Increased risk of tuberculosis and HIV co-infection for migrants in the Uganda EU/EAA

Adult migrants in the UK and EU/EEA have worse TB outcomes than non-migrants

New research published today in the European Respiratory Journal found that adult migrants in the UK and EU/EEA fare worse on a range of TB outcomes than non-migrants in those countries.

Researchers led by Dr Heinke Kunst, Reader in Respiratory Medicine at Queen Mary University of London and Honorary Consultant in Respiratory Medicine at Barts Health NHS Trust, conducted a systematic review of current evidence on diagnosis of active TB in migrants entering the European Union/European Economic Area (EU/EEA) and UK.

The work, titled “Tuberculosis in adult migrants in Europe: a TBnet consensus statement” was delivered in collaboration with TBnetscientists with key contribution from Professor Christoph Lange, Professor of Respiratory Medicine.

The review included the clinical presentation and diagnostic delay, treatment outcomes of drug sensitive TB, prevalence and treatment outcomes of multidrug/rifampicin-resistant (MDR/RR)-TB and TB/HIV co-infection.

It showed that migrants have an increased risk of extrapulmonary tuberculosis (TB infection that occurs in organs other than the lungs) compared to pulmonary tuberculosis. It also showed that migrants have an increased risk of tuberculosis and HIV co-infection compared to non-migrants.

The findings also showed an increased risk for multi drug-resistant/rifampicin resistant tuberculosis in migrants with TB when compared to non-migrants with TB. Further to this, migrants with drug susceptible tuberculosis (TB which is not resistant to treatment drugs such as rifampicin) had an increased risk for unfavourable treatment outcomes when compared to non-migrants.

This is the first systematic review to show that migrants with tuberculosis in the UK and EU/EAA have worse outcomes compared to non-migrants with tuberculosis. Based on these findings and expert opinions consensus, the researchers provided recommendation statements to guide the management of migrants with tuberculosis in these countries.

Consensus recommendations include screening of migrants for tuberculosis/latent tuberculosis infection (LTBI) according to country data; a minimal package for tuberculosis care in drug susceptible and multidrug/rifampicin drug resistant tuberculosis; implementation of migrant-sensitive strategies; free healthcare and preventive treatment for migrants with HIV co-infection.

Dr Kunst said: “Migrant populations entering Europe have poorer tuberculosis outcomes than native populations. As cases of tuberculosis are rising in Europe, we need urgent robust strategies to strengthen screening, rapid diagnosis, and treatment in these hard-to-reach populations.”

Migrant-sensitive strategies have been shown to be effective to improve migrant health. These include availability of interpreters and language-appropriate written materials, healthcare provider training in culture-sensitive issues, health education of migrants, strengthening community engagement and social support.

Interestingly, there was no evidence on use of migrant sensitive strategies to improve outcomes of migrants with tuberculosis in the UK and EU/EEA. The researchers hope that the findings may influence public health policy nationally and internationally. Migrant sensitive strategies should be included into routine care of migrants not only for migrants with tuberculosis but also those with other infectious diseases such as viral hepatitis.

Tuberculosis research at Queen Mary

This work complements existing tuberculosis research at Queen Mary in migrants and tuberculosis. Dr Kunst has conducted The CATAPULT trial (Treatment of latent tuberculosis infection in migrants in primary care versus secondary care) funded by Barts Charity recently published in the European Respiratory Journal. The trial showed that the treatment of latent tuberculosis infection in recent migrants to the UK can be safely and effectively managed within primary care when compared to specialist secondary care services at a lower cost. Read more.

Dr Kunst has conducted a NIHR funded study on evaluating uptake of latent tuberculosis infection screening in migrants (Uptake, effectiveness and acceptability of routine screening of pregnant migrants for latent tuberculosis infection in antenatal care) and Prof. Adrian Martineau leads a tuberculosis research programme to develop a new diagnostic test for latent tuberculosis infection.

Surveying ECDC report presents the results of survey on HIV prevention and barriers among migrants in the EU/EEA

HIV and migrants in the EU/EEA – Monitoring the implementation of the Dublin Declaration on partnership to fight HIV/AIDS in Europe and Central Asia: 2024 progress report

This report presents the results of a survey among EU/EEA Member States in relation to the HIV epidemic among migrants and current national prevention interventions, policies and barriers to the public health response.

Executive summary

Background

In 2023, migrants accounted for almost half of new HIV diagnoses in the European Union and European Economic Area (EU/EEA) remaining a key population affected by HIV across the European region. Migrants living with HIV face numerous intersecting stigmas related to their HIV and migration status, as well as broader racial and cultural discrimination. Moreover, access to health services for undocumented migrants is not universally guaranteed in the EU/EEA, which hinders HIV prevention, testing and treatment services for this group and could contribute to HIV transmission in these communities, including post-migration acquirement of HIV.

For this report, migrants are defined as ‘people born abroad’ (i.e. those born outside the reporting country, regardless of place of HIV acquisition or diagnosis). This categorisation encompasses a broad range of individuals, some of whom may also be included in other key populations such as men who have sex with men, people who inject drugs, or sex workers. It includes those who have migrated from within the EU/EEA as well as those who have come from outside the region and will be diverse in terms of socio-demographic and socio-economic characteristics including ethnicity, nationality, migration status, gender, income, and educational level.

Methods

ECDC monitors the implementation of the 2004 Dublin Declaration [1,2]. Between February and May 2024, ECDC implemented an online survey among EU/EEA Member States to collect the most recent data from 2023. The survey contained specific questions in relation to the HIV epidemic among migrants, in addition to questions relating to the current national prevention interventions, policies and barriers to the public health response. This report presents the results of the survey.

