Pan American Health Organization · 2021
Strategic guidance for health authorities and service providers to ensure HIV prevention, care and treatment access for refugees and migrants regardless of immigration status.
- Issuer
- Pan American Health Organization
- Edition
- 2021
- Audience
- Health policymakers, national AIDS programme managers, health service providers, NGOs working with refugees and migrants
- Evidence
- Expert consensus, WHO recommendations, multi-country technical consultation
- Reviewed
- 19 Oct 2026 · GMJ
What this guideline says
GMJ summary
This PAHO/UNAIDS guidance addresses the largest migration movement in Latin American history: over 5 million Venezuelans fleeing economic and health system collapse, including those seeking life-saving antiretroviral treatment. The document presents five strategic lines of action to expand health coverage for refugees and migrants living with HIV, adapted to the COVID-19 context which has further limited access to services and mobility.
Central to the proposal is harmonization of antiretroviral regimens around dolutegravir (DTG)-based treatment as recommended by WHO since 2018, ensuring continuity of care across borders through multi-month dispensing (at least three months), and removing immigration status as a barrier to prevention, testing, and treatment services. The guidance emphasizes that treatment interruptions during migration journeys risk ARV resistance development with both individual and epidemiological consequences.
The document provides detailed clinical algorithms for selecting appropriate ARV regimens based on treatment history, availability of medical records, and viral load status. It calls for strengthening epidemiological surveillance disaggregated by migrant status, cross-border electronic health records, and intersectoral collaboration including health, education, social welfare and migration authorities to protect the rights of refugees and migrants, particularly LGBTI+ individuals facing compounded stigma and discrimination.
Key points
For clinicians — doses and thresholds as stated in the guideline
- Use DTG-based regimens (DTG + 2 NRTIs: tenofovir disoproxil fumarate + lamivudine for ≥30 kg; or abacavir + lamivudine for infants ≥4 weeks) as preferred first-line treatment for HIV-positive refugees and migrants
- Ensure multi-month dispensing (MMD) of antiretrovirals for at least three months of treatment to maintain continuity of care during migration
- For migrants with treatment interruption and no medical records, use ARVs with high genetic barrier to resistance (DTG or boosted protease inhibitors) due to likely NNRTI resistance
- Women of childbearing age on DTG should be offered effective contraception and informed about potential neural tube defect risk during conception/first trimester
- Provide post-exposure prophylaxis (PEP) for non-occupational exposure, particularly for survivors of sexual violence, and pre-exposure prophylaxis (PrEP) according to national guidelines
- Offer HIV, syphilis and STI testing to all refugees and migrants with no immigration status restrictions, especially survivors of gender-based violence and pregnant women
- Ensure influenza and pneumococcal vaccines for migrants and refugees living with HIV in the COVID-19 pandemic context
- If viral load is suppressed on current ARV regimen, continue treatment and monitor according to host country guidelines; if unsuppressed without records, use DTG or boosted PIs
Guidelines for selection of an ARV regimen for refugees and migrants
Table extracted from the guideline
| Patient status | Guidelines |
|---|---|
| ARV-naïve patients (diagnosed in host country or previously knew HIV status) | Follow antiretroviral therapy guidelines of the host country. Host countries urged to adopt latest WHO recommendations. |
| Previously used ARVs, currently untreated (treatment interruption) – medical record available | Review prior ARV use and viral load and genotype results (if available), select regimen based on resistance profile and host country guidelines for patients with prior ARV use. |
| Previously used ARVs, currently untreated – NO medical record | Use ARV-based regimen with high genetic barrier to resistance (e.g., DTG or boosted PIs) |
| Currently taking ARVs – continue regimen if available and viral load suppressed | Continue regimen and monitor according to host country guidelines. |
| Currently taking ARVs – viral load NOT suppressed with medical records | Review previous ARV use and viral load/genotype results, choose regimen based on resistance profile and host country guidelines for treatment failure |
| Currently taking ARVs – viral load NOT suppressed, NO medical records | Choose regimen based on resistance profile and host country guidelines for treatment failure. Use ARVs with high genetic barrier (e.g., DTG or boosted PIs). |
Source: Pan American Health Organization, Proposal for Increasing Health Care Coverage for Venezuelan Refugees and Migrants Living with HIV. Update in Response to the COVID-19 Pandemic. Reproduced in summary form.
From the guideline
Verbatim
“Ensure access to antiretroviral treatment, in accordance with national guidelines and in alignment with WHO recommendations concerning ARVs, for refugees and migrants living with HIV, regardless of their migration status.”
