Epidemiology of STIs (including HIV and HBV infections) in undocumented migrants in Europe: what do we know?

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1 Epidemiology of STIs (including HIV and HBV infections) in undocumented migrants in Europe: what do we know? Andrew Amato, Head of HIV/STI/Hepatitis Programme, European Centre for Disease Prevention and Control, Stockholm

2 Outline Introduction Difficulties with the data STIs: gonorrhoea and syphilis Viral hepatitis B and C HIV Conclusions

3 Migrant health and infectious disease remain a priority

4 Expert opinion on the public health needs of irregular migrant, refugees and asylum seekers

5 Surveillance notification data Local Regional National Report Positive specimen Clinical specimen Seek medical attention Symptomatic Infected Exposed

6 the exception rather than the rule For undocumented migrants, access to basic healthcare, including sexual and reproductive health services, is the exception rather than the rule in the majority of EU Member States. Platform for International Cooperation on Undocumented Migrants (PICUM), 2016

7 Surveillance notification data Local Regional National Report Positive specimen Clinical specimen Seek medical attention Symptomatic Infected Exposed

Data on migration status, ECDC Variables currently collected through TESSy Variable HIV TB HBV HCV Gonorhoea Syphilis Measles Rubella Malaria Country of

8 Data on migration status, ECDC Variables currently collected through TESSy Variable HIV TB HBV HCV Gonorhoea Syphilis Measles Rubella Malaria Country of birth X X X X X X Country of nationality X X X X X X Probable country of X X X X X X X X infection Imported X X X X X Region of origin X Chagas disease*

9 Burden of infectious diseases among migrants, 2014 Objective: To produce a comprehensive overview of the key infectious diseases affecting migrant populations in the EU/EEA TB HIV HEPATITIS B HEPATITIS C MEASLES RUBELLA GONORRHOEA SYPHILIS MALARIA CHAGAS DISEASE

10 Reported cases of gonorrhoea in EU/EEA by migrant status, 2015 Range from 0 to 33.3% excluding the unknowns Romania Estonia Cyprus Norway Slovakia Lithuania United Kingdom Slovenia Hungary Denmark Czech Republic Portugal France Iceland Netherlands Luxembourg Malta Croatia Bulgaria Greece Finland Latvia Poland Itlay Ireland Belgium Sweden Spain 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Migrant Native Unknown

11 Reported cases of gonorrhoea in the EU/EEA in migrants by country of origin, 2015 Germany; 2,93 United Kingdom, 2.35 Suriname; 6,53 Slovakia; 3,02 Poland; 3,07 Brazil; 5,23 Spain; 3,6 United States; 3,98 Romania; 3,94 Italy; 3,94 Based on 1.1% of the total number of reported cases, percentages exclude unknowns

12 Reported cases of syphilis in EU/EEA by migrant status, 2015 Range from 0 to 88.9% excluding the unknowns Romania Estonia Norway Lithuania United Kingdom Slovenia Hungary Slovakia France Portugal Czech Republic Denmark Netherlands Malta Ireland Cyprus Luxembourg Sweden Poland Latvia Italy Iceland Croatia Finland Spain Greece Germany Bulgaria Belgium 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Migrant Native Unknown

13 Reported cases of syphilis in EU/EEA in migrants by country of origin, 2015 Suriname; 2,66 Algeria; 2,4 Italy; 2,66 [CATEGORY NAME], [VALUE] United Kingdom; 2,74 Slovakia; 2,74 Spain; 2,92 Ukraine; 3 Poland; 3,43 Romania; 5,23 Based on 1.7% of the total number of reported cases, percentages exclude unknowns

14 Hepatitis B and C virus WHO European Region Estimated 13 million people with chronic hepatitis B virus (HBV) 15 million are chronic hepatitis C virus (HCV). ECDC estimates Overall prevalence of both hepatitis B and C infection around 1% in the countries of the EU/EEA Prevalence in the EU/EEA in migrants born in endemic countries is 6% for HBsAg and 2.3% for anti-hcv. European Centre for Disease Prevention and Control. Epidemiological assessment of hepatitis B and C among migrants in the EU/EEA. Stockholm: ECDC; 2016.

