HIV in migrant & mobile populations in

industrialised countries

Chris Lemoh

Monash Infectious Diseases

Refugee Health Service

Global AIDS epidemic

HIV/AIDS in 2012

Number of PLHIV 35.3 million

New HIV infections 2.3 million

AIDS-related deaths

1.6 million

Origins of AIDS epidemic

Key affected populations

• Priority based on:

– Incidence

– Prevalence

– Vulnerability

MIGRANTS?

Key features of combination prevention programmes

Based on local knowledge of transmission routes, context and populations at risk

Structural, biomedical and behavioural actionReduce both immediate risks + underlying vulnerability

Sustainable, multi-level, synergistic strategic interventions

Strategic prioritization of investmentsMeaningful engagement of affected communities

Flexibility to assess and incorporate new knowledge and changing epidemiology

UNAIDS 2010

UN Political Declaration on HIV/AIDS: targets for 2015

1. Reduce sexual HIV transmission by 50%

2. Reduce HIV transmission in PWID by 50%

3. Eliminate new infections in children & substantially reduce maternal AIDS-

related deaths

4. 15 million PLHIV on treatment

5. Reduce TB-associated deaths in PLHIV by 50%

6. Close resource gap: US$ 22–24 billion in low/middle-income countries

7. Eliminate gender inequalities/violence: increase capacity of women & girls to

protect themselves against HIV

8. Eliminate HIV-related stigma & discrimination

9. Eliminate HIV-related restrictions on entry/stay/residence

10. Integrate AIDS response into global health & developmentUN General Assembly 2011

UNAIDS 2011–2015 strategy:

Getting to zero

• Zero new HIV infections

• Zero AIDS-related

deaths

• Zero discrimination

HIV in Australia 1984 – 2012

Kirby Institute (2013)

PLHIV born abroad

Proportion of new HIV diagnoses

Region of birth 2006

2010

2012

Australia 57% 53%

54%

Asia 12% 15%

17%

Sub-Saharan Africa

7% 12%

7%

Diagnosis rate, by region of birth (cases/100 000/year)Australia 4.0 – 4.5Asia 4.3 – 7.0Sub-Saharan Africa 27.3 – 37.1 Kirby Institute 2013

“I keep six honest serving men

(They taught me all I knew);

Their names are What and Why and

When

And How and Where and Who...”

- Rudyard Kipling

Dimensions of mobility , vulnerability and resilience

What What sort of migrants? Categorisation/objectification

Legal status

What resources do they have?

Intellectual and social capital

Where Where to they come from?

Country of origin

Where do they pass through?

Country of transit

Where do they go to? Country of residence

When When did they arrive? Duration

When will they leave? Permanence

When will they return? Cyclical migration

How How did they arrive? Mode of travel

Why Why did they migrate? Purpose

Who Who are they? Identity

Rights

Agency

Migrants in OECD

• Migrants in 2013:

– 3.2% of total world population (231.5 million people)

– 11% of population in high-income countries

– Refugees 7% of all international migrants

OECD –UNDESA Oct 2013

Migrants amongst EU HIV cases 2006

• Migrants

– 58% of all HIV cases

– 18% of MSM PLHIV

– Wide variation

between countries

Del Amo Eur J Public Health 2010

Migrant PLHIV in Israel

Jewish and non-Jewish migrants with HIV 1981–2009

Male

Female Mor et al. BMJ Open 2013

Ethiopian Jews

Migrants from high-burden countries

Migrants in US HIV cases - 1

Foreign-born:23% of HIV cases36% of population

• Over-representation of African-born and ethnic minorities

Migrants in US HIV cases - 2

HIV & the African diaspora

OECD proportion of recent African immigrants amongst new HIV cases 2009

Number of recent African immigrants

Clinical issues for migrant PLHIV

• Late diagnosis

• TB

– Africa, Asia, Eastern

Europe

• Mother-to-child

transmission

• HIV-related stigma

• Poverty

Del Amo, Eur J Pub Health (2010)Easterbrook, JAIDS (2010)Caro-Murillo, Enferm Infec Microbiol Clin (2009)Dodds, J Commun Applied Soc Psychol (2006)

