Latest epidemiology on migrants in the European Union - ECDC

European Centre for Disease Prevention and
Control:
Latest epidemiology on migrants in the
European Union
Teymur Noori, ECDC
22nd International AIDS Conference, Amsterdam 2018
2018 European African HIV/AIDS & Hepatitis C Community Summit. "Our Voices Matter for a lasting solution!!"
Sunday 22 July 2018 – 11:30-12:00

Outline
1. Surveillance of infectious diseases among migrants in the
EU/EEA
2. HIV among migrants in the EU/EEA
− Epidemiological data
− Continuum of care among migrants
− Testing data
− Prevention data
3. Evidence-based guidance on screening and vaccination of
infectious diseases among newly arrived migrants in the
EU/EEA

Putting migrant health and infectious
diseases in context
510 million persons living in the EU-28 in 2015*
*Eurostat: http://ec.europa.eu/eurostat/statistics-explained/index.php/Migration_and_migrant_population_statistics
54.4 million foreign-born
(10.7%)*
35.1 million born outside
the EU-28 (6.9%)*
Health
issues
Infectious
diseases

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

Migrant related variables collected through TESSy
Variable HIV TB HBV HCV Gonorrhoea Syphilis Measles Rubella Malaria
Chagas
disease*
Country of
birth
Country of
nationality
Probable
country of
infection
Imported
Region of
origin
*Not under EU surveillance
ECDC. Assessing the burden of key infectious diseases affecting migrant populations in the EU/EEA. Stockholm: ECDC; 2014.

Completeness (%) of migrant related variables
collected through TESSy (2011-2013)
Variable HIV TB HBV HCV Gonorrhoea Syphilis Measles Rubella Malaria
Chagas
disease*
Country of
birth
62 95.6 19.1 14.4 17 26
Country of
nationality
28 96.3 6.8 6.6 4 17
Probable
country of
infection
17 20.2 7.6 9 10 3 5 90.1
Imported 39.1 40.5 82 96 98.7
Region of
origin
62.5
*Not under EU surveillance

Estimated new HIV infections are decreasing globally
1,400,000
1,600,000
1,800,000
2,000,000
2,200,000
2,400,000
2,600,000
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Global
Source: UNAIDS/WHO global estimates.

Estimated new HIV infections are decreasing globally,
but increasing in the WHO European Region
0
20,000
40,000
60,000
80,000
100,000
120,000
140,000
160,000
180,000
1,400,000
1,600,000
1,800,000
2,000,000
2,200,000
2,400,000
2,600,000
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Global
WHO European
Region
Source: ECDC/WHO (2016). HIV/AIDS Surveillance in Europe, 2015. UNAIDS/WHO global estimates.

Estimated new HIV infections are decreasing globally,
but increasing in the WHO European Region
0
20,000
40,000
60,000
80,000
100,000
120,000
140,000
160,000
180,000
1,400,000
1,600,000
1,800,000
2,000,000
2,200,000
2,400,000
2,600,000
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Global
WHO European
Region
East
West
Centre
Source: ECDC/WHO (2016). HIV/AIDS Surveillance in Europe, 2015. UNAIDS/WHO global estimates.

>160 000 persons were diagnosed with HIV in the
WHO European Region in 2016
Source: ECDC/WHO (2017). HIV/AIDS Surveillance in Europe 2017– 2016 data
East
80%
≈ 128,000
cases
Centre
4%
≈ 5,800
cases
West
16%
≈ 26,000
cases

HIV diagnoses per 100,000 population
EU/EEA vs non-EU/EEA, 2007-2016
0
5
10
15
20
25
30
35
40
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
HIVdiagnosesper100000popoulation
Year of diagnosis
EU/EEA
non-EU/EEA

13Source: ECDC/WHO (2017). HIV/AIDS Surveillance in Europe 2017– 2016 data
HIV diagnoses, by mode of
transmission, 2007-2016, EU/EEA
Injecting drug use
Heterosexual all
Sex between men
Other/
undetermined
Mother-to-child
transmission
Data is adjusted for reporting delay. Cases from Estonia and Poland excluded due to incomplete reporting on transmission mode during the
period; cases from Italy and Spain excluded due to increasing national coverage over the period.
0
2000
4000
6000
8000
10000
12000
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

14
Percentage of new HIV diagnoses, by
transmission and country, EU/EEA, 2016
Injecting
drug use
Heterosexual
Sex between men
Other/
undetermined
51%