Status of implementation of combination prevention

Combination prevention is an approach that combines biomedical, behavioural, and structural interventions and strategies for HIV prevention, working on different levels, including individual, community, and societal/national levels, into one comprehensive programme. Key findings include:

Twenty-seven countries of the EU/EEA reported having a national HIV prevention strategy to reduce the number of new HIV infections. Of those, 89% (24 countries) reported that their strategy specifically mentioned migrants as a key population to whom actions and services are targeted.
Only seven countries reported medium-to-high coverage of condom and lubricant provision programmes targeting migrants.
Pre-exposure prophylaxis (PrEP) availability in the EU/EEA has improved significantly since 2016. While data on the number of migrants accessing PrEP was generally limited, other findings suggest that PrEP may be inaccessible to many migrants: 13 countries reported difficulties in reaching both documented and undocumented migrants with PrEP, and three more countries reported difficulties in reaching only undocumented migrants. Seven countries reported that PrEP was not accessible for undocumented migrants, and in at least five more countries, it was accessible only at cost or through private providers.
The vast majority of countries reported no restrictions on access to testing for undocumented migrants. They also reported the availability of different testing interventions which might facilitate access to testing for undocumented migrants. However, no data to support this assumption were available. It should also be noted that self-testing and community-based testing were not universally provided across EU/EEA countries and these need to be scaled up to reach key migrant populations.

Progress in reaching the continuum of HIV care targets

The continuum of HIV care is a conceptual framework that provides a snapshot of the critical stages in achieving viral suppression among people living with HIV. Only five out of 30 countries provided full data to monitor all stages of the continuum of care for migrants. Key findings include:

There is progress for migrants along the continuum of HIV care across the EU/EEA, but limited available data suggest that only some countries were meeting one or more of the Joint United Nations Programme on HIV/AIDS (UNAIDS) 95-95-95 targets to be achieved by 2025:
- Approximately 93% of migrants living with HIV in the EU/EEA knew their HIV status (based on
  reporting from six countries).
- Of migrants diagnosed with HIV, 84% had initiated antiretroviral treatment (ART), (based on
  reporting from nine countries).
- Of the migrants on treatment, 95% were virally suppressed (based on reporting from nine
  countries).
As of 2023, only Luxembourg was meeting the 2025 substantive target of 86% viral suppression among all migrants estimated to be living with HIV, followed by Belgium, which was within 5% of the target.

Conclusions and recommendations

Progress has been made in the implementation of combination prevention and in reaching the continuum of HIV care targets for migrant populations in the EU/EEA. Recommendations include implementing migrant-tailored, nonstigmatising, linguistically and culturally appropriate HIV prevention programmes for all migrant populations, scaling up testing services, in particular community-based efforts including self- and home testing, and strengthening links between HIV support services and other services such as social services to meet patient needs.

Only five countries within the EU/EEA reported data for all stages of the continuum of care. Countries should continue to improve monitoring and surveillance data for HIV in migrant populations, to inform decision-making on the provision and targeting of prevention, testing and care services.

The full report can be downloaded here: HIV and migrants in the EU/EEA – Monitoring the implementation of the Dublin Declaration on partnership to fight HIV/AIDS in Europe and Central Asia: 2024 progress report (2023 data)

Australia: Migration policies for People with HIV perpetuate criminalisation and expose them to harm

David Carter Delivers Keynote at the Australasian HIV&AIDS Conference

Health+Law’s research lead David Carter, delivered a keynote address at the recent ASHM HIV Conference in Sydney, exploring the controversial past and present of HIV criminalisation in Australia. His urgent, provocative address challenged us to consider how current legal and policy processes in migration law recreate conditions of criminalisation, producing serious health and other harms for people living with HIV. 

Talking to Health+Law researchers in an interview about legal issues, Sergio*, a man in his thirties originally from South America and living with HIV, described the experience of migration to Australia:

I didn’t have to face any court, but I [did] have to prove that I wasn’t a bad person just because I have HIV […] I [had] to prove myself to someone else, who probably is not living with HIV, that I was not a bad person, and I was a good citizen and I deserve to be here.

The migration process is a complex one – and this complexity is amplified for people living with HIV. Sergio’s reflections express a particularly grim aspect of this process for migrants, especially those living with HIV.

Indeed, as Scientia Associate Professor David Carter, Health+Law’s research lead, argued in an invited keynote at the 2024 Australasian HIV&AIDS Conference hosted by ASHM Health in September this year, the experience of people living with HIV seeking to migrate to Australia is part of Australia’s long history of the criminalisation of HIV. Speaking to delegates from Australia, New Zealand, Asia and the Pacific at Sydney’s International Convention Centre on Gadigal Country, David reminded the audience that criminalisation is a policy approach, that doesn’t just use the criminal law. To show this he set out five stages of criminalisation that are also evident in the migration process for those living with HIV.

First, as he explained, criminalisation characterises specific behaviour as harmful or carrying a risk of harm to the community. In this case the harm presented is, to quote Australian migration law, that a person’s HIV care represents a ‘significant cost to the Australian community or prejudice [to] the access of Australian citizens or permanent residents to health care or community services’.

Second, criminalisation creates a suspect population, made up of people thought to warrant suspicion because they come to be associated with the potential harm.

Third and fourth, this suspect population attracts surveillance from the state, with a hierarchy created within the suspect population whereby some members are subject to further and intensified surveillance.

Fifth, and finally, some members of this suspect population are subjected ‘to the most severe forms of the state’s coercive and punitive authority’, including investigation, more intensive supervision, detention or arrest, and in some cases, criminal or civil proceedings.

The criminalisation of HIV has a long and storied history, going back to the very early days of the AIDS crisis. Vocal members of HIV-affected communities, legal and human rights advocates and many others have argued strongly against criminalisation, viewing it as draconian and as an approach to public (health) policy with very negative consequences for HIV epidemics.

In Australia, arguments against HIV-specific criminal offences have been broadly successful, and yet the ‘temptation’ to criminalise – as the very first Australian National HIV Strategy described it – continues to emerge in some policy responses to HIV and other communicable diseases.

In 1987, when the authors of the first national HIV strategy were writing, they were warning against measures including compulsory universal HIV testing, the closure of gay venues, criminal penalties for HIV transmission, and limitations on the movement of HIV positive people, including forced quarantine. Today, HIV criminalisation is operating in Australian migration policy and law.