15 Relative contribution of migrants to the total number of chronic hepatitis B cases per EU/EEA country 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Ireland Netherlands Sweden Cyprus Finland Austria United Kingdom Estonia Norway Belgium Luxembourg Germany France Liechtenstein Denmark An estimated 1 to 1.9 million CHB-infected migrants from endemic countries (prevalence 2%) reside in the EU/EEA. Migrants comprise 10.3% of the total EU/EEA population but account for 25% of all CHB cases in the EU/EEA. Spain Portugal Croatia Latvia Malta Iceland Italy Greece Czech Republic Hungary Slovenia Lithuania Slovakia Poland Bulgaria Romania EU/EEA European Centre for Disease Prevention and Control. Epidemiological assessment of hepatitis B and C among migrants in the EU/EEA. Stockholm: ECDC; 2016.

16 Relative contribution of migrants to the total chronic hepatitis C cases per country Migrants comprise 10.3% of the total EU/EEA population but account for 14% of all CHC cases European Centre for Disease Prevention and Control. Epidemiological assessment of hepatitis B and C among migrants in the EU/EEA. Stockholm: ECDC; 2016.

17 Magnitude and trends of the HIV epidemic among migrants in the EU

18 Proportion of HIV diagnoses among natives and migrants* EU/EEA, 2015 Migrants: 37% Natives: 63% * Migrants: all persons born outside of the country in which they were diagnosed ECDC/WHO (2016). HIV/AIDS Surveillance in Europe, 2015

19 Proportion of HIV diagnoses among migrants* by country, EU/EEA, 2015 (n= ) New diagnoses in people originating from countries with generalised HIV epidemics 37% New diagnoses in people originating from other countries * Data presented here are among cases with known region of origin; there were no cases reported among migrants in Hungary or Liechtenstein ECDC/WHO (2016). HIV/AIDS Surveillance in Europe, 2015

20 Trends in the distribution of reported HIV in the EU/EEA, by geographical origin ( ) 100,0 % 10, ,0 Natives Subtotal migrants Sub-Saharan Africa Latin America & Caribbean Central and Eastern Europe Western Europe South and Southeast Asia Other ECDC/WHO joint HIV database of The European Surveillance System (TESSy)

Reported HIV cases by transmission category and geographical origin, EU/EEA, 2007 2011 (n=125 225) European Centre for Disease

21 Reported HIV cases by transmission category and geographical origin, EU/EEA, (n= ) European Centre for Disease Prevention and Control. Assessing the burden of key infectious diseases affecting migrant populations in the EU/EEA. Stockholm: ECDC; 2014.

22 New HIV diagnoses among natives, European migrants and non-european migrants, WHO European Region, ECDC/WHO (2016). HIV/AIDS Surveillance in Europe, 2015

23 HIV diagnoses, by transmission mode and migration status, , EU/EEA 8000 Number of cases % -7% Year of diagnosis Heterosexual contact (native) Heterosexual contact (foreign-born) Data are adjusted for reporting delay. Cases from Estonia, Italy, Poland, Spain excluded due to inconsistent reporting over the period ECDC/WHO (2016). HIV/AIDS Surveillance in Europe, 2015

24 HIV diagnoses, by transmission mode and migration status, , EU/EEA % 6000 Number of cases % -46% % Year of diagnosis Heterosexual contact (native) Sex between men (native) Heterosexual contact (foreign-born) Sex between men (foreign-born) Data are adjusted for reporting delay. Cases from Estonia, Italy, Poland, Spain excluded due to inconsistent reporting over the period ECDC/WHO (2016). HIV/AIDS Surveillance in Europe, 2015

25 Late presenters: CD4 cell count at time of HIV diagnosis and region of origin, EU/EEA, 2015 ECDC/WHO (2016). HIV/AIDS Surveillance in Europe, 2015

A new method to assign country of HIV infection among heterosexuals born abroad and diagnosed with HIV in the UK.

