Background In the UK, TB medication is free but access to additional resources necessary for treatment completion is conditional. Patients with no recourse to public funds (NRPF), including undocumented and some European Economic Area migrants, have no rights to benefits, public housing or social care. The International Union Against Tuberculosis and Lung Disease (IUATLD) recommends that undocumented migrants with tuberculosis (TB) should receive free treatment and not be deported until completion of treatment. We used case reviews to explore how this guidance translates into current practice in London.
Methods We reviewed clinical, social circumstances and treatment outcomes for 32 NRPF patients with active TB referred from September 2007 to June 2010 to Find and Treat, a pan-London multi-disciplinary project developed to strengthen TB control in hard-to-reach groups.
Results The case reviews demonstrated that, while TB medication is free, lack of access to public funds severely compromises treatment access, completion and cure. Patients are unable to pay for transport to attend clinic appointments, buy food or access accommodation. Many (7/32) in fact were sleeping rough. More than a third (10/32) had resistant forms of TB, including 3 to a single drug (Isoniazid) and 7 with Multi Drug resistance (MDR). Despite close working relationships with Border Control Agencies, threat of deportation is a reality. Nine patients (28%) were lost to follow-up care, of which almost half (4/9) have never been found. Consequences included unsupervised medication, street homelessness, hospital admission (including for malnutrition) and treatment interruption and default.
Conclusion Though ensuring access to free treatment, current guidance does not address the wider determinants of health in tuberculosis. This results in severe inequity of care, and poor treatment outcomes with potentially serious public health implications. Political commitment to provide for basic social needs as well as free medication for all patients is required to effectively control TB.
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Funding This project was supported by the Department of Health.