‘This contemporary criminalisation of HIV begins’, David argued, ‘like all criminalisation, with the characterisation of behaviour in terms of harm and risk of harm’. He continued, arguing that:

This characterisation of migrating while HIV positive as harmful establishes, and in-turn enlivens, the suspect population management and criminalising processes of our medical border […] This criminalising logic establishes an adversarial relationship between the person living with HIV and the state, and between them and members of the Australian community, whose access to health care it is alleged may be prejudiced by providing care for a person living with HIV who wishes to migrate.

Among the many negative effects of this process is that it can discourage migrants living with HIV from engaging in testing, treatment and HIV care. Interviews conducted by Health+Law as part of our national legal needs (LeNS) study confirm that this is happening. They show that many migrants living with HIV in jurisdictions across Australia experienced an alienating and hostile environment: a ‘threat environment so elevated’, as David described it in his keynote, that they frequently described withdrawing from HIV care and community life as a coping mechanism.

Unfolding the history of ‘unjust and unhelpful’ HIV criminalisation in Australia, David outlined how the current legal and policy conditions that prospective migrants living with HIV face in Australia today work to recreate conditions of criminalisation and expose both individuals and the community to multiple health harms.

You can read more about David’s keynote in The Medical Republic’s coverage of the conference.

US: Restrictive immigration policies would undermine Public Health and economic stability

Expected Immigration Policies under a second Trump administration and their health and economic implications

Introduction

Immigration was a central campaign issue during the 2024 Presidential election with President-elect Trump vowing to take strict action to restrict both lawful and unlawful immigration into the U.S. Such actions would have stark impacts on the health and well-being of immigrant families as well as major economic consequences for the nation. As of 2023, there were 47.1 million immigrants residing in the U.S., and one in four children had an immigrant parent.¹ Increased immigration boosts federal revenuesand lowers the national deficit through immigrants’ participation in the country’s economy, workforce, and through billions of dollars in tax contributions.

This issue brief discusses key changes to immigration policies that may take place under the second Trump administration based on his previous record and campaign statements, and their implications. President-elect Trump has indicated plans to restrict and eliminate legal immigration pathways, including humanitarian protections, and deport millions of immigrants, which would likely lead to separation of families, negative mental and physical impacts for immigrant families, and negative consequences on the nation’s workforce and economy.

Expected Policy Changes

Elimination of Deferred Action for Childhood Arrivals (DACA) Program

The future of the DACA program remains uncertain due to pending litigation, and President-elect Trump has indicated plans to eliminate it, which would lead to over half a million DACA recipients losing protected status. DACA was originally established via executive action in June 2012 to protect certain undocumented immigrants who were brought to the U.S. as children from removal proceedings and receive authorization to work for renewable two-year periods. During his prior term, President-elect Trump sought to end DACA but was blocked by the Supreme Court in 2020. The Biden administration issued regulations in 2022 to preserve DACA protections. In September 2023, a district court in Texas ruled the DACA program unlawful, preventing the Biden administration from implementing the new regulations while the case awaits a decision in the Fifth Circuit Court of Appeals. Under pending court rulings, while the Department of Homeland Security (DHS) is accepting first-time DACA requests, it is unable to process them. DHS is continuing to process DACA renewal requests and related requests for employment authorization. After the attempt to end DACA failed in 2020, the Trump administration saidthat it would try again to eliminate DACA protections, and, if the pending court ruling finds the program unlawful, the administration is unlikely to appeal the decision. There are over half a million active DACA recipients, a majority of whom are working and many of whom have U.S.-born children, who could be at risk of deportation if the program is eliminated.

A recent health coverage expansion to DACA recipients also is subject to pending litigation and would, if eliminated, leave many DACA recipients without access to an affordable coverage option. In May 2024, the Biden administration published regulations to extend eligibility for Affordable Care Act (ACA) Marketplace coverage with premium and cost-sharing subsidies to DACA recipients, who were previously ineligible for federally funded health coverage options. The regulation became effective November 1, 2024, allowing for enrollment during the 2025 Open Enrollment Period. In August 2024, a group of states filed a lawsuit against the federal government alleging that the ACA Marketplace coverage expansion for DACA recipients violates the Administrative Procedure Act. The case is currently under review at a district court in North Dakota and a decision is expected in the coming months. Elimination of the expansion could leave the nearly 100,000 uninsured DACA recipients it is estimated to cover without an affordable coverage option.

Changes to Public Charge Policy

President-elect Trump could reinstate changes to public charge policy that he made during his first term, which led to increased fears and misinformation among immigrant families about accessing programs and services, including health coverage. Under longstanding immigration policy, federal officials can deny entry to the U.S. or adjustment to lawful permanent resident (LPR) status (i.e., a “green card”) to someone they determine to be a public charge. During his prior term, President-elect Trump issued regulations in 2019 that broadened the scope of programs that the federal government would consider in public charge determinations to newly include the use of non-cash assistance programs like Medicaid and the Children’s Health Insurance Program (CHIP). Research suggests that these changes increased fears among immigrant families about participating in programs and seeking services, including health coverage and care. Prior KFF analysis estimated that the 2019 changes to public charge policy could have led to decreased coverage for between 2 to 4.7 million Medicaid or CHIP enrollees who were noncitizens or citizens living in a mixed immigration status family. The Biden administration rescinded these changes. However, as of 2023, a majority of immigrant adults said in a KFF survey that they were “not sure” about public charge rules, and roughly one in ten (8%), rising to about one in four (27%) of likely undocumented immigrant adults, said they have avoided applying for assistance with food, housing, or health care in the past year due to immigration-related fears (Figure 1). As of November 2024, President-elect Trump has not indicated whether his administration plans to reinstate his first term changes to public charge policy.

