The US Refugee Resettlement Program actively resettles 34,000–119,000 refugees annually [1,2]. Refugees face challenges to their physical and mental health. Before migration, refugees undergo medical screening for diseases of public health concern. Certain conditions are considered excludible by US law. These conditions, when identified, must either be treated successfully or the refugee must apply for a waiver that allows immigration despite the condition (US State Department Class A waiver). Upon arrival in the United States, all refugees are encouraged to have a domestic health screening assessment [3]. Medical screening includes obtaining a general medical history and physical examination, screening for infections (e.g., intestinal parasites and hepatitis B), and provision of preventive services (e.g., vaccinations) and counseling [3]. Each state is notified of newly arriving refugees and facilitates medical follow-up, with particular attention paid to refugees who arrive with Class A conditions. In Minnesota, surveillance data from the initial refugee medical screening are collected by the Minnesota Department of Health (MDH). These data are evaluated and used to guide public health prevention and control activities [4].

During 1993–2009, human immunodeficiency virus (HIV) infection was listed as a communicable disease of public health importance and an excludible condition for entry to the United States [5]. Refugees were allowed to migrate to the United States despite the HIV infection for humanitarian reasons after obtaining a Class A waiver. The Class A waiver notification system alerted states and health care providers to underlying medical conditions for refugees [5]. During 2000–2009, Minnesota was among states that participated in the resettlement waiver program for refugees with HIV infection. On 2 November 2009, the Department of Health and Human Services (DHHS) and Centers for Disease Control and Prevention (CDC) published a final rule that removed HIV infection from the list of communicable diseases of public health significance [5]. Beginning January 2010, HIV testing was removed from the overseas medical examination before arrival in the United States. CDC has issued guidance that highly encourages post-arrival medical screening and testing for HIV-infection among refugees [6].

Epidemiologic and clinical data regarding arriving HIV-infected refugees before the US government rule change have been limited [7,8,9]. As a supplemental surveillance project, epidemiologic and clinical data on arrival and during ≥1 year of follow-up care were collected for HIV-infected refugees who resettled to Minnesota during 2000–2007. We sought to describe these refugees’ stage of HIV infection, the burden of concomitant disease, and the initial clinical course. Because the impact of the rule change on the health of refugees arriving in the United States is unknown, these data can provide baseline information for subsequent evaluation of the impact of the rule change on refugee health status after US arrival.

During 1 January 2000–31 December 2007, a total of 31,141 refugees were resettled to Minnesota, among whom 19,292 were adults aged ≥17 years, and 17,013 completed the initial refugee health assessment. There were 174 adult refugees identified as having HIV. One hundred fifty-seven (85%) had medical charts reviewed and were eligible for inclusion (Figure 1, Table 1). This included two adult refugees with an HIV waiver who missed their refugee health screening, but received follow-up HIV care.

Characteristics of the HIV-infected refugees identified through health screening and those with or without medical charts are described in Table 1. Among the 157 persons with medical charts reviewed, 83 (53%) indicated they were married or had a partner (49 had a partner with unknown HIV status). Among the 83 who had medical charts noting that they had a partner, 41 (49%) had a partner in the United States; 30 (36%) did not have their partner in the United States, and 12 (14%) had unknown partner location status. Of the 41 who reported having a partner in the United States, 11 (27%) had it noted in their medical chart that their partner was also HIV-infected; 20 (49%) had partners who were reportedly uninfected; and 10 (24%) had reported no information on partner’s HIV status. Overall, 80 (51%) reported having children, and 30 (19%) had no children; 47 (30%) had no information regarding children. Among the 80 refugees with children, three (4%) had medical charts that noted having children with HIV infection; 37 (46%) had children without HIV infection; and 40 (50%) had no record of children’s HIV-status. Among 74 female refugees, two (3%) were pregnant on initial presentation; 20 (27%) became pregnant sometime after their initial presentation to a health clinic. After arrival, the median time to pregnancy for 16 females with both pregnancy and arrival dates documented was 2.2 years (range, 0.1–7.5 years).

In Minnesota, during the period prior to the cessation of the waiver requirement, HIV-infected refugees arrived in Minnesota at varying stages from asymptomatic infection to advanced disease. A majority had no prior record of ART; coinfections detected at post-arrival domestic health screening were common; and three AIDS-related deaths occurred. Two HIV-infected refugee women were pregnant at arrival, and 20 became pregnant after arrival, thus requiring specialized care to prevent mother-to-child HIV transmission. These findings reinforce the importance of providing information regarding HIV-infection to refugee populations [8]. In addition, these data may serve as useful baseline comparison for the evaluation of changing practices and guidelines of HIV-testing.

