1. HIV and population movements Short & Long term migration and travelling Eleni Kakalou, MD, MSc Athens, January 2012

2. Moving away from established links Loss of cultural norms, taboos, societal control Loss of family & social support Social vulnerability to the host environment Loss of steady sexual partners Access to preventive & care services (cultural, legal, financial & perception barriers) Perception of risk & ‘’bargaining’’ safer sex capacity Internal migration, travelling to visit friends- family, expatriates, military personnel, sex tourism, sexual industry all play a pivotal role in the dynamics of the HIV epidemic Prevalence rates may reflect the risk up-taking in the host country rather than that of origin (both ways South-North direction)

8. Access to diagnosis & care 87% of black men, 85% of Whites and 84% of Carribbean origin with known HIV infection receive ARTs In France foreign born pregnant women showed similar up take of HIV testing and showed the same results once in clinical care 40-70% of MTCT cases in EU27 are found among babies born to non native mothers

9. Late diagnosis

10. Gender issues & sexual concurrency Migrant women disproportionately affected by HIV Gender imbalances, inability to bargain safer sex Sexual concurrency and its contribution to HIV spread (in Norway concurrent sexual contacts were 16.5% among migrants vs 9% among natives)

11. Reasons for no uptake of testing & care services Legal (no papers, fear of expulsion) Social (marginalized, lower social status) Cultural (cultural insensitivity, institutional racism) Poor Communication (linguistic & cultural issues) Risk perception Gender issues Knowledge, attitudes & health seeking behavior

12. The host environment 25-35% of heterosexual migrants LWHA* have acquired HIV infection in UK 50% of MSM migrants LWHA* have acquired HIV infection in UK 77% of LWHA* migrants in Italy have acquired HIV infection in the host country 40-70% of MTCT** occurs among babies born to migrant women (sentinel event) 30% of expats (US Peace Corps, 1080 participants) reported using condom with local partner in high prevalence countries 25% of German expats reported condom use with local partners *LWHA=Living With HIV & AIDS **MTCT=Mother to Child Transmission

13. Tailored approaches to various needs Not all migrants are the same Ethnicity Gender Age Sexual orientation Substance abuse Education Degree of integration Legal and work status

14. Approaches for various sub-groups Provider initiated testing (opt-out) Counseling, education and testing outside health care setting (POC* testing) Culturally sensitive, non-judgmental attitudes Community involvement & empowerment NGO involvement Cultural mediation Social support services Clinical care at community settings * POC=Point of Care

15. Special needs when in care Perception of risk, vulnerability and life expectations Socio-economic context Substance abuse patterns Parenthood expectations Ethical and emotional considerations Sexual practices & taboos Social & self-stigmatization Attitudes to health and clinical care services Misconceptions and disbeliefs Use of alternative medicine approaches

16. Sources Suligoi B., Guliani M. Le Malattie Sessualmente Trasmesse e l’infezione da HIV. In Il Medico ed il Paziente Immigrato (a cura di Pasini W.), 1996: 113-122 Moore J., Beeker C., Harrison J.S., Eng T.R., Doll L.S. HIV risk behaviour among Peace Corps Volunteers. AIDS, 1995; 9: 795-9 Houweling H, De Grave A, Smits SP, et al. HIV infections, needles, ticks and sexual behavior among Deutch expatriates in subSaharan Africa. In: Lobel HO, Steffen R, Kozarsky PE, eds. Travel medicine 2. Proceedings of the Second Conference on International Travel Medicine, Atlanta, GA, May 12-19, 1991. International Society of Travel Medicine, 1992: 204-206. Bonneaux L, van der Suyft P, Tallman H et al. Risk factors for HIV infections among Europeans expatriates in Africa. BMJ 1988; 297:581-584. HPA. Migrant health Infectious diseases in non-UK populations in the UK. An update to the baseline report-2011 FRA. Fundamental Rights of migrants in irregular situations in the European Union ECDC TECHNICAL REPORT. Migrant health: Access to HIV prevention, treatment and care for migrant populations in EU/EEA countries-2009 MG van Veen. Concurrent sexual partenerships & and risk taking among African and Carribean migrants. Int J STD & AIDS