Editor’s perspective
Why this matters for Georgia and the region
Prof. Giorgi Pkhakadze, MD, MPH, PhD
Editor-in-Chief, Georgian Medical Journal · Chair, Public Health Institute of Georgia · WHO consultant, health and migration
As someone who has worked extensively on health systems strengthening and migration health in the WHO European Region, I recognize the immediate relevance of this guidance for Georgia and neighbouring South Caucasus countries. While the document addresses Venezuelan migration, the strategic framework—particularly the separation of immigration enforcement from health service delivery and the emphasis on multi-month ARV dispensing—directly applies to our regional context of labour migration, internally displaced populations, and cross-border movement. I would stress to Georgian colleagues the clinical algorithm for managing patients without medical records: the recommendation to use DTG or boosted protease inhibitors rather than NNRTI-based regimens when treatment history is unavailable is critical to preventing further resistance development. The key implementation challenge for Georgia will be ensuring that the universal health coverage package explicitly covers migrants and displaced persons for chronic HIV care, as current regulations may create ambiguity about eligibility for non-citizens, and establishing the cross-border health information systems necessary for treatment continuity will require bilateral agreements with Armenia, Azerbaijan and Turkey that currently do not exist.
ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 19 Oct 2026
Applicability
Georgia and the South Caucasus
Georgia’s strategic location at the crossroads of Europe and Asia, coupled with its universal health coverage programme since 2013, positions it as both a transit and destination country for migrants from the former Soviet space. While Venezuelan migration primarily affects Latin America, the strategic principles—removing immigration status as a barrier to HIV services, harmonizing ARV regimens around DTG, implementing multi-month dispensing, and establishing cross-border health information systems—are directly applicable to Georgia’s context of migration flows from Armenia, Azerbaijan, and Central Asia. Georgian national HIV programmes would need to assess current ARV regimen diversity, transition timelines to DTG-based first-line therapy, legal frameworks governing migrant access to chronic disease treatment under the UHC package, and epidemiological surveillance capacity to disaggregate data by migration status. The emphasis on protecting LGBTI+ migrants facing compounded stigma is particularly relevant given documented challenges in this area within the South Caucasus region.
Questions this guideline answers
Quick answers
What ARV regimen should I prescribe for a refugee with HIV who has no medical records and reports prior treatment interruption?
Use a regimen with high genetic barrier to resistance: DTG-based (DTG + 2 NRTIs such as tenofovir/lamivudine) or boosted protease inhibitors (atazanavir/ritonavir or lopinavir/ritonavir) with optimized 2-NRTI backbone. Do not use NNRTI-based regimens due to high likelihood of resistance after treatment interruption.
How much antiretroviral medication should I dispense to a migrant patient who may be continuing their journey?
Ensure multi-month dispensing (MMD) of at least three months of ARV treatment, along with all other required medications (prophylaxis for opportunistic infections, treatment of chronic conditions). This maintains treatment continuity and adherence during migration.
Can I prescribe DTG to women of childbearing age who are refugees or migrants?
Yes. Offer effective contraception and inform about potential neural tube defect risk during conception/first trimester. DTG can be prescribed to women who wish to become pregnant or lack consistent contraceptive access if adequately informed about therapeutic benefits and risks. The benefits of DTG (effectiveness, tolerability, low resistance development) support its use.
Should I require proof of legal immigration status before providing HIV testing or treatment to refugees and migrants?
No. The guidance explicitly recommends offering HIV, syphilis and STI testing and ensuring access to ARV treatment regardless of immigration status. Immigration law enforcement should be clearly separated from health service provision to protect migrants with chronic illnesses and associated risks.
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Quality & accreditation
- ASF PHC — Standard 4 — Acute & Same-Day Care · Primary Health Clinic
- ASF PHC — Standard 7 — Governance & Staffing · Primary Health Clinic
- ASF Hospital — Standard 9 — Refugee & Migrant Health
- ASF Laboratory — Standard 9 — Refugee & Migrant Health
- ASF Medical Transport — Standard 8 — Refugee & Migrant Health
Other guidelines on this topic
- Panorama of Diabetes in the Americas
- HEARTS in the Americas: Guide and Essentials for Implementation
- Microplanning manual to guide implementation of preventive chemotherapy to control and eliminate neglected tropical diseases
- Updated Recommendations for Determining the Number of People with HIV Receiving Antiretroviral Therapy, September 2021
- Infection Prevention and Control for the Management of Mpox in People in Situations of Vulnerability such as Prisons and Other Custodial Facilities
- Issuer
- Pan American Health Organization
- Type
- Procedures, manuals, guidelines
- Edition
- 2021
- Status
- Current
- Published
- 2021-01-01
- Languages
- English, Spanish
- Scope
- Regional (Latin America and Caribbean, with global applicability)
- Audience
- Health policymakers, national AIDS programme managers, health service providers, NGOs working with refugees and migrants
- Licence
- CC BY-NC-SA 3.0 IGO
- Evidence
- Expert consensus, WHO recommendations, multi-country technical consultation
- Record history
- Created 19 Oct 2026 · updated 19 Oct 2026 · next check Apr 2027
Pan American Health Organization, Joint United Nations Programme on HIV/AIDS. Proposal for Increasing Health Care Coverage for Venezuelan Refugees and Migrants Living with HIV. Update in Response to the COVID-19 Pandemic. Washington, D.C.: PAHO; 2021. (PAHO/UNAIDS/CDE/COVID-19/21-0013).GMJ Guidelines Library records are original summaries written by the GMJ editorial team from the issuer’s published document and reviewed by a physician. They do not replace the full guideline. The document is the copyright of its issuer and is linked, not hosted. Spotted an error or a newer edition? Tell the Guidelines Desk.
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