Many Countries Deny Antiretrovirals to Undocumented Migrants

Marcia Frellick

October 27, 2015

BARCELONA, Spain — Migrants who have come to Europe from low- and middle-income countries who become infected with HIV start antiretroviral therapy later than native populations, and when their CD4 counts are lower, new research indicates.

A large proportion of people living with HIV in Europe are migrants, and this finding means that they are more likely develop AIDS-related illnesses, said Julia del Amo, MD, PhD, from the National Center of Epidemiology, Institute of Health Carlos III, in Madrid.

Dr del Amo presented early findings from the aMASE — Advancing Migrant Access to Health Services in Europe — clinical study here at the 15th European AIDS Conference. Results come from a survey of 2249 migrants living in nine European countries.

Most respondents acquired the HIV virus in the country they migrated to, rather than in their home country.

In general, most governments in the European Union and European Economic Area have full treatment programs for migrants, according to a 2014 progress report from the European Centre for Disease Prevention and Control. Only in Finland, Italy, and Latvia is treatment not delivered at scale.

However, the situation is different for undocumented migrants, who receive full HIV treatment in only 15 of 27 countries. In other countries, migrants come to clinics to get tested and don't get treatment if they can't produce documents, or they don't even come forward for testing because they know they're not entitled, Dr del Amo said.

 
It's a public health disaster. Why test and not treat?
 

"It's a public health disaster," Dr del Amo told Medscape Medical News. "Why test and not treat?" She pointed out that denying antiretroviral therapy to undocumented migrants hinders progress toward the elimination of HIV.

Spain stopped providing antiretroviral therapy for undocumented migrants in 2012, but after pressure from the medical community and nongovernmental organizations, treatment was reinstated. The implementation of antiretroviral therapy, however, differs among the 17 autonomous regions of Spain, Dr del Amo reported.

"Physicians in Spain and other countries tell me that somehow they manage to get through the system, but that's not the way to go — to get around it. It should be policy," she said.

Linkage to care is also important, said Justyna Kowalska, MD, PhD, from the Hospital for Infectious Diseases in Warsaw, Poland.

"As much effort must be invested in linking people who test HIV-positive into care as is put into scaling up testing services," she said.

There is no standard timeline for linkage to care in Europe, which means it can vary substantially, Dr Kowalska explained. Sometimes it is measured from diagnosis to first CD4 count, and sometimes it is measured from diagnosis to first clinic visit.

A critical component of linkage is a central registry. In the United Kingdom and Germany, for example, special codes are used to identify a patient's path from testing to clinics. In Ukraine, however, there is no central registry at all, she said.

The healthcare system often influences where a patient seeks care, and when patients do enter care, the system can be fractured. In some countries, antiretroviral therapy can be prescribed only by an infectious disease doctor affiliated with a hospital. For patients who choose an HIV specialist as their primary doctor, the specialist becomes the person responsible for all vaccinations, cancer screenings, and the management of comorbidities.

Evidence points to the need for a "shared care" model for people with HIV, said Markus Bickel, MD, from the HIVCENTER in Frankfurt, Germany.

"Shared care will be increasingly important because we're facing an aging population, and cancer prevention will play a bigger role," he said. This will necessitate more testing and monitoring.

The European AIDS Clinical Society released updated guidelines last week, as reported by Medscape Medical News.

That update calls for aggressive monitoring of renal function in people with a declining estimated glomerular filtration rate or a rate below 90 mL/min. It also recommends the use of chronic kidney disease risk equations, screening for depression, and smoking cessation.

Dr del Amo, Dr Kowalska, and Dr Bickel have disclosed no relevant financial relationships.

15th European AIDS Conference: Presented October 24, 2015.

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