Undocumented migrants more likely to be lost to follow-up and have poor virological outcomes after starting ART, Milan study confirms

Undocumented migrants living with HIV have especially poor rates of retention in care and virological suppression after starting antiretroviral therapy (ART), investigators from Italy report in the online edition of the Journal of Acquired Immune Deficiency Syndromes. The single-centre study compared outcomes according to migration and residency status among people starting HIV therapy in Milan between 2001 and 2013. Undocumented migrants were more likely to be lost to follow-up and both documented and undocumented migrants were less likely to attain virological suppression compared to Italian citizens.

A significant proportion of the migrants receiving care at the clinic were from Latin America, and many were trans women. “A high proportion faced problems related to the clandestine nature and gender identity that put them at higher risk of stigma, poverty, social marginalisation, and psychological distress,” suggest the authors. “The interplay of these multiple vulnerabilities may at least partially explain the patients’ poorer adherence to cART [combination antiretroviral therapy] and their poorer virological outcomes.”

In 2013, an estimated 27% of new HIV diagnoses in Italy involved migrants, a figure reflective of wider European trends. Previous research suggests that migrants often have poorer outcomes, such as retention in care and viral suppression after starting treatment, compared to non-migrant populations.


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.

retention in care

A patient’s regular and ongoing engagement with medical care at a health care facility. 


An umbrella term for people whose gender identity and/or gender expression differs from the sex they were assigned at birth.

adjusted odds ratio (AOR)

Comparing one group with another, expresses differences in the odds of something happening. An odds ratio above 1 means something is more likely to happen in the group of interest; an odds ratio below 1 means it is less likely to happen. Similar to ‘relative risk’. 

loss to follow up

In a research study, participants who drop out before the end of the study. In routine clinical care, patients who do not attend medical appointments and who cannot be contacted.

Investigators from the University of Milan wanted to see if legal status was a factor in the poorer outcomes seen for some migrants.

They designed a study involving people who started HIV therapy at the Luigi Sacco Hospital between 2001 and 2013. The main outcomes were retention in care and viral suppression twelve months after starting HIV therapy.

The study population consisted of 885 people, 245 (28%) of whom were migrants, with 77 migrants (31%) lacking documentation. Special arrangements mean that undocumented migrants are able to access free urgent and essential health care in Italy, including for the treatment of infectious diseases.

The migrants mainly came from Latin America (83 documented and 56 undocumented), sub-Saharan Africa (52 documented and 11 undocumented), with a minority from other regions including Asia, Central and Eastern Europe and North Africa (33 documented and 10 undocumented).

Overall, 53% of undocumented migrants were trans women.

Migrants from Latin America were especially likely to be men who have sex with men or trans women (47% and 91% undocumented respectively).

There were no significant differences between Italian citizens, documented migrants and undocumented migrants in terms of HIV disease stage or CD4 cell count at the time antiretroviral therapy was started.

A year after starting treatment, 696 patients (79%) were still in care and receiving regular follow-up at the clinic. Of the other patients, 2% had died, 5% had transferred to another treatment centre and 15% were not being regularly followed up.

The proportion of patients retained in follow-up was significantly lower among undocumented migrants (65%) compared to documented migrants (83%) and Italian citizens (79%) (comparison: p = 0.004).

Undocumented migrants were also significantly more likely to have missing data compared to both documented migrants and Italian citizens (28 vs 14 vs 13%), reflecting missed clinic visits. Moreover, undocumented migrants were the group most likely to be lost to follow-up (19 vs 4 vs 4%, p < 0.001).

Statistical analysis controlling for potential confounders showed that undocumented migrants status (aOR 8.05; 95% CI, 2.51-25.84, p < 0.001) was independently associated with an increased risk of being lost to follow-up.

Of the people who remained in care, 610 (88%) had an undetectable viral load twelve months after starting HIV therapy. The proportion with viral suppression was significantly lower among undocumented (78%) and documented (81%) migrants compared to Italian citizens (91%) (comparison: p = 0.001).

After controlling for confounders, patients from Latin America were significantly less likely than Italian citizens to have viral suppression (aOR = 0.30; 95% CI, 0.12-0.75, p = 0.011).

Analysis also showed a significant association between lack of legal migration status and worse virological outcome (aOR = 0.39; 95% CI, 0.20-0.75, p = 0.005).

“Despite their free access to ART, subgroups of migrants at higher levels of social vulnerability (including undocumented transgender sex workers) may still have difficulties in gaining access to optimal HIV care, and the consequences of failing to provide them this care may be considerable in both clinical and preventive terms,” conclude the authors. “It is therefore necessary to implement a patient-centred approach to cART [combination antiretroviral therapy] provision based on relationships of trust and the intervention of social workers and intercultural mediators in order to make it easier for more socially vulnerable populations to obtain continuous and effective HIV treatment.”


Ridolfo AL et al. Effect of legal status on the early treatment outcomes of migrants beginning combined antiretroviral therapy at an outpatient clinic in Milan, Italy. J Acquir Immune Defic Syndr, online edition. DOI: 10.1097/QAI.0000000000001388 (2017).