The economic burden of immigrants with HIV/AIDS: When to say no?

Presenter: Peter Coyte, University of Toronto

Abstract

Rationale: The Canadian Immigration and Refugee Protection Act (IRPA) of 2001 outlines the conditions under which individuals may be granted or denied admission to Canada. Specifically, prospective immigrants will be rejected if their health is expected to generate excessive demand on Canadian health or social services.

Objective: This research synthesis and knowledge dissemination study offers a statistical definition of excessive demand and applies this threshold to persons living with HIV/AIDS who seek admission to Canada.

Methods: A hypothetical cohort of immigrants living with HIV/AIDS was simulated for three time horizons (5-years, 10-years, and lifetime) using a Markov model. Disease progression probabilities and costs were derived from the literature. This model was used to yield direct health system cost estimates by age, sex, HIV/AIDS disease progression (as assessed using CD4 cell counts) and the time horizon for assessment. Costs were presented in 2007 Canadian dollars and discounted at 2 percent to yield present values. These cost estimates for prospective immigrants were then compared to both the current threshold for excessive demand on health care services used by Citizenship and Immigration Canada and new proposed thresholds that were based on assumptions concerning the distribution of health care costs, and its mean and relative variance. These new cost thresholds were constructed to distinguish (statistically) immigrants with cost profiles that werer significantly higher than that for a representative Canadian.

Results: This paper offers three substantive findings. First, there is an inverse relationship between disease progression (measured by CD4 cell counts) and health care costs, with annual costs increasing from under $8,000 for CD4 > 500 cells/mm3 to over $35,000 for CD4 < 100 cells/mm3. Second, the current cost threshold used by Immigration Canada to assess whether an immigration applicant is likely to pose “excessive” demand ($4,867.40/yr Cdn dollars) is too low. A statistically more appropriate threshold is three-fold greater at $14,581.43/year. Finally, application of these cost estimates to the revised cost threshold for inadmissibility yields classification based on individual characteristics, including age, sex and health status, as well as on the time horizon over which each applicant’s projected demand is assessed. “Excessive” demand is more likely to occur for applicants with low CD4 cell counts and a shorter time horizon for assessment (i.e., 5-years versus their lifetime). Women and younger applicants are slightly more likely to be deemed inadmissible than men and older immigration applicants.

Conclusion: Too many immigration applicants with HIV/AIDS are being denied admission to Canada due to the current rules used by Immigration Canada. Application of evidence-informed estimates of the cost of HIV/AIDS and a more appropriate statistical threshold for immigration denials would allow for more admissions. Even with the revised guidelines, many prospective immigrants with HIV/AIDS will still be denied admission if they have a low (<200) CD4 cell count.