1. 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

2. 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

3. 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

4. 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

5. Who is a migrant?

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

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

8. 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

9. 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

10. 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

13. 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

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

15. 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

18. 53% of the HIV reports from LAC 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

19. 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

20. 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

21. 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

22. Pre and post-migration HIV acquisition
aMASE

23. 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?

24. 68% men 36 years median age 2249 migrants living with HIV 46% MSM
We finally performed interviews, 68% in men with a median near to 38 years old

25. 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.

26. 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

27. 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

28. 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

29. 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

30. 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.

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 Dublin Declaration monitoring 2018; validated unpublished data.

32. 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