Social, structural, behavioural and biological factors potentiating STI epidemics Migrants Dr Julia del Amo National Center for Epidemiology Institute of Health Carlos III Madrid, Spain

Julia del Amo has received research grants awarded to her institution from Companies BMS, Gilead, ViiV and epidemiology teaching fees from ViiV, Gilead and MSD

Outline Heterogeneity of migrant populations Different HIV epidemics among migrants in the EU Factors driving post-migration acquisition of HIV in the EU Structural barriers to access to testing & treatment in the EU

Outline Heterogeneity of migrant populations Different HIV epidemics among migrants in the EU Factors driving post-migration acquisition of HIV in the EU Structural barriers to access to testing & treatment in the EU

Who is a migrant?

Heterogeneous groups of persons with different migration drivers Who is a migrant? Heterogeneous groups of persons with different migration drivers

Who is a migrant? Heterogeneous groups of persons with different migration drivers Distinct risk-contexts for HIV and STIs infections

Individual characteristics (sex, age or country of origin) Economic deprivation & transactional sex Social inequity However, different factors put Migrants at an increased risk for HIV. In fact, migrant populations suffer an increased risk of HIV related to their individuals characteristics, economic deprivation, social inequality and human rights abuses, Human rights abuses & sex trade Homophobia, xenophobia, racism

Individual characteristics (sex, age or country of origin) Strong gender axis Economic deprivation Social inequity However, different factors put Migrants at an increased risk for HIV. In fact, migrant populations suffer an increased risk of HIV related to their individuals characteristics, economic deprivation, social inequality and human rights abuses, Human rights abuses Homophobia, xenophobia, racism

Outline Heterogeneity of migrant populations Different HIV epidemics among migrants in the EU Factors driving post-migration acquisition of HIV in the EU Structural barriers to access to testing & treatment in the EU

Proportion HIV diagnoses in migrants* by country of report, EU/EEA 2016 40% Source: ECDC/WHO (2017). HIV/AIDS Surveillance in Europe 2017– 2016 data

Heterosexual migrants New HIV diagnoses, by year of diagnosis, transmission and migration status, EU/EEA, 2007-2016 Migrant MSM Heterosexual migrants Migrant IDU Data is adjusted for reporting delay Source: ECDC/WHO (2017). HIV/AIDS Surveillance in Europe 2017– 2016 data

New HIV diagnoses, by year of diagnosis, transmission and migration status, EU/EEA, 2007-2016 Source: ECDC/WHO (2017). HIV/AIDS Surveillance in Europe 2017– 2016 data

53% of the HIV reports from LAC 2004-2015 were MSM; 84% of reports from South America to 46% of reports from the Caribbean Unknown region SA men Andean men MSM from all sub-regions consistently show higher CD4 counts at HIV diagnosis

HIV dynamics in migrants from Central, Eastern and Western Europe in the Europe Union/Economic Area (EU/EEA) In Western, Central and Eastern European migrants, 74%, 57% and 26% of the HIV reports MSM WE men CE men MSM from all sub-regions consistently show higher CD4 counts at HIV diagnosis

Outline Heterogeneity of migrant populations Different HIV epidemics among migrants in the EU Factors driving post-migration acquisition of HIV in the EU Structural barriers to access to testing & treatment in the EU

Those driving HIV in countries of origin Factors underlying high rates of HIV infection Those driving HIV in countries of origin Risk behaviors and risk contexts during migration transit Risk behaviors and risk contexts in countries of destination

Pre and post-migration HIV acquisition aMASE

Before or after migration? Stat Methods Med Res December 2017 CASCADE: repeated mesurements that allow to estimate trends in CD4 and VL after seroconversion. CD4 VL AIDS Sociodemographic characteristics HIV acquisition HIV Diagnosis Starting from the date of diagnosis we performed calculations based on data from Cascade and we calculated date of HIV acquisition and we assess if it was pre or post migration. Before or after migration?

68% men 36 years median age 2249 migrants living with HIV 46% MSM We finally performed 2.117 interviews, 68% in men with a median near to 38 years old

11% 10% 5% 33% 31% 5% 5% Geographical origin Western Central Eastern SSA LA & Caribbean Asia Other 11% 10% 5% 33% 31% 5% 5% The results we will present are based on data of 2143 subjects with preliminary information. 58% were men and a mean age of our sample was 38 y.o. and here you can see the geographical origins. Main origins were SSA and LA and Caribbean with a third each of our sample.

Approx 72% of migrant MSM and 50% heterosexual migrants from SSA acquired HIV post-migration Estimated post-migration HIV acquisition probability (95% CI) by country of destination

MSM were more likely to… To be single To have stable residency status To have higher education & income Higher socio-economic status than heterosexuals and PWID Postmigration HIV acquisition was very high regardless of the method used

Outline Heterogeneity of migrant populations Different HIV epidemics among migrants in the EU Factors driving post-migration acquisition of HIV in the EU Structural barriers to access to testing & treatment in the EU

Barriers to access testing and care in migrants Location of barriers Structural Healthcare Community levels Barriers act in synergy limiting access to, or acceptance of, HIV&STI testing, treatment uptake and responses Nature of barriers Socio-economic inequalities Legal Stigma and discrimination Cultural & linguistic & gender Psychological “low risk perception” They undermines public health approaches for HIV&STI control

Availability of ART for undocumented migrants, 2018 Undocumented migrants face particular difficulties in accessing HIV-related services. Undocumented migrants are more likely to face barriers to prevention, testing, treatment and care, due to lack of legal residence status and health insurance. In many countries, undocumented migrants are only entitled to emergency healthcare and therefore do not have access to long-term HIV treatment. In 2014, 26 out of 46 countries, that is 57% of countries, reported that undocumented migrants DO NOT have access to HIV treatment, care and support. This is unacceptable and does not make any sense from a public health perspective. As we all know, early access to HIV treatment reduces morbidity and mortality significantly. Also, the transmission of HIV is significantly reduced if detected early and treated appropriately. Source: ECDC. From Dublin to Rome: ten years of responding to HIV in Europe and Central Asia: Stockholm, ECDC; 2014 Source: ECDC. Dublin Declaration monitoring 2018; validated unpublished data.

Status of formal PrEP implementation in Europe July, 2018 Source: ECDC. Dublin Declaration monitoring 2018; validated unpublished data.

Outline Global & inclusive strategies in origin & destination Heterogeneity of migrant populations Different HIV epidemics among migrants in the EU Factors driving post-migration acquisition of HIV in the EU Structural barriers to access to testing & treatment in the EU Global & inclusive strategies in origin & destination Increase HIV&STI testing & linkage to care PrEP & comprehensive STIs approach Universal access to ART in Europe … inclusing PrEP