Expanded Interior Enforcement Actions

President-elect Trump has indicated that his administration plans to carry out mass detentions and deportations of millions of immigrants, including long-term residents, which could lead to family separations and negative mental and physical health consequences. President-elect Trump has stated that he will declare a national emergency and use the U.S. military to carry out mass deportationsof tens of millions of undocumented immigrants residing in the U.S., many of whom have been living and working in the country for decades. Such a policy could lead to family separations as well as mass detentions, which can have negative implications for the mental health and well-being of immigrant families and also put their physical health at risk. Tom Homan, who was the director of U.S. Immigration and Customs Enforcement (ICE) during the first Trump administration and has been selected as the incoming administration’s “border czar”, has said that it is possible to carry out mass deportations without separating families by deporting an entire family unit together, even if the child may be a U.S. citizen. As was the case during his first term, he may also carry out workplace raids as part of mass deportation efforts. Research shows that such raids can lead to family separations, poor physical and mental health outcomes for immigrant families, negative birth and educational outcomes for the children of immigrants, and financial hardship due to employment losses. Prior KFF research shows that restrictive immigration policies implemented during the first Trump administration, including detention and deportation led to increased fears and stress among immigrant families and negatively impacted the health and well-being of children of immigrants, most of whom are U.S. citizens.

Mass deportations could also negatively impact the U.S. workforce and economy, where immigrants make significant contributions. Immigrants have similar rates of employment as their U.S.-born counterparts and play outsized roles in certain occupations such as agriculture, construction, and health care. Research has found that immigrants do not displace U.S.-born workers and help foster job growth through entrepreneurship and the consumption of goods and services. Further, federal data show that unemployment rates for U.S.-born workers have not decreased between 2022 and 2023 and have remained similar to those for immigrant workers. In addition, immigrants, including undocumented immigrants, pay billions of dollars in federal, state, and local taxes each year. Mass deportation of immigrants could lead to workforce shortages in key sectors which could have negative economic consequences including an increase in the cost of essential goods such as groceries. Vice President-elect Vance has stated that immigrants are responsible for the U.S. housing crisis. While some studies show a link between immigration and rising housing costs, in general, economists are skeptical of immigration being a primary driver. Mass deportation of immigrants could also worsen housing shortages since immigrants make up a significant share of construction workers. Workplace raids can exacerbate existing labor shortages and have a negative impact on the local economies of the communities where they take place. Further, research shows that without the contributions undocumented immigrants make to the Medicare Trust Fund, it would reach insolvency earlier, and that undocumented immigrants result in a net positive effect on the financial status of Social Security. There also is likely to be a significant cost to taxpayers for the government to carry out large-scale detention and deportations.

Ending Birthright Citizenship

President-elect Trump has stated that he will sign an executive order to end birthright citizenship for the children of some immigrants despite it being a guaranteed right under the U.S. Constitution, which would negatively impact the health care workforce and economy. This proposed action would limit access to health coverage and care for the children of immigrants since they may not have lawful status. It could also have broader ramifications for the nation’s workforce and economy, potentially exacerbating existing worker shortages, including in health care. KFF analysis of federal data shows that adult children of immigrants have slightly better educational and economic outcomes than adult children of U.S.-born parents and make up twice the share of physicians, surgeons, and other health care practitioners as compared to their share of the population (13% vs. 6%) (Figure 2). Other research also has found that children of immigrants contribute more in taxes on average than their parents or the rest of the U.S.-born population, and that their fiscal contributions exceed their costs associated with health care, education, and other social services.

Reinstatement of “Remain in Mexico” Policy

President-elect Trump has stated that he will reinstate the “Remain in Mexico” border policy and that he may use military spending to carry out stricter border enforcement, which would leave an increased number of asylum seekers facing unsafe conditions at the border. The first Trump administration implemented Migrant Protection Protocols, often referred to as the “Remain in Mexico” policy, in 2019. Under this policy, asylum seekers were required to remain in Mexico, often in unsafe conditions, while they awaited their immigration court hearings. The Biden administration ended this policy in 2022, following some legal challenges, although it implemented a series of increasingly restrictive limits on asylum eligibility in 2023 and 2024 in response to a high number of border encounters. President-elect Trump said he plans to reinstate the Migrant Protection Protocols. He also has indicated that he will deploy the National Guard, as well as active duty military personnel, if needed, to the U.S.-Mexico border, although details of the plan remain unclear. Heightened military presence at the border can lead to increased fears among immigrant families living in border areas and using part of the military budget for border security could face legal challenges.

Restrictions on Humanitarian Protections

President-elect Trump said he plans to significantly limit the entry of humanitarian migrants into the U.S. during his second term by restricting refugee limits, shutting down the CBP One application for asylum seekers, and eliminating Temporary Protected Status (TPS) designations for immigrants from some countries. During his first term, President Trump set the annual refugee admissions ceiling at its lowest levels, ranging from 50,000 in 2017 to a historic low of 18,000 in 2020. The Biden administration increased the limit to 65,000 in 2021, a level close to the annual ceilings prior to the first Trump term, and further increased the limits in 2022 and 2024 in response to humanitarian concerns. It is likely that President-elect Trump will reduce the admissions ceiling for refugees in his second term. The President-elect has also said that he will close the CBP One application created by the Biden administration which allows asylum seekers to seek lawful entry to the U.S. by making an interview appointment with the DHS. While there have been implementation challenges with the CBP One application, shutting down the application could lead to “mass cancellation of appointments” and possibly an increase in attempts to cross the border outside of ports of entry. President-elect Trump also has indicated that he will roll back TPS designations for some immigrants, including those from Haiti. TPS designations protect immigrants from countries deemed unsafe by the DHS from deportation and provide them with employment authorization but do not provide a pathway to long-term residency or citizenship. As of March 2024, over 860,000 immigrants from 16 countries were protected by TPS. Loss of TPS would put people at risk for deportation, which could contribute to family separation which in turn can have negative impacts on the mental and physical health of immigrant families, and broader negative consequences for the workforce and economy.

Endnotes

KFF analysis of 2023 American Community Survey 1-year Public Use Microdata Sample.

