An analysis of over 150,000 people living with HIV in eleven western European countries shows that people born abroad are more likely to start HIV treatment with a lower CD4 cell count, especially men coming from African or Caribbean countries.
“Later cART [combination antiretroviral therapy] initiation in migrants can result in worse health outcomes, but is also of public health concern, as it facilitates ongoing transmission of HIV within the community,” write the researchers in an article published online ahead of print in AIDS.
In western Europe, 41% of people diagnosed with HIV were born in a different country. Barriers to healthcare for migrants include social exclusion, language difficulties, economic instability, geographic mobility and policies which restrict access to publicly subsidised health services. Confusion and uncertainty about eligibility discourages some migrants from engaging with healthcare or means that healthcare professionals deny care to people who are in fact eligible.
Data were pooled from 24 observational cohort studies of people with HIV attending routine clinical care in Austria, Belgium, Denmark, France, Germany, Greece, Italy, the Netherlands, Spain, Switzerland and the United Kingdom. Data were collected from 1997 to 2013.
All cohorts recorded information on participants’ geographical origin. Two exceptions were the Swiss and UK cohorts – in these cases, ethnicity was used as a proxy for geographical origin (for example assuming that people of black Caribbean ethnicity were born in the Caribbean, or that white people were born in the country they were diagnosed in). This is obviously imprecise but excluding these studies from the data did not substantially change the results.
Of the 110,592 men included, 22% were migrants. Significant numbers of men came from sub-Saharan Africa (9.4% of all men), Latin America (3.8%) and western European and other western countries (2.5%).
Of the 41,082 women included, 52% were migrants. Large numbers came from sub-Saharan Africa (39.4% of all women) as well as the Caribbean (3.4%).
The researchers looked at median CD4 counts for individuals starting HIV treatment, according to geographical origin. As the data stretch back two decades, the averages are lower than might be expected today.
Findings differed between men and women. The average CD4 counts for men starting treatment were:
- Native men: 230 cells/mm3
- Eastern Europe: 230 cells/mm3
- Latin America: 220 cells/mm3
- Western Europe and other western countries: 206 cells/mm3
- Asia & Oceania: 194 cells/mm3
- North Africa and the Middle East: 190 cells/mm3
- Sub-Saharan Africa: 161 cells/mm3
- Caribbean: 161 cells/mm3.
The lower probability of starting treatment was particularly marked for migrant men who were diagnosed or entered the cohort with a high CD4 count. Compared to native men with a CD4 cell count over 500 cells/mm3, Caribbean men with the same CD4 cell count were 45% less likely to start ART, Eastern European men were 30% less likely, and African men 25% less likely.
The differences were not as large for women. The researchers say this is probably due to women being tested and starting ART during pregnancy. Median CD4 counts for women starting HIV treatment were:
- Eastern Europe: 236 cells/mm3
- Native women: 235 cells/mm3
- Caribbean: 225 cells/mm3
- North Africa and the Middle East: 223 cells/mm3
- Western Europe and other western countries: 220 cells/mm3
- Sub-Saharan Africa: 205 cells/mm3
- Latin America: 203 cells/mm3
- Asia & Oceania: 185 cells/mm3.
“Addressing existing barriers to access HIV testing and care, and ensuring universal and free access to cART is important if we are to advance the elimination of inequities and in the control of the HIV epidemic in Western Europe,” conclude the researchers.
The Migrant Health Working Group for the Collaboration of Observational HIV Epidemiological Research in Europe (COHERE) in EuroCoord. Timing of cART initiation in Male and Female Migrants Living with HIV in Western Europe: an observational cohort study (1997-2013). AIDS, online ahead of print, 2017.