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)