Migrants, ethnic minorities, drug use and HIV Lucas Wiessing, EMCDDA, Lisbon, 7 June 2007

HIV prevalence among IDUs in the EU, samples with national and sub-national coverage Notes: Data in [brackets] are sub-national Colour indicates midpoint of national data or if not available sub-national data Data Ireland 2003; Latvia 2003; Slovakia and from 2006 in case of Spain and Sweden < 5% 5% or higher not available

HIV prevalence among injecting drug users – national and subnational studies

HIV prevalence in samples of IDUs (‘all’) and in the subgroup of IDUs under age 25 (‘young’)

Some questions Are IDUs among migrants or ethnic minorities at higher risk than other IDUs? What is the impact of migration on the IDU - HIV epidemics in the EU? Do migrants or ethnic minorities have equal access to prevention and treatment? Should we collect data on migrant/ethnic status of IDUs? And if yes how?

‘Social exclusion, drugs and minorities in the EU’ (EMCDDA 2000) Assimilated minorities ‘Nomadic’ minorities Jewish communities ‘Visible’ minorities Recent arrivals -> much heterogeneity

Ethnic minorities and drug use (EMCDDA 2007) Most studies show similar or lower levels of drug use A larger gender gap, particularly for non-Western migrants However, greater risk of developing drug use problems (McCambridge and Strang 2005) In turn, drug problems can reinforce social exclusion Sometimes different patterns of drug use, e.g. khat among Somalians in England and northern Europe and the aversion to injection among Surinamese in the Netherlands (EMCDDA 2002; EMCDDA 2001).

Roma and HIV risks Two studies in Spain (prisoners, IDUs -1995) showed a significantly lower seroprevalence of HIV among Roma than non-Roma inmates [data refer to periods and 1995 respectively, both in Spain: Martin-Sanchez V, 1997; Martin V, 1998; citation in Hajioff S & McKee M 2000] Among 324 men in a Roma community in Sofia, Bulgaria, 72% had had anal sex with women and 10% with men in the past 3 months, frequently unprotected; 16% reported selling sex and 32% paying someone for sex [Kabakchieva E et al. 2002; cited in Hamers F et al ]

Discrimination from within: nine qualitative interviews with Bengali women in drug treatment, London Bengali female drug users are a hidden population engaging in high-risk behaviours, especially unsafe sex Shame about drug use, antipathy towards injecting and stigmatization of drug use Gender role expectations are strong and they face greater gender discrimination from within their community regarding drug use than their counterpart males They experience profound barriers to treatment, which prevent them from accessing services at an earlier stage in their drug use [Cottew & Oyefeso, 2005]

EuroHIV – ‘Country of origin’ of HIV+ IDUs Data for 2005 from 15 EU countries (54%) 1462 IDU cases, 204 with different country of origin (12%) 64 of the 204 come from ‘the West’ (WHO region), 65 come from ‘the East’, 8 from ‘the Centre’, thus the majority migrated within the European region High proportions of ‘HIV+ IDU from other country of origin’ are found in countries with low rates of HIV in IDUs Caution in interpretation: Country of birth, nationality, country of probable infection… many missing data Source EuroHIV

HIV-IDU cases reported in 2005 in EU countries where data are available on ‘country of origin’ Source: EuroHIV Note: Lux excluded

HIV in IDUs in low prevalence EU countries Czech Republic: currently finding very high prevalence among Russian speaking IDUs Slovak Republic: only 5 IDU cases to date, however most were likely infected abroad [L. Okruhlica pers. comm. 2007] UK: HIV in IDUs perhaps increasing? large proportion of imported cases (from southern Europe) Estonia was low prevalence country for IDUs up to 2000, then explosive spread among Russian speaking IDUs Estonia had no harm reduction measures in place…

Molecular typing of HIV in IDUs: Estonia, Northwestern Russia Estonian outbreak caused by simultaneous introduction of two strains, one subtype A very similar to Eastern European strain (~8% of cases) and another similar to African strains (77%). Small variability in Estonia suggests point source introductions [Zetterberg et al. 2004] HIV in IDUs in Northwestern Russia closely linked to other Russian IDU epidemics [Smolskaya etal. 2006]

Access to health care Disparities in HIV-related mortality due to lower access to HAART of people with lower socio- economic status, female gender, ethnic minorities, and IDUs [Wood E et al. 2003] Education and health literacy are important factors in HIV-treatment adherence and access to medical care [Kalichman 1999] Likely also: insurance, legal status of migrants

Discussion Is it useful to distinguish people by ethnicity, migrant status? This will depend on activity, policy in question If intended to improve situation, probably yes But, policies and attitudes to migrants can change from positive to negative Country of birth, nationality, perhaps less sensitive Ethnicity, race, religion… perhaps better collect unlinked and anonymously

Need to know at national level: Are migrants / ethnic minorities at higher risk of specific health problems (IDU, HIV, other)? Are the standard data collection systems sensitive enough to provide reliable data? Is there a need for additional targeted (ethnographic) studies, prevention or treatment programmes, other services?

Conclusions Data lacking and defining these groups is difficult Drug use in migrants not necessarily higher Immigration of HIV+ IDUs may have significant impact, but only on low level epidemics, and outbreak risk depends on prevention coverage Access to services generally lower? (few data) Collect sensitive data unlinked & anonymous and combine with repeated (ethnographic) surveys

Acknowledgements Anthony Nardone, EuroHIV Valerie Delpeche Linda Montanari Lubomir Okruhlica