Research papers explore challenges in HIV care for migrants and refugees, highlighting social and structural barriers

Report reveals how nations downplay migrants HIV care

A study has revealed how countries across the world have downplayed the health of international migrants who face barriers while accessing HIV care along the migration routes.

In many countries, the study shows that people on the move are confronted with stigma related to migration status, racialism, discrimination and unfavourable policies that run health care systems.

The study focused on migrants who are not aware of their HIV status but are either infected with or are vulnerable to acquiring HIV, and migrants who know their positive status and require linkage and adherence to HIV treatment.

“Migration is a common phenomenon and will remain an important health determinant when attempting to successfully strengthen health systems, including the access to continuity of HIV care,” the journal published by Lancet notes.

The worst hit are the undocumented migrants who due to fear of deportation and stigma may never seek HIV care from a health facility.

Although documented migrants have the right to access health care in some countries, they might still face barriers while accessing HIV care.

In some countries, documented migrants reportedly faced verbal abuse and discrimination in healthcare settings and were denied access to treatment even when they had the right to it, or were charged higher fees.

According to the study, the migration trajectory, including a pre-migration period in departure countries and transition periods before arriving at destination countries, presents HIV-related risks for migrants.

“Along this trajectory, migrants are likely to face different risk-inducing social, physical, political, and economic environments. Migrants’ departure countries might contribute to their overall determinants of HIV including specific vulnerabilities, practices around safer sex, and health-care seeking,” it reads in part.

The study cites a case where migrants arriving from countries with a patriarchal culture where sex is considered taboo, such as Arab countries, have been reported to experience a high burden of gender-related stigma associated with a high likelihood of acquiring HIV and delayed testing.

Additionally, the report says that experiences and familiarity with healthcare systems in departure countries might also shape migrants’ practices around seeking HIV care in transition or destination countries.

In the context of forced displacement, the research states that challenges related to accessing HIV care during the transition stage are major points of concern, especially where some migrants have to reside in refugee facilities in transition countries for long periods, which might substantially delay their access to HIV care.

These 2 research papers are part of the Lancet SERIESHIV in Migrant Populations Online first accessible freely after registration:

Humanising and optimising HIV health care for refugees and asylum seekers

Interventions to ensure access to and continuity of HIV care for international migrants: an evidence synthesis

Vietnam: Vietnam and IOM sign MoU to promote migrant inclusion in National Health Systems

IOM and Ministry of Health sign partnership to promote migrants’ health

The International Organisation for Migration (IOM) and the Ministry of Health (MoH) on Wednesday afternoon strengthened their collaboration in promoting the health and well-being of migrants.

HÀ NỘI — The International Organisation for Migration (IOM) and the Ministry of Health (MoH) on Wednesday afternoon agreed to strengthen their collaboration in promoting the health and well-being of migrants by signing a new Memorandum of Understanding (MoU).

Under the MoU, they also agreed to promote migrants’ inclusion in national health systems and policies.

The MoU reflects nearly 40 years of collaboration between IOM and MoH, which began in the early 1980s.

Over the years, this partnership has grown from IOM health assessment programmes for populations moving to destination countries to public health efforts that facilitate better access to healthcare services for migrants and strengthen cross-border disease control and public health emergency response and preparedness.

Việt Nam has become a significant source of migrants, particularly those seeking employment opportunities abroad.

Recent data shows a resurgence in international labour migration, with approximately 155,000 Vietnamese citizens securing employment abroad last year alone, equivalent to nearly a third of the new workers entering the labour market.

Similar to other countries in the ASEAN region, the burden of health issues in Việt Nam remains complex, including infectious diseases, occupational health hazards and injuries, mental health challenges, non-communicable diseases such as cardiovascular disease and diabetes and maternal and child health problems.

Infectious diseases like human immunodeficiency virus (HIV), acquired immunodeficiency syndrome (AIDS), tuberculosis (TB) and malaria continue to be significant concerns.

Achieving Universal Health Coverage (UHC) remains a challenging goal and presents an even greater challenge for migrants.

Recent studies conducted by IOM in the region have highlighted the challenges faced by cross-border migrants in accessing healthcare, including language barriers, discrimination, financial constraints, lack of health insurance across borders and lack of official cross-border referral mechanisms for migrant patients.

They can be made even more vulnerable in pandemic situations due to inadequate access to needed health care and services, as shown during the COVID-19 pandemic.

Park Mi-Hyung, Chief of Mission of IOM in Việt Nam, stressed the importance of this collaboration to ensure the health and well-being of migrants, aligning with the goals of the Global Compact for Safe, Orderly, and Regular Migration (GCM) and the Sustainable Development Goals (SDGs).

“In a world where an increasing number of people are on the move, collaborations and partnerships are crucial to enhance the health and well-being of migrants. Healthy migrants contribute to healthy communities,” she said.

Nguyễn Tri Thức, Deputy Minister of Health, said that in recent years, the MoH and IOM have actively cooperated in many areas related to ensuring the health of migrants, including raising awareness of migrants’ health, strengthening bilateral cooperation in cross-border tuberculosis control and preparing for and responding to public health emergencies.

In addition, he said, IOM supported enhanced regional cooperation last year through regional workshops on migration and migrant health.

Goal 3 of the United Nations Sustainable Development Goals is good health and well-being.

“I hope we will continue to promote closer cooperation to successfully implement the United Nations Sustainable Development Goals,” said Thức. — VNS

Australia: Criminalisation fuels healthcare disparities for migrants living with HIV

HIV in Australia: shades of injustice remain

Elimination is the goal, but migrants living with the virus experience a criminalised environment that thwarts access to care.

Health Minister Mark Butler painted a largely rosy picture of the progress towards elimination of HIV in Australia today, speaking on the second morning of the ASHM HIV/AIDS Conference in Sydney.

A legal academic, however, said people with HIV in Australia were still living under a pall of criminalisation, none more so than migrants.

Mr Butler praised the Australian response to the epidemic, especially in NSW, which was most affected in the early days.

