Nearly four out of every ten people with HIV in the European Economic Area (EEA) is a migrant to the country in which they are diagnosed, a recent report by the Spanish Centre for Epidemiology shows. The EEA comprises the countries of the EU plus Norway and Iceland.
Between 2007 and 2012, 60,446 out of 156,817 new cases of HIV (38%) were in people who were not native to the country where they were diagnosed. Nearly all HIV-positive migrants are concentrated in the richer countries of western Europe, with only 5% of diagnoses in central Europe and 1% in eastern Europe being migrants.
The UK remains the European country with the highest number of HIV diagnosed in migrants: 6358 people diagnosed in the UK in 2012 were known not to have been born there, though this represents a decline of 1000 since 2007. France comes next on the list with 4066 people in 2012, though their diagnoses have fallen even further since 2007, by 1600. In contrast, the next six countries on the list – Italy, Spain, Germany, Belgium, Greece and Poland – have all seen increases in the number of migrants diagnosed with HIV, with figures doubling in Italy and Greece, probably reflecting the new wave of trans-Mediterranean migration.
It is important to note that these figures did not include 30,000 people whose country of origin could not be established. This report also cannot establish whether people acquired HIV in their native country or after they migrated.
The proportion of newly diagnosed people who are migrants fell from 40% to 35% between 2007 and 2012, the report shows. This is largely due to falls in HIV prevalence among people of sub-Saharan African origin. While the biggest group of newly diagnosed migrants is still from sub-Saharan Africa, the proportion is falling, especially in women. The number of new diagnoses in African women fell by 37% between 2007 and 2012.
However, largely because African women still form the largest single group of migrants diagnosed with HIV, 43% of migrants with HIV in 2012 were women compared with 16% of non-migrants, and 53% of newly diagnosed people of non-native origin in the EEA were from sub-Saharan Africa.
Twenty-one per cent were from other European countries, of whom 9%, 7% and 4% were from western, central and eastern Europe respectively. Twelve per cent came from Latin America, 5% from south and southeast Asia, 4% from the Caribbean, 3% from north Africa and the middle east, and small numbers from east Asia, North America, Australia and New Zealand.
In contrast to sub-Saharan Africa, the proportion of people with HIV from some other parts of the world has increased, even if populations from other areas remain smaller than people of African origin. Between 2007 and 2010, there was a considerable increase in the proportion of newly diagnosed people, both men and women, that came from Latin America. This has significantly declined in the last few years however, partly due to austerity-related changes in healthcare entitlement in Spain, the country with by far the highest number of HIV-positive migrants from this region.
More recently, there have been significant increases, especially among men, in the proportion diagnosed who come from the former-Communist countries of central Europe, and among women from both central and eastern Europe. In men, there are also smaller but increasing proportions from south and south-east Asia and from north Africa and the Middle East.
Many of these are gay men and other men who have sex with men (MSM) and HIV diagnoses among MSM increased by 28%, in line with a general increase in MSM diagnoses, between 2007 and 2012. In terms of immigrants from eastern Europe, a ‘non-negligible’ proportion of these are people who inject drugs, reflecting, according to the authors, an upsurge in cases of HIV in people who inject drugs in Romania and Greece during these years.
In 2012, for the first time since at least 1999, the number of new diagnoses among migrant MSM was larger (2459) than it was among sub-Saharan African women (2354). Throughout the EEA, almost exactly 50% of non-migrant people with new HIV diagnoses in 2012 was an MSM. Areas of origin where the proportion who are MSM is lower than 50% include central Europe, south and southeast Asia, the Caribbean, north Africa and the middle east, eastern Europe and sub-Saharan Africa; in contrast more than 50% of diagnoses were in MSM in migrants from east Asia, Latin America, western Europe, and the small number of migrants from North America, Australia and New Zealand.
Migrants diagnosed with HIV tend to be younger than non-migrants. The average age at HIV diagnosis in the EEA was 38 in men and 34 in women. Among nearly all groups of migrants it was lower. In men, migrants from central and eastern Europe and Latin America had an average age of 32-33; in women, migrants from central and eastern Europe were aged 29-30 on average.
Nearly all groups of migrants, with the exception of those from high-income countries, were more likely to be diagnosed late (defined as with a CD4 count of less than 350 cells/mm3). In non-migrants in the EEA the average CD4 count on diagnosis was 379 cells/mm3; in migrants it was 304 cells/mm3, and in women lower than this at 290 cells/mm3. Men from sub-Saharan Africa remain the group who are diagnosed with the lowest CD4 counts, at 240 cells/mm3. In women, south and south-east Asians were most likely to be diagnosed late, at 259 cells/mm3. Sub-Saharan Africans were 60% more likely to be diagnosed late than non-migrants, and so were Latin Americans. Some smaller groups were at even more risk and even though numerically there were fewer of them, both east Asians and south and southeast Asians were more than twice as likely to be diagnosed late than non-migrants.