15Source: ECDC/WHO (2017). HIV/AIDS Surveillance in Europe 2017– 2016 data
HIV diagnoses, by mode of
transmission, 2007-2016, EU/EEA
Heterosexual all
Sex between men
Data is adjusted for reporting delay. Cases from Estonia and Poland excluded due to incomplete reporting on transmission mode during the
period; cases from Italy and Spain excluded due to increasing national coverage over the period.
0
2000
4000
6000
8000
10000
12000
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

New HIV diagnoses, by year of
diagnosis, transmission and migration
status, EU/EEA, 2007-2016
0
1000
2000
3000
4000
5000
6000
7000
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Numberofdiagnoses
Year of diagnosis
Heterosexual (born in reporting country) Heterosexual (foreign-born)
-36%
-9%

New HIV diagnoses, by year of
diagnosis, transmission and migration
status, EU/EEA, 2007-2016
0
1000
2000
3000
4000
5000
6000
7000
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Numberofdiagnoses
Year of diagnosis
MSM (born in reporting country) MSM (foreign-born)
Heterosexual (born in reporting country) Heterosexual (foreign-born)
-2%
+58%
-36%
-9%

Proportion of HIV diagnoses among natives and migrants*
EU/EEA, 2016
Source: ECDC/WHO (2015). HIV/AIDS Surveillance in Europe, 2014
* Migrants are all persons born outside of the country in which they were diagnosed
40%
60%
Migrants
Natives

Proportion HIV diagnoses in migrants*
by origin of report, EU/EEA 2016
* Migrants are all persons born outside of the country in
which the diagnosis was made.
New diagnoses in
migrants from Sub-
Saharan Africa
New diagnoses in
migrants from other
regions
40%

Proportion HIV diagnoses in migrants*
by origin of report, EU/EEA 2016
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Poland
Latvia
Lithuania
Bulgaria
Slovakia
Estonia
Croatia
Slovenia
Greece
Czech Republic
Portugal
Spain
Italy
Germany
Netherlands
EU/EEA Average
Austria
Cyprus
Denmark
Finland
France
Iceland
United Kingdom
Norway
Belgium
Luxembourg
Ireland
Malta
Sweden
Percentage of new diagnoses
Sub-Saharan Africa
Central and Eastern Europe
Western Europe
Latin America and Caribbean
South and Southeast Asia
Other
40%

21
Proportion of persons diagnosed late*
by demographic, EU/EEA, 2016
Age group (years) Transmission Region of originGender
0
10
20
30
40
50
60
70
%diagnosedlate(<350mm3)
*Diagnosed late=CD4<350 cells/mm3 at diagnosis
48%

22
Where do migrants acquire
HIV infection (prior to or after
arrival to the EU)?

Where do migrants get infected with HIV (prior
to or after arrival to the EU)?
18%
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): 1961-6
7%
Clinic-based estimate CD4-based estimate
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): 1961-6

18%
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): 1961-6
24%
7%
Clinic-based estimate CD4-based estimate
46%
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): 1961-6
Where do migrants get infected with HIV (prior
to or after arrival to the EU)?

Proportion of migrants who acquired HIV post-migration
in Belgium, Italy, Sweden and the United Kingdom
 Multi-country estimates
among 24,000 migrants
diagnosed between 2000-
2013
 Over 1/3 of migrants
diagnosed acquired HIV
post-migration in 2011
 MSM migrants were
particularly affected with
more than 2/5 estimated
to have acquired HIV post-
migration
Source: Zheng et al. Post migration acquisition of HIV: Estimates from four European countries. 2017. Submitted to peer-reviewed journal.

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 2000-
2013
 Over 1/3 of migrants
diagnosed acquired HIV
post-migration in 2011
 MSM migrants were
particularly affected with
more than 2/5 estimated
to have acquired HIV post-
migration
Source: Zheng et al. Post migration acquisition of HIV: Estimates from four European countries. 2017. Submitted to peer-reviewed journal.
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
 Countries should develop and deliver targeted primary HIV
prevention programmes to migrant populations at risk
− Including for those visiting friends and relatives

Continuum of care in migrants in Europe and Central Asia

Fast Track Targets by 2020
73%
of all people living
with HIV
VIRALLY
SUPPRESSED
=
Target 1 Target 2 Target 3 Overall target
diagnosed with HIV
ON ART
living with HIV
DIAGNOSED
on ART
VIRALLY
SUPPRESSED

Availability of data along the various stages of the
continuum of care, Migrants
41
3
7
5
3 2
41
13
4
12
10
6
0
5
10
15
20
25
30
35
40
45
No data Estimated nr of
migrants living
with HIV
Diagnosed On ART Virally
suppressed
All four stages
Nrofcountriesreportingdata
2016 2018
Source: ECDC. Dublin Declaration monitoring 2018; validated unpublished data.

