Men from Latin America and central Europe now outnumber sub-Saharan Africans in HIV diagnoses in European migrants

Swedish study finds doctors underestimate proportion of infections caught after migration

The latest figures from the European Centre for Disease Control (ECDC), presented at the recent HIV in Europe HepHIV2017 meeting in Malta, show that while in the last ten years in Europe the proportion of people with HIV who are not from the country where they are diagnosed has hardly changed, the makeup of the migrant population has. Although sub-Saharan Africans still form the largest regional population, diagnoses (in countries that document ethnicity adequately) in migrants from Latin America and the Caribbean, and intra-European migrants from central and eastern Europe, now comfortably outnumber new diagnoses in sub-Saharan Africans.

Julia del Amo, from the National Center for Epidemiology in Spain, told the conference that the annual number of HIV diagnoses has been falling in sub-Saharan Africans since 2008 and is now in steep decline.

In the migrant groups in which HIV is increasing most diagnoses are in men and most of those in men who have sex with men. HIV diagnoses among Latin American men seem to have peaked around 2010-11 and may be starting to decline. But diagnoses in migrants from central Europe – the former communist countries from Poland south to the Balkans, plus Turkey – are continuing to rise, as are the smaller number of migrants from eastern Europe (the former USSR). In addition, migrants from western European countries also form a considerable proportion of diagnoses among non-natives, though these are not increasing significantly.

Glossary

90-90-90 target

A target set by the Joint United Nations Programme on HIV/AIDS (UNAIDS) for 90% of people with HIV to be diagnosed, 90% of diagnosed people to be taking treatment, and 90% of people on treatment to have an undetectable viral load. 

mathematical models

A range of complex mathematical techniques which aim to simulate a sequence of likely future events, in order to estimate the impact of a health intervention or the spread of an infection.

epidemiology

The study of the causes of a disease, its distribution within a population, and measures for control and prevention. Epidemiology focuses on groups rather than individuals.

virological suppression

Halting of the function or replication of a virus. In HIV, optimal viral suppression is measured as the reduction of viral load (HIV RNA) to undetectable levels and is the goal of antiretroviral therapy.

Johanna Brönnström from Sweden’s Karolinska Institute said that in terms of prevalence, the proportion of people living with HIV in European countries who are migrants varies from 1% in Romania to 75% in Sweden, and in all countries but Sweden and France, sub-Saharan Africans now form a minority of those migrants.

Over Europe as a whole, the proportion of HIV diagnoses that occur in people not born in the country of diagnosis is 38%, and this proportion has hardly changed in the last ten years. But Julia del Amo said that while diagnoses in sub-Saharan Africans (most of them in the UK) fell from 2250 in 2007 to 1600 in 2012, diagnoses among people from Latin America and the Caribbean rose from 730 in 2007 to 1300 in 2010 before falling to 900 in 2012. Diagnoses in people from central Europe rose from 300 in 2007 to 600 in 2012, and from eastern Europe from 100 to 300 in the same period. Diagnoses among migrants from western Europe have stayed steady at about 800 a year during that time.

Between 2004 and 2013, a total of 252,609 people were diagnosed in Europe. Six per cent (14,621) were from Latin America and the Caribbean (LAC) and 8% (19,452) from a European country other than the one they were diagnosed in.

Thirty-seven per cent of diagnoses in people from LAC countries were in Spain or Portugal (reflecting these countries’ ties with the region), 20% in the UK, and 18% in France. A third of diagnoses in people from other European countries were in the UK, 13% in Germany, 10% in Spain and 7% in France.

Five times as many men from the South American continent (as opposed to the Caribbean or central America) were diagnosed as women, and of those men, more than three-quarters were men who have sex with men (MSM). Diagnoses in men from South America increased from 320 in 2004 to 1070 in 2013. After this, there are signs of a fall, with 850 diagnoses in 2012. In contrast, diagnoses from central America and the Caribbean were somewhat less likely to be among men, and male diagnoses have not increased since 2004. Among women, the majority of women diagnosed from this part of the world were from the Caribbean; and female diagnoses from that region fell from 225 in 2004 to 120 in 2013.

Among intra-European migrants, diagnoses in men increased from 960 to 1950 between 2004 and 2013. The majority of these were from western Europe but the biggest proportional increase, from 160 to 610, was in men from central Europe. Three-quarters of men from western Europe and over half from central Europe were MSM, but only one quarter from eastern Europe. Diagnoses in women from central and eastern Europe rose too, from (taking both regions together) 140 in 2004 to 660 in 2012. Diagnoses in women from western Europe fell, from 150 to 120.

The proportion of migrants diagnosed late fell in migrants from western Europe but rose in migrants from central and eastern Europe: the average CD4 count at diagnosis rose from approximately 350 to 450 cells/mm3 in migrants from western Europe but fell from 430 to 320 cells/mm3 in central and eastern Europeans.

Some of this may be due to delays in establishing treatment eligibility, and Julia del Amo commented on the disarray in Europe on treatment policy for immigrants with HIV, and particularly undocumented immigrants. In the Nordic countries, for instance, Sweden provides access to antiretroviral therapy to undocumented migrants, but other countries do not; in the Baltic countries, Lithuania and Estonia do but Latvia does not; in central Europe, Hungary does (despite its hostility to migrants in other ways), but other countries do not; and among western European countries, most do but Germany and Austria do not.

Speaking of Sweden, Johanna Brönnström exposed a paradox. Sweden was the first country in the world to show that it had achieved the UNAIDS 90-90-90 target of 71.9% people with HIV on treatment and virally suppressed. And yet in Europe it also has one of the highest proportions of people diagnosed late; over 50% of people diagnosed with HIV in Sweden have a CD4 count of below 350 cells/mm3, as opposed to 30-40% in the UK. This is mainly due to the fact that such a high proportion of people diagnosed with HIV in Sweden are migrants – 75% compared with the EU average of 37% (47% in the UK) – and Sweden is one of the few countries where the majority of migrants with HIV are still people from sub-Saharan Africa.

It might be assumed that this shows that people are mainly becoming infected with HIV in their country of origin and only testing when they reach the safety of Sweden. This is true in the majority of cases, but computer modelling of CD4 counts, which allows back-calculation to the estimated time of infection, shows that doctors tend to underestimate the proportion of migrants with HIV who actually caught HIV in Sweden. Whereas physicians estimated that only 8.5% of migrants with HIV caught it after migrating to Sweden, the CD4 trajectories showed that the true figure was closer to 20%.

References

Del Amo J et al. HIV diagnoses in migrants from Western, Central and Eastern Europe in the EU/EEA; emerging epidemics and HIV diagnoses in migrants from Latin America & Caribbean in Europe; distinct epidemics. Abstract PS2/01, HIV in Europe HepHIV2017 Conference, Malta, 2017. See presentation here.

Bränströmm J et al. A high rate of HIV-1 acquisition post immigration among migrants in Sweden determined by a CD4+ T-cell decline trajectory model indicates missed opportunities for testing and primary prevention. Abstract PS2/02, HIV in Europe HepHIV2017 Conference, Malta, 2017.