Legal barriers to healthcare for migrants in Europe
One reason for late diagnosis among migrants could be difficulties in accessing healthcare or understanding how to navigate different systems in Europe. A 168-page report on legal access to healthcare in nine EU countries plus Switzerland, Turkey and Quebec in Canada by the French organisation Médecins du Monde finds a complexity of different healthcare systems and barriers to healthcare for migrants, especially undocumented migrants.
The barriers are different in different countries, it finds. In some countries with previously universal access, austerity has led to ill-considered legislation that has suddenly excluded migrants from care or even criminalised certain groups (examples include Greece and Spain); in many countries that have a universal healthcare framework but provision by private or mutual companies, the requirement to prove addresses (France, Belgium) or tax status (Switzerland) puts many migrants off seeking care; Germany has a particularly repressive requirement that any public body, including hospitals, must report suspected undocumented migrants; while Turkey is an example of a country that has been trying to establish a national healthcare system but still does not pay for HIV treatment and finds itself with a sudden refugee crisis.
In a number of countries, including the UK and Spain, legal challenge to laws that excluded migrants from healthcare have been at least partly successful, though the report documents both confusion among healthcare providers as to the state of the law, and bureaucratic disputes between national, local and private bodies as to who is responsible for enforcing decisions. Since 2012, the UK has had relatively good provision for undocumented migrants, largely because there is no bureaucratic requirement for GPs to report patients to insurance or legal bodies; but the UK scores badly on its harsh treatment of the relatively small number of migrants with serious health problems who are forcibly removed.
Do exclusion policies have a long-term impact on migrants’ health?
Finally, a small but suggestive French/Dutch/Danish collaboration finds links between migrants’ legal status and their mortality. Using a score (MIPEX) that measures the relative degree to which immigrants are able to legally integrate into their host country, it divides European counties into ones with three different legal climates:
- “Integrative” countries like the UK, Netherlands and Sweden, where migrants are allowed to attain citizenship and other legal status but where a multicultural attitude allows them to maintain their own ethnic identity and communities;
“Exclusionist” countries like Austria, Denmark, Greece and Germany, that restrict citizenship even to long-term immigrants, regarding then as a workforce rather than as citizens and enshrining other inequalities in law;
“Assimilationist” countries like France and, latterly, Switzerland, that allow citizenship to be attained but also expect immigrants to blend their culture with their host country’s and have a lower tolerance of multiculturalism (it was noted that Germany has been moving to a more assimilationist model).
Taking the Netherlands, Denmark and France as respective examples of these three climates, the researchers studied causes of death from a number of different causes ranging from infectious disease through cardiovascular disease and cancer to accidents and suicide. They used the Turkish and Moroccan immigrant communities as examples because these both had fair representation in all three countries. Based on previous studies, they hypothesised that immigrant mortality would be higher in exclusionist and lower in integrative countries than average, and that differential mortality would be concentrated among young people, men, and people who died by accidents and suicide.
They did find a strikingly higher mortality rate among immigrants in Denmark: over twice that of the general population. However, immigrant mortality in France was in fact lower than it was in the Netherlands, and lower than in the general population. Differential mortality was more marked in men, but in middle-aged (45-69) men rather than young men: and it was cardiovascular disease, rather than accidents or suicide, that was the most disproportionate cause of death in migrants.
The researchers comment that their main finding supports the idea that a “restrictive turn in immigration policy, politics and social climate may contribute to higher mortality rates of…immigrants” but also suggest that this mainly operates via long-term stress and poor healthcare rather than via acute stress, poor mental health and violence.
Hernando V et al. HIV infection in migrant populations in the European Union and European Economic Area in 2007-2012; an epidemic on the move. JAIDS, early online publication: doi: 10.1097/QAI.0000000000000717. See abstract here. June 2015.
Médecins du Monde Legal Report on Access to Healthcare in 12 Countries. See https://mdmeuroblog.files.wordpress.com/2014/05/mdm-legal-report-on-access-to-healthcare-in-12-countries-3rd-june-20151.pdf
Ikram UZ et al. Associations between integration policies and immigrants’ mortality: an explorative study across three European countries. PLOS One 10(6): e0129916. doi: 10.1371/journal.pone.0129916