“Since HIV was first detected more than 40 years ago in Australia, Australia’s response has been one to be proud of,” he said.

“When you go back to those early years, AIDS was highly feared here as it was around the world. There was huge stigma, misinformation, homophobia and such loss and so much grief for communities.

“But Australia’s response early on was characterised by partnership and collaboration: governments, people living with HIV, communities affected by HIV, non-government organisations, health professionals and academics all came together and worked together.”

He said HIV notifications were declining in Australia, at one of the fastest rates in the world – “but as you have all heard, I’m sure, transmission has also gone up in 2023, reminding us there is always more work to be done”.

“Eliminating transmission of HIV here in Australia is ambitious, but I am absolutely assured it is now achievable,” he said today, citing inner Sydney – once the epicentre of the epidemic – as a place that had effectively achieved elimination.

Mr Butler set up the HIV Taskforce last year with a goal to “virtually” eliminate transmission by 2030. The Ninth National HIV Strategy covers from last year to 2030, continuing the work of the Eighth – whose goal was virtual elimination by 2022.

He said transmission rates had grown “among temporary residents who are here in Australia on work or study visas”.

“So we will provide subsidised access to PrEP to make healthcare more equitable for people who don’t have access to Medicare … We will make sure that at-risk populations can get free HIV self-testing kits through an expansion of the national HIV self-test mailout program [run by the National Association of People with HIV Australia (NAPWHA)] as well as HIV self-testing vending machine programs,” said Mr Butler.

For David Carter, Scientia Associate Professor at the faculty of Law & Justice at UNSW, the necessary changes for people on visas won’t be found in any vending machine but in immigration policy.

Professor Carter, who leads the Health+Law Research Partnership for social justice for people living with HIV or hepatitis B, walked through the history of “unjust and unhelpful” HIV criminalisation in Australia – a public policy environment that includes but is not limited to action by law enforcement and courts. It begins with the creation of a “suspect population”.

He quoted the very first National HIV Strategy in 1987, which warned of the “temptation” of criminalisation measures, including “universal or selective testing, closure of gay venues, criminal penalties for transmission, compulsory notification of HIV infection and restrictions on freedoms of infected people through limitations on employment, quarantine or compulsory detention”, and noted these would jeopardise health measures to prevent transmission.

A working party in 1992 concluded that “even in the face of decisions by individuals that generate harm, it was the wrong decision to restrict the free choice of individuals in modern society, as draconian measures would merely alienate people at risk of infection and deter them presenting for counselling, testing and treatment”.

While pressure to enforce such measures may have been largely resisted, and the situation for Australians has greatly improved, migrants living with HIV are still experiencing an alienating and hostile environment, said Professor Carter.

Characterising them as posing potential harm to Australians “establishes an adversarial relationship between the person living with HIV and the state” and compromises health care by promoting defensive behaviour.

He and his team have interviewed migrants in Australia living with HIV over the past two years, for whom “criminalisation is indeed very active, and it is producing serious, negative health and other impacts of individuals or communities and respects”.

He quoted one interviewee, “Sergio”, who told the team: “I don’t have to face any court, but I did have to prove that I wasn’t a bad person just because I have HIV.”

Others spoke of experience going through the migration process as being “subject to an unending interrogation”.

“Laurence” told his interviewer: “It’s like a tattoo on your mind. The government will treat you different for every single step of your life from here on out.”

“Manish”, who was on a temporary visa, avoided getting tested for 10 months after beginning to suspect he had HIV, for fear of having his visa revoked. His health deteriorated during this time.

“The elevated threat levels produced by the interaction of migration law and public health law … significantly harmed Manish’s health, caused psychological distress and steered him towards coping responses that denied him the testing and treatment, access to medical care and other supports that he deserves and that we all collectively affirm are essential and are his right,” said Professor Carter.

“Manish said to us: ‘I feel like if I had reassurance that nothing’s going to happen to me if I tested positive for this, I would not have been afraid to go and get a test for HIV’.”

Others described feelings of “hopelessness and depression, because there is no hope for us to stay permanently while living with HIV” (in fact there are pathways for permanent migration despite living with HIV). These people would go for weeks without medication in a form of self-sabotage “because they just don’t have hope for their future anymore”.

For these and other people like them, the Australian environment “is just a set of undifferentiated threats to autonomy, wellbeing and safety, to which they are forced to respond with adaptation, distancing and adopting a posture of self-defence”.

Professor Carter concluded that “it may be different today [from the 90s], but it is not over, and it won’t be over here or elsewhere until the stigma of HIV, unconventional sexuality and drug use are gone”.

The HIV/AIDS Conference is running in Sydney this week back-to-back with the 25^th IUSTI World Congress.

US: City initiative aims to combat rising STIs rates among vulnerable populations

NYC to launch STD outreach program for uninsured New Yorkers, migrants

The city is launching a new outreach program to try to curb sexually transmitted diseases among uninsured New Yorkers, including migrants, The Post has learned.

Health Department officials reported a significant 36% spike in syphilis cases among women and an 11% jump in the gonorrhea rate among men in the city in 2022 — when a tidal wave of migrants began flooding the Big Apple, according to the most recent data available.

For both sexes combined, the city saw a 3% increase in syphilis cases that year compared to 2021, a 3% increase in chlamydia cases and 10% increase in gonorrhea cases.

“Assuring comprehensive and timely screening and treatment for STIs [Sexually Transmitted Infections], including chlamydia, gonorrhea, and syphilis, is critical for preventing … infertility, increased susceptibility to HIV, and congenital syphilis—as well as preventing onward spread to sex partners,” the department said in a pitch to potential bidders to run the program.

“Those who have immigrated to the US face barriers including insurance ineligibility (for undocumented and DACA recipients), delays in eligibility to access public health insurance programs (for documented immigrants), and barriers in understanding eligibility standards,” it added.

More than 212,000 migrants have sought assistance since arriving in the city starting in mid-2022, with 63,000 currently in the Big Apple’s shelter system, Mayor Eric Adams said Tuesday.