• Similar disease

progression

– Adherence

– HIV-1 subtypes

• Similar response to cART

Responding to challenges

• UK

– Ethnic surveillance data

– Community mobilisation

• EU

– Enhanced surveillance

– Migrant HIV projects

• US

– HIV entry ban rescinded

– Black AIDS activism

• Canada

– ABDGN

– Special report on Black African/Caribbean

• Israel

– HIV prevention and support for Jewish

African PLHIV

– ?response to non-Jewish African PLHIV

• NZ

– HIV Futures 3: CALD refugee PLHIV

– Ethnic surveillance data

• Australia

– Medicare-ineligible ART project

– CALD PLHIV support services and

health promotion

– AFAO African Australian HIV project

– Research: epidemiology

HIV and mobility: UNAIDS

http://data.unaids.org/publications/irc-pub02/jc513-popmob-tu_en.pdf

International Organisation for Migration

Future challenges

Acknowledgements

Supported by a Project Grant from the Department of Human Services and a scholarship from the Centre for Clinical Research Excellence in Infectious Diseases

Melbourne HealthBurnet InstituteMelbourne Sexual Health CentreAlfred HealthRoyal Women’s HospitalSouthern Health (Monash Medical Centre)St Vincent’s Hospital (Melbourne)Centre for Youth Multicultural IssuesInner South Community Health ServiceScarlet AllianceNew Hope FoundationPositive WomenStraight ArrowsIslamic Women’s Welfare Council of VictoriaHealthWorksKirby Institute for Infection and Immunity in Society

African Australian Welfare CouncilFamily and Reproductive Rights ProgramSudanese Community Association of VictoriaHorn of Africa Senior Women’s GroupDinka Jieng Community Council of VictoriaUnited Somali WomenOromo Community Association in Victoria

African Australian Welfare CouncilFamily and Reproductive Rights ProgramSudanese Community Association of VictoriaHorn of Africa Senior Women’s GroupDinka Jieng Community Council of VictoriaUnited Somali WomenOromo Community Association in Victoria

Special thanks to all study participants

Acknowledgements

Beverley-Ann BiggsMargaret HellardAlan StreetSamia BahoTenenet TayeAbraha GebremariamSahra HusseinWilliam Malouk DawShangale AliShiraz HakimMohanad HakimNeveen HannaRhiannon PalmerRachel ThamMirella OzolsChristalla HajisavaMegan BrooksGina Barri-RewellAnn McIntyreSonia Curuana

Jim BlackVirginia De CrespignyJeanette VenkatayaNick ChristopherThao NguyenPaulette MantonGraham BrownMary LjubanovicJamileh Abu-DuhouPascale Allotey

Liz NicholRebecca GuyCarol El-HayekLisa NatoliMarion BrownKeflemariam YohannesJenny LewisMaelenn GouillouTim Spelman

Suzanne CroweEman NaimClaire RyanZamberi Sekawi

Doris ChiboChris BirchTamara SpeedAnna HearpsVicki GreengrassLisa Morris

Sophie DutertreStephen McNallyJeffrey GriersonMartha MorrowMartha MacIntyreSandy GiffordKaterina Lagios

Tony KormanSuzanna GarlandTim ReadTina SchmidtChristopher FairleyKerrie BoydPeter StanleyKirsty BuisingIan WoolleyAnne MijchChristine Bowtell-HarrisKerrie Watson

Shroug MohamedFaten MohamedMalyun AhmedAbdinur WeliMargaret ChoulKofi OseiJanelle FawkesJulie FutolAlison CoelhoKate BeanNaomi Ngo

“No man is an island entire of itself”“No man is an island entire of itself”

John Donne (1572-1631)John Donne (1572-1631)