HIV-AIDS in migrant populations in Europeepidemiology, testing strategies and access to antiretroviral treatment

Zusammenfassung

Introduction: HIV is a major public health problem in the European Union (EU) and the European Economic Area (EEA). The HIV epidemic in the EU/EEA is predominantly masculine and its epidemiological characteristics vary within the different regions that conform the EU/EEA. While in Central and Western Europe the transmission among men who have sex with men (MSM) and heterosexuals is the most prevalent route of infection, in the Eastern European countries heterosexuals and intravenous drug users (IDU) are the most affected groups. Migrant populations are exposed to experiences that could potentially affect their health in a negative way; they face greater vulnerability to HIV infections and its consequences and face specific barriers to access health care. Objetives: The objective of this Doctoral Thesis is to analyse the HIV epidemic in migrant populations in the EU/EEA, as well as the strategies developed by the countries to increase HIV testing uptake. Finally, our position regarding the importance of real access to antiretroviral therapy (ART) by this population is stated. Methodology: A search of national policy documents and a survey to EU countries representatives was conducted to analyse national policies on HIV testing in migrant population. The documents published by different international organizations (IOs) on HIV testing were reviewed to assess specific recommendations for migrants and ethnic minorities. Furthermore, a systematic review of the available scientific literature was developed to analyse the barriers to HIV testing and access to health care and prevalence of HIV testing in migrants. In addition, a qualitative study was conducted with key informants to identify challenges in the implementation of these policies and propose innovative interventions to promote HIV testing. European Surveillance data on new HIV diagnosis in the EU/EEA were analysed according to geographical origin and sex to determine the relative importance of this group in the epidemic. Finally, the available information on magnitudes and trends of migrant population recorded in European data sources such as Eurostat were analysed. The availability of ART since 1996 has been a turning point in the HIV epidemic in Europe. Results: Many countries acknowledge the benefits of early diagnosis in their policy documents, both at individual and at community level and most of them identify migrants as vulnerable populations to HIV infection and its consequences. This vulnerability is related to social, economic and legal issues, as well as cultural differences and gender imbalances. However, not all countries specifically recommend HIV testing in migrants. International Organizations such as UNAIDS, recognize the importance of HIV testing in migrant population and emphasize the need to link HIV testing with universal access to ART. In addition, IOs unequivocally indicate the test must always be voluntary and with informed consent, and call against mandatory testing practices at the country entry done in some places. The main barriers to access health care and HIV testing are related to poverty, low social status and inequality, and to the fear that the test results may negatively affect their visa application. HIV testing rates varies greatly in the different studies analysed. Specific initiatives aimed at increasing HIV testing in this population, especially those that take place in community settings, are proposed. HIV testing strategies targeting specific groups are able to reach individuals at high risk, but are perceived as discriminatory. While general population HIV testing strategies are more likely to prevent discrimination, they may not reach some groups of migrants. In general, the importance of developing innovative strategies and using community settings to increase the number of HIV tests conducted in migrants are stressed. Migrants account for two-fifths of new HIV diagnoses in the EU/EEA. The relative and absolute numbers show a decline in new HIV reports between 2007 and 2012 which may be reflecting a true decline in the number of infections or a decrease in the number of the HIV tests performed or a decrease in the number of migrants. In Western Europe, migrants from Sub-Saharan Africa, Latin America and other Western European countries are the most common among new HIV infections, while migrants from Eastern Europe are the most common in Central Europe. Regarding population registries, available data on cumulative numbers of migrants are heterogeneous and incomplete and do not allow to confirm what has happened with migrant flows in the current scenario of financial constraints. However, migrant flows show a deceleration and this could be one of the explanations for the decrease in the number of new HIV diagnoses in migrant populations. Conclusions:These results are key to understand the specific vulnerability to HIV of migrants in order to develop policies aimed at promoting HIV testing and to ensure access to ART in these populations.