26 Where do migrants get infected with HIV (prior to or after arrival to the EU)? Source: Rice BD, Elford J, Yin Z et al (2012). A new method to assign country of HIV infection among heterosexuals born abroad and diagnosed with HIV in the UK. AIDS 26 (15): Clinic-based estimate CD4-based estimate 46% 24% 18% 7% Rice BD, Elford J, Yin Z et al (2012). A new method to assign country of HIV infection among heterosexuals born abroad and diagnosed with HIV in the UK. AIDS 26 (15):

27 Proportion of migrants who acquired HIV post-migration in Belgium, Italy, Sweden and the United Kingdom Multi-country estimates among 23,906 migrants diagnosed between Over 1/3 of migrants diagnosed acquired HIV postmigration in 2011 MSM migrants were particularly affected with more than 2/5 estimated to have acquired HIV postmigration Why is this important? Screening newly arrived migrants at point of entry is not enough Some sub-populations of migrants are at-risk for HIV acquisition many years after arrival to the EU Need for ongoing targeted primary HIV prevention programmes to migrant populations at risk Zheng et al. Post migration acquisition of HIV: Estimates from four European countries Submitted to peer-reviewed journal.

28 Dublin Declaration thematic report on migrants

Monitoring implementation of the Dublin Declaration on Partnership to

29 76% of countries identify migrants as an important sub-population in their HIV response Yes No No data reported Non EU/EEA ECDC. Monitoring implementation of the Dublin Declaration on Partnership to Fight HIV/AIDS in Europe and Central Asia: 2012 Progress Report. Stockholm: ECDC; 2013.

30 Availability of ART for undocumented migrants, 2016 Source: ECDC. From Dublin to Rome: ten years of responding to HIV in Europe and Central Asia: Stockholm, ECDC; 2014 ECDC. Monitoring implementation of the Dublin Declaration on Partnership to Fight HIV/AIDS in Europe and Central Asia: 2012 Progress Report. Stockholm: ECDC; 2013.

31 Data on HIV prevalence among migrants, 2012 ECDC. Monitoring implementation of the Dublin Declaration on Partnership to Fight HIV/AIDS in Europe and Central Asia: 2012 Progress Report. Stockholm: ECDC; 2013.

32 Data on HIV testing or condom use among migrants, 2012 ECDC. Monitoring implementation of the Dublin Declaration on Partnership to Fight HIV/AIDS in Europe and Central Asia: 2012 Progress Report. Stockholm: ECDC; 2013.

33 Conclusions HIV/STI/Hep in migrants recognised as an important issue, especially by the western EU/EEA Member States but data on the health of migrants are poor and on undocumented migrants extremely poor: Epidemiological data poor; Behavioural data poor Needs investment!: both financial and human resources. Most migrants entering the EU/EEA are healthy and do not represent a threat to the EU/EEA with respect to infectious diseases. Certain subgroups of migrants carry a disproportionate burden of HIV, hepatitis (and TB) reflecting the prevalence of infectious diseases in their country of departure: need better linkage to care to avoid future complications.

Acknowledgements A special thank you to the EU/EEA national expert surveillance contact points and other Member State collaborators on the Dublin Monitoring.

34 Acknowledgements A special thank you to the EU/EEA national expert surveillance contact points and other Member State collaborators on the Dublin Monitoring. Thank you also to Anastasia Pharris, Teymur Noori, Gianfranco Spiteri and ECDC s HIV/AIDS, STI and Viral Hepatitis B and C Disease Programme team and Prof Julia del Amo, National Center for Epidemiology, Madrid, Spain

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