Policy Forum Antiretroviral Therapy for Refugees and Internally Displaced Persons: A Call for Equity Joshua B. Mendelsohn 1 *, Paul Spiegel 2 , Marian Schilperoord 2 , Nadine Cornier 2 , David A. Ross 1 1 MRC Tropical Epidemiology Group, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom, 2 Public Health and HIV Unit, United Nations High Commissioner for Refugees, Geneva, Switzerland Background For people living with HIV and AIDS (PLHIV), treatment with antiretroviral ther- apy (ART) can result in viral suppression, prolonged life expectancy, and reduced HIV transmission [1–3]. To realize these benefits, PLHIV require regular access to medica- tions and supportive services. Within con- flict-affected settings, there are unique chal- lenges to providing, accessing, and adhering to ART [4,5]. An estimated 1.5 billion people live in countries impacted by violent conflict and 45.2 million are forcibly dis- placed as a result of persecution, conflict, violence, and/or human rights violations [6,7]. In 2006, 1.8 million PLHIV were affected by conflict, disaster, or displacement. Half of countries (7/15) with the largest number of PLHIV were affected by a major conflict between 2002 and 2006 [8]. Con- flict-affected persons reside in areas of recent or active conflict, or in a post-conflict camp, urban, or rural setting, and may be accorded an official status depending on their situation [9,10]. Refugee status is available to individ- uals with ‘‘a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion, is outside the country of his/her nationality and is unable or unwilling (owing to such fear) to avail him/herself of the protection of that country’’ [11]. Internally displaced persons (IDPs) are citizens who have ‘‘been forced or obliged to flee or to leave their homes or places of habitual residence, in particular as a result of or in order to avoid the effects of armed conflict, situations of generalized violence, violations of human rights or natural or human-made disasters, and who have not crossed an internationally recog- nized State border’’ [12]. A protracted refugee situation occurs when .25,000 refugees of the same nationality have been in exile for $5 years. At the end of 2012, 6.4 million refugees, or 61% of the global total of 10.5 million, lived in a protracted situation [7]. In the post-emergency phase of forced displacement, refugees and IDPs live in relatively ‘‘stable’’ settings, meaning that exceptional measures are no longer required to remove threats to life or well-being [13]. Here, we synthesize norms of practice with evidence on the impact of ART programs in stable settings, including our own experienc- es delivering and evaluating ART as part of the United Nations High Commissioner for Refugees (UNHCR) mandate. We then propose operational recommendations for improving HIV treatment outcomes among refugees and IDPs in stable settings. Moral, legal, and public health principles, in combination with recent evidence, provide a clear rationale for sustainable treatment provision and adequate support for refugees and IDPs. Equity and Sustainability Debates over the merits of providing ART to refugees and IDPs have echoed earlier discussions on treatment scale-up Policy Forum articles provide a platform for health policy makers from around the world to discuss the challenges and opportunities in improving health care to their constituencies. Citation: Mendelsohn JB, Spiegel P, Schilperoord M, Cornier N, Ross DA (2014) Antiretroviral Therapy for Refugees and Internally Displaced Persons: A Call for Equity. PLoS Med 11(6): e1001643. doi:10.1371/journal. pmed.1001643 Published June 10, 2014 Copyright: ß 2014 Mendelsohn et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Funding: Financial support was provided by Canadian Institutes of Health Research (Doctoral Research Award, Priority Announcement for HIV/AIDS #200710IDB), the Parkes Foundation (PhD Grant Fund), the London School of Hygiene & Tropical Medicine (Research Training Support Grant), and the United Nations High Commissioner for Refugees (UNHCR). UNHCR, but not the other funding agencies, assisted in study design, interpretation of results, and drafting of the manuscript. Competing Interests: The authors have declared that no competing interests exist. Abbreviations: ART, antiretroviral therapy; IDP, internally displaced person; NSP, National Strategic Plan; PLHIV, people living with HIV and AIDS; UNHCR, United Nations High Commissioner for Refugees. * E-mail: joshua.mendelsohn@lshtm.ac.uk Provenance: Commissioned; externally peer reviewed. Summary Points N Available evidence suggests that refugees and internally displaced persons (IDPs) in stable settings can sustain high levels of adherence and viral suppression. N Moral, legal, and public health principles and recent evidence strongly suggest that refugees and IDPs should have equitable access to HIV treatment and support. N Exclusion of refugees and IDPs from HIV National Strategic Plans suggests that they may not be included in future national funding proposals to major donors. N Levels of viral suppression among refugees and nationals documented in a stable refugee camp suggest that some settings require more intensive support for all population groups. N Detailed recommendations are provided for refugees and IDPs accessing antiretroviral therapy in stable settings. PLOS Medicine | www.plosmedicine.org 1 June 2014 | Volume 11 | Issue 6 | e1001643