Before 2010, documentation of HIV infection through the waiver program was the primary means of identifying HIV-infected refugees prior to arrival. The impact of the 2009 rule change on refugee health, particularly those who are HIV-positive, is unknown. Because early identification and appropriate initiation of therapy for HIV is associated with decreased morbidity and improved overall survival [11], collaboration between refugee health programs and HIV counseling and testing services will be of increased importance. Current CDC guidelines recommend HIV screening in health-care settings for all persons aged 13–64 years, including refugees [3]. Voluntary screening is encouraged by CDC for all refugees on arrival, when counseling and referrals for care, treatment, and preventive services are available [6]. These changes are in accordance with the United Nations High Commissioner for Refugees (UNHCR), WHO, and United Nations Program on HIV/AIDS recommendations regarding HIV testing and counseling in health facilities for refugees, internally displaced persons, and other persons of concern to UNCHR [12].

Identifying health needs and providing care to resettled refugees fits within the framework of upholding health as a human right. Data regarding HIV prevalence and risks for acquiring HIV infection among refugee populations are sparse [13,14], and testing might not be available before arrival. After the change from required HIV testing, timely and accurate HIV diagnosis and treatment is of increased importance. Therefore, the arrival refugee medical examination provides an optimal opportunity to identify HIV infection among refugees and provide treatment. Coinfections are common and morbidity likely can be reduced with earlier diagnosis and treatment of HIV infection. As illustrated by the frequency of pregnancy among this population, the early identification of HIV after arrival can also reduce the likelihood of perinatal HIV transmission. Continued collaboration between public health agencies and health care providers will be necessary to follow and assess refugees’ health status, including HIV infection, in Minnesota and throughout the United States.

Similar to other reports investigating the health of HIV-infected refugees, coinfections were commonly detected [7,15,16]. The high prevalence of TB among refugees described in this analysis is expected, considering that TB is a common coinfection among HIV-infected persons and in sub-Saharan Africa [17,18]. Knowing a patient’s HIV status may influence clinicians suspicion and approach to TB infection and disease diagnosis. Moving forward, with the rule change, clinicians will not have the advantage of knowing the HIV status prior to arrival, making post-arrival screening important in detecting both HIV and TB disease.

During the period covered by chart reviews, US immigrant and refugee TB screening requirements were updated from 1991 requirements. In 1991, the requirements included a chest radiograph and three sputum samples (acid-fast–bacilli stain only) for disease detection. In 2007, these technical instructions were updated to require screening to include mycobacterial culture and completion of directly observed therapy before US arrival for anyone with TB disease [19]. These data indicate that a substantial proportion (52%) of those with LTBI detected during their domestic health assessment did not complete treatment or treatment outcome was missing; LTBI patients do not have access to directly observed therapy making it challenging for public health and/or health care providers to monitor their treatment through completion. Linguistic or socio-cultural barriers and loss to follow-up due to out-migration are additional challenges that can disrupt LTBI treatment adherence. LTBI and treatment completion are not reportable to the TB surveillance or refugee health programs, which may have led to underreporting of treatment outcomes. In recent years, the refugee health program at the Minnesota Department of Health has improved its processes to actively track LTBI treatment outcomes. For refugees arriving from 2008 to 2010, the program has seen an increase in the proportion of refugees who follow LTBI treatment through to completion, due in part to improved tracking and reporting; 78% of all refugees who completed LTBI treatment, compared to only 48% during 2000–2007. However, this is still inadequate, particularly for those with HIV infection where the TB reactivation rate is excessive.

These data, based on medical chart review of resettled refugees, provide a unique summary of the health status of HIV-infected refugees during a period when HIV-infection status was known before US arrival. However, this study has certain limitations. As a retrospective medical chart review, certain clinical details might not be recorded in medical charts; others might have been missed during the process of chart abstraction; and patients might have sought health care elsewhere from the site of medical chart abstraction. To maintain a simplified data collection tool, certain details (e.g., the date that ART was prescribed) and treatment rationale were not ascertained. This review did not include psychosocial components, as others have included [16]. Despite these limitations, our findings provide additional information given the limited data that exist regarding HIV-infection among refugee populations and can serve as useful baseline comparisons in lieu of changing practices and guidelines of HIV-testing and availability of ART. To complement medical chart abstractions, future evaluations of health status of HIV-infected refugee populations should include culturally appropriate patient interviews to better understand their knowledge, attitudes, and beliefs regarding HIV/AIDS testing and care.

In Minnesota, evaluating the health of all refugees through a health screening assessment, regardless of HIV-infection status is a routine MDH activity, provides a means for determining care and prevention needs, and includes constant interaction within MDH programs (e.g., TB prevention services follow-up). During 2000–2007, the refugee health screening rate was 94.8% of 29,182 eligible resettled refugees. Refugees are ineligible if they move out of state or to an unknown location or have incorrect contact information. In lieu of the waiver program, routine HIV screening is the most efficient way to detect HIV infection and provide appropriate and timely care.