Last year, Health Commissioner Ashwin Vasan raised the alarm that half the migrants entering the city had not been tested for the contagious and potentially deadly polio virus.

Most low-income citizens have access to health insurance such as Medicaid to be screened and treated for sexually transmitted infections including chlamydia, gonorrhea, syphilis and HIV.

But the department said it’s more difficult to reach the hundreds of thousands of uninsured New Yorkers, including asylum-seekers, undocumented migrants here illegally and other young people.

Residents who lack insurance are unlikely or unable to self-pay for treatment out of pocket or may resist testing on their own, too, officials said.

“Lack of insurance and financial instability are among the frequently noted barriers to STI care, and they are often correlated,” the department said in its “concept paper” explaining the outreach.

Younger residents, LGBT individuals, blacks and Latinos and the unemployed who are uninsured or underinsured are also less likely to get screening, officials added.

Reported STI cases in the city have risen steadily since 2018, the department said.

But officials said the increase may partially reflect the resumption of STI screening services that were suspended or postponed during the COVID-19 pandemic.

Such services were impacted by lockdown protocols and restrictions and nationwide shortages in testing supplies.

The department said it is seeking up to three contractors to provide STI-related services to uninsured New Yorkers in neighborhoods with the highest rates of chlamydia, gonorrhea, and syphilis.

The services would include screening and treatment as well as providing vaccines for hepatitis A, hepatitis B, HPV, and mpox.

“The purpose of this RFP [request for proposals] is to ensure that these individuals have equitable access to STI services,” the proposal said.

The Health Department had no immediate comment on how much the initiative would cost or how much each contractor would be paid and over how many years.

Tajikistan: Rising HIV cases among migrants highlight urgent need for testing and repeal of HIV criminalisation law

Every third person with HIV in Tajikistan is a labour migrant

Translated with Deepl.com. For article in Russian, please scroll down.

There are more and more people living with HIV among migrants

In Tajikistan, every third person with HIV is a labour migrant. Over the past five years, 5,463 cases of HIV infection have been detected, according to data from the Republican Centre for HIV/AIDS Prevention and Control. Of these, migrants account for 22 per cent of those infected. While in 2019 migrants accounted for only 17 per cent of those infected, by 2023 that figure had risen to 32.5 per cent.
Balajon Davlatov, a specialist of the dispensary department of the Republican HIV Centre, strongly recommends to take a free test at one of the HIV prevention and control centres in Tajikistan immediately after arrival.

“Every migrant, after returning home, should be tested for HIV infection if they have doubts about it,” Davlatov said.
More than 300 migrants are already on the Republican HIV Centre’s dispensary register, he said. Their identities and test results are not disclosed to third parties.
“Any information about each person should be confidential. It is possible to get express tests, which within 15 minutes by analysing saliva report the patient’s HIV status – completely anonymously,” he says.
Such tests are available free of charge at one of the 67 government HIV prevention and control centres in all regions of Tajikistan.
In addition to testing through blood at AIDS centres, self-testing using near-blood fluid is now available. Self-test kits are available in Dushanbe, Rudaki, Khujand and B.Gafurov through online ordering at hivtest.tj.

The ordering process involves filling out a simple form with a few questions. This platform helps people confidentially find out their HIV status and provides up-to-date information on protection and prevention methods.
Those who test positive for HIV can learn more about their result and get a follow-up confirmatory test at the AIDS Centre.

We had a case with a woman who tested positive for HIV,” says Balajon Davlatov, “after treatment with antiretrovirals, she gave birth to two HIV-negative children. Now she lives in Russia, and we send her the necessary medication and counselling.
This proves that HIV-infected people can give birth to healthy children and live a full life.

It is an offence to infect another person with HIV

However, a positive HIV status can carry certain risks, which are not only related to the state of health. If a person knows that he or she is HIV-positive but hides it from his or her sexual partner, he or she can be fined from 720 to 1440 somoni under Article 120 of the Code of Administrative Offences (CAO).

Evasion of treatment for HIV or other infectious diseases is also punishable by a fine of 1,440 to 2,160 somoni. This liability is stipulated in Article 119 of the Code of Administrative Offences.

If a person deliberately infects another person with HIV, he or she may be punished with restriction of freedom for up to 3 years or imprisonment for up to 2 years. If, knowing his/her HIV status, he/she infects another person, he/she may face 2 to 5 years in prison. The term of imprisonment can be longer, from 5 to 10 years, if more than one person was infected or if the victim was a minor. This punishment is already stipulated in article 125 of the Criminal Code, which characterises these actions not as an offence but as a criminal offence.

Therefore, it is very important to periodically take tests and check your status, especially if you are in a risk group.

Среди мигрантов всё больше людей, живущих с ВИЧ

В Таджикистане каждый третий человек с ВИЧ – это трудовой мигрант. За последние 5 лет выявлено 5463 случая заражения ВИЧ инфекцией, говорят данные Республиканского центра по профилактике и борьбе с ВИЧ/СПИД. Из них 22% инфицированных приходится на мигрантов. Если в 2019 году мигранты составляли всего 17% зараженных, то к 2023 году эта цифра увеличилась до 32,5%.
Баладжон Давлатов, специалист диспансерного отделения Республиканского центра ВИЧ, настоятельно рекомендует сразу после прибытия пройти бесплатный тест в одном из центров по профилактике и борьбе с ВИЧ-инфекцией в Таджикистане.

