution 60/262 “Political Declaration on HIV/AIDS”, committing member states

to intensifying efforts to enact, strengthen or enforce, as appropriate, legislation, regulations and other measures to eliminate all forms of discrimination against … people living with HIV.[2]

In 2008, Kyung-wha Kang, the UN Deputy High Commissioner for Human Rights stated that

we know that there are no … public health rationale for restricting the freedom of movement based on HIV status. As a result, any such differentiation is discriminatory and thus unacceptable.

If we were to implement forcible screening for HIV status at the UK Border, it would mean that people are tested without being told beforehand, without counselling around such testing, with no guarantee that they would be provided with the results, without the results being kept confidential, without being referred to medical care and without being connected to forms of treatment or support. Testing under such conditions is a violation of medical ethics and of the rights to privacy and health.[3]

To quote the chief executive of the National Aids Trust last week:

Far from being ‘drains’ on the public purse — as this amendment seems to suggest — people living with HIV contribute hugely to the UK’s society and economy. … If these MPs are really interested in protecting public health through immigration policy, they would oppose the current Department of Health plans to limit migrant access to primary care services, which are vital for disease prevention and early treatment. They would support efforts to reduce the unacceptable high rates of late and undiagnosed HIV in our community.[4]

Travel restrictions rely on an insulting assumption that HIV-positive individuals act irresponsibly and, as a result, transmit the virus to others, despite the fact that people who know they’re positive and are on treatment reduce their risk of passing the virus on by 96% and that almost half of all infections occur within the first few months of infection, so individuals who are not newly-infected pose substantially less risk.[5,6]

One of the biggest problems in this public health crisis, however, is directly exacerbated by a policy of entry barriers — stigma. In 2009, US President Barack Obama announced the overturning of the 22-year-old American travel ban, saying that “this is a major step in ending the stigma associated with HIV”.[7] Amongst other things, stigma associated with HIV leads individuals to avoid testing programmes. Speaking last November, Paul Ward of the Terrence Higgins Trust said: “Reducing undiagnosed HIV is now the single most important step we can take to halt the spread of HIV within the gay community”, as almost one in five gay and bisexual men with HIV are unaware that they are infected.[8]

In 2009, UNAIDS, the Joint United Nations Programme on HIV/AIDS, published a document Entry Denied — Denying entry, stay and residence due to HIV status: Ten things you need to know.[9] It’s a very readable booklet of under 30 pages; I would strongly recommend that you read through it.

To come back to the Siracusa Principles’ three requirements of “necessary, effective and … least-restrictive”, it seems clear that border controls are not necessary, as other means of disease control are available. They are not effective, as the spread of HIV within the UK is substantially fuelled by native Brits who are unaware they are infected. Finally, it seems self-evident that barring entry to a class of individuals is not the least-restrictive means of doing anything. Such a policy would fail to deliver on its aims, while fuelling the stigma that exacerbates this public health crisis.

If you would like to discuss issues around HIV and AIDS in more detail then I would be very happy to meet with you to do so. Alternatively, you could get in touch with any of the many organisations working in this area in the UK, such as the Terrence Higgins Trust or the National Aids Trust.

Yours sincerely,

Owen Blacker

Footnotes

1. World Health Organization (1988), Statement on screening of international travellers for infection with Human Immunodeficiency Virus, WHO/GPA/INF/88.3.
2. UN General Assembly (15 June 2006), Resolution 60/262: Political Declaration on HIV/AIDS (PDF).
3. UNAIDS and WHO state that any testing for HIV should occur under conditions of informed consent, counselling and confidentiality and be linked to positive health outcomes. See UNAIDS/WHO Policy Statement on HIV Testing (PDF, 2004). See also UNAIDS/WHO (2007), Guidance on Provider-initiated Testing and Counselling in Health Facilities (PDF).
4. National Aids Trust press release, (30 January 2014), MPs urged to reject amendment to refuse visas to people living with HIV.
5. International Aids Society (2013), Fact sheet: HIV/AIDS, IAS conference 2013 (PDF).
6. RJ Hayes and RG White (2006), “Amplified HIV Transmission during Early-Stage Infection”, Journal of Infectious Diseases 193(4):604–05, doi:10.1086/499606.
7. White House Office of National AIDS Policy (30 October 2009), Honoring the Legacy of Ryan White.
8. Terrence Higgins Trust press release (21 November 2013), Terrence Higgins Trust urges gay men to get tested as Public Health England releases report on HIV.
9. UNAIDS (2009), Entry Denied — Denying entry, stay and residence due to HIV status: Ten things you need to know (PDF).

Image credits

The header image is adapted from UK Border, Heathrow, by Danny Howard, found on the Wikimedia Commons, released under a Creative Commons Attribution 2.0 Generic licence. The font used for the overlay is None Shall Pass, by KC Fonts, made available free for personal use.

The map image is my own creation, based on Blank Map—World—Microstates, by User:NuclearVacuum, from the Wikimedia Commons and released into the public domain. The data used to colour countries according to their border control policies was taken from the website www.hivrestrictions.org in February 2014.