«Каждый мигрант после возвращения на родину должен пройти обследования на факт заражения ВИЧ, если у него есть сомнения по этому поводу», – говорит Давлатов.
По его словам, уже более 300 мигрантов находятся на диспансерном учете республиканского центра ВИЧ. Их личность и результаты теста не разглашаются третьим лицам.
«Любая информация о каждом лице должна быть конфиденциальной. Можно получить экспресс-тесты, которые в течение 15 минут путем анализа слюны сообщают о ВИЧ-статусе пациента – полностью анонимно», – говорит он.
Такие тесты можно получить бесплатно в одном из 67 государственных центров по профилактике и борьбе со ВИЧ во всех регионах Таджикистана.
В дополнение к тестированию через кровь в Центрах СПИД, сегодня доступно самотестирование с использованием околодесновой жидкости. Наборы для самотестирования можно получить в городах Душанбе, Рудаки, Худжанд и Б.Гафуров через онлайн-заказ на сайте hivtest.tj.
Процесс заказа включает заполнение простой формы с несколькими вопросами. Эта платформа помогает людям на конфиденциальной основе узнать свой ВИЧ-статус и предоставляет актуальную информацию о методах защиты и профилактики.
Те, у кого тест на ВИЧ оказался положительным, могут узнать о своем результате подробнее и пройти повторное подтверждающее тестирование в Центре СПИД.

«У нас был случай с женщиной с положительным ВИЧ статусом, – рассказывает Баладжон Давлатов, – после лечение антиретровирусными препаратами она родила двоих детей с отрицательным ВИЧ-статусом. Сейчас она живёт в России, и мы отправляем ей нужные медикаменты и даём консультации».
Это доказывает, что ВИЧ инфицированные люди могут рожать здоровых детей и полноценно жить.

Заражение ВИЧ другого человека – это преступление

Однако положительный ВИЧ-статус может нести определенные риски, которые связаны не только с состоянием здоровья. Если человек знает, что у него положительный ВИЧ-статус, но скрывает это от своего сексуального партнера, то в рамках статьи 120 Кодекса об административных правонарушениях (КоАП) РТ ему могут выписать штраф от 720 до 1440 сомони.

За уклонение от лечения от ВИЧ или других инфекционных заболеваний тоже выписывается штраф от 1440 до 2160 сомони. Эта ответственность предусмотрена статьей 119 КоАП.
Если человек умышленно заражает другого ВИЧ, он может быть наказан ограничением свободы до 3 лет или лишением свободы до 2 лет. Если, зная о своем ВИЧ-статусе, он заразил другого человека, ему может грозить от 2 до 5 лет тюрьмы. Срок лишения свободы может быть больше – от 5 до 10 лет, если было заражено более одного человека или жертвой стало несовершеннолетнее лицо. Это наказание предусматривается уже в статье 125 Уголовного кодекса РТ, что характеризует эти действия не как правонарушение, а как уголовное преступление.
Поэтому очень важно периодически сдавать анализы и проверять свой статус, особенно, если человек находится в группе риска.

Migrants in Switzerland are in a situation of greater intersectional vulnerability to HIV

The authors of a study advise that specific preventive interventions be carried out that take into account the needs of this population.

Migrants in Europe are at much higher risk of acquiring HIV – and also developing AIDS – due to numerous social factors that place them in a vulnerable position. On the other hand, these vulnerabilities are enhanced by sexism, cisgenderism and racism, according to a Swiss study published in Culture, Health and Sexuality. All this is reflected in the fact that a significant number of these people are infected with HIV in their host country, so it is necessary to carry out specific preventive interventions for this population, which address the identified risk factors.

The conclusions of previous studies indicated that migrants faced not only particular legal and socioeconomic factors that put them in a situation of vulnerability, but that there were also other more specific aspects that also influenced that risk, such as not being a cis person, not being heterosexual or being a sex worker.

Intersectional inequality is produced by the interaction of several axes of inequality and oppression such as age, class, sex, sexual diversity, religious beliefs or national or ethnic origin, among others. The intersection of social vulnerabilities increases the risk that migrants will acquire HIV or develop advanced HIV disease due to lack of adequate care.

As a result, the Swiss public health authorities decided to collect data to inform HIV/STI prevention policies in the migrant population. To this end, a sociological, participatory and qualitative study was launched by a team of social researchers from the University of Freiburg. Special attention was paid to people coming from countries with high HIV prevalence, sex workers, gay men, bisexuals and other men who have sex with men (GBHSH), injecting drug users, trans and undocumented people or with temporary residence status in Switzerland.

All participants were over 18 years of age who were subjected to in-depth interviews. It was attended by prevention specialists working in the field of migration and HIV.

The results of the study reveal that the biographical, interactional and contextual dimensions are intertwined and create social vulnerabilities that affect this population. Thus, the team of researchers reports that, by not allowing irregular migrants to work, Swiss laws lead them to undeclared and poorly paid jobs. This exposes them to exploitation and deprives them of housing, social protection and health insurance. Lack of health care is very common among these people, who live with the constant fear of being reported or deported.

The link between the three dimensions and social vulnerabilities is also observed in relation to work. All these limitations can translate into both a precarious housing situation and the need to practice transactional sex in exchange for economic, housing and other resources.

That is, the difficulties faced by migrants in a host country condition their behaviours and sexual relations, and increase their vulnerability to HIV, especially due to an increase in transactional relationships. On the other hand, limitations to access antiretroviral treatment increase their risk of developing advanced HIV disease.

The structural conditions in which interactions with sexual partners occur may increase the vulnerability of these people to HIV. Thus, they can be seen in situations where they cannot negotiate safe practices. Added to this, in the case of needing post-exposure prophylaxis against HIV (PEP), you may find stigmatizing attitudes towards sex work.

In their conclusions, the study authors indicate that these findings have important implications for HIV prevention and HIV treatment in the context of migration. For example, they highlight the need for a structural shift towards greater equity in health care and universal access to it. In addition, if migrants had greater economic and legal security (for example, thanks to economic benefits and long-term residence permits) they would be less likely to enter into intimate relationships with an unequal balance of power. They also suggest that HIV and AIDS prevention among the migrant population requires a review of social and cultural structures and power systems, such as sexism, cisgenderism and racism.

These conclusions are in line with those from the aMASE study (Expanding access to health services for immigrants in Europe), carried out in 10 European countries. The study not only reflected that a large proportion of migrants were infected in their host country (agent the preconceived idea that they had been infected in their home country), but also advocated that migrant communities be considered more actively in HIV prevention campaigns.