Progress toward achieving the first 90, migrants:
Target 1: 90% of all PLHIV who know their status (n=7)
Target reached
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
United Kingdom Luxembourg Austria Finland France Israel Czech Republic
Global target 90%
Below target

Progress toward achieving the second 90, migrants:
Target 2: 90% of those diagnosed on ART (n=10)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
United
Kingdom
Sweden France Luxembourg Belgium Austria Slovakia Czech
Republic
Greece Finland
Target reached
Global target 90%
Below target

Availability of ART for undocumented migrants
2018
Source: ECDC. From Dublin to Rome: ten years of responding to HIV in Europe and Central Asia: Stockholm, ECDC; 2014

Availability of ART for undocumented migrants
2018
Source: ECDC. From Dublin to Rome: ten years of responding to HIV in Europe and Central Asia: Stockholm, ECDC; 2014
Why is it important to provide ART to
undocumented migrants:
 From a clinical perspective, treatment reduces morbidity
and mortality
 From a public health perspective, you are 96% less likely to
transmit HIV if you are on treatment and virally suppressed
 From a human rights perspective, it is the right thing to do

Progress toward achieving the third 90, migrants:
Target 3: 90% of those on ART virally suppressed (n=8)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
United Kingdom France Finland Belgium Sweden Czech Republic Luxembourg Austria
Target reached
Global target 90%
Below target

Progress toward achieving the overall target among
migrants: 73% of all PLHIV virally suppressed (n=6)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
United Kingdom Luxembourg France Austria Finland Czech Republic
Target reached
Global target 73%
Below target

Comparison of the continuum of care for key
populations, 2018
100%
86%
78% 75%
100%
90%
50%
39%
100%
84%
75% 71%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
LivingwithHIV
Diagnosed
ReceivingART
Virallysuppressed
LivingwithHIV
Diagnosed
ReceivingART
Virallysuppressed
LivingwithHIV
Diagnosed
ReceivingART
Virallysuppressed
MSM (n=10) PWID (n=8) Migrants (n=6)

100%
86%
78% 75%
100%
90%
50%
39%
100%
84%
75% 71%
100%
87%
77%
70%
100%
86%
75%
67%
100%
88%
81%
76%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
LivingwithHIV
Diagnosed
ReceivingART
Virallysuppressed
LivingwithHIV
Diagnosed
ReceivingART
Virallysuppressed
LivingwithHIV
Diagnosed
ReceivingART
Virallysuppressed
MSM (n=10) PWID (n=8) Migrants (n=6)
Comparison of the continuum of care for key
populations against national continua, 2018

HIV testing in Europe and Central Asia

Are new innovative approaches to HIV testing
included in national HIV testing guidelines? (n=55)
Testing approaches Yes No
No
response
Community-based testing delivered by
trained medical staff
28 12 15
Community-based testing delivered by non-
medical staff (e.g. trained lay people)
14 26 15
Self-sampling kits 4 36 15
Self-testing kits 9 32 14
Source: Dublin Declaration monitoring 2018; validated unpublished data.
Up from 2
in 2017

Coverage of community-based testing by trained
medical staff in Europe and Central Asia, 2018

Coverage of community-based testing by lay
providers in Europe and Central Asia, 2018

Coverage of self-sampling in Europe and Central Asia, 2018

Coverage of self-testing in Europe and Central Asia, 2018

Are sufficient funds available for HIV prevention to decrease
the number of new infections in your country? 2018

Status of formal PrEP implementation in Europe
July, 2018

What issues are limiting or preventing the
implementation of PrEP in your country?
0% 20% 40% 60% 80% 100%
Drug resistance
Adherence
Concerns about lower condom use
Increases in STIs
Feasibility
Cost of service delivery
Limited tehnical capacity
Cost of the drug
Percentage of countries (n=33)
High importance Medium Importance Low importance

Evidence-based guidance on screening and
vaccination of infectious diseases among newly
arrived migrants in the EU/EEA

Project objectives
1. Collect and synthesise the scientific evidence on screening and
prevention for infectious diseases among migrants, taking into
account the:
a.Individual and public health benefits of screening
b.Limitations and ethical considerations regarding screening
c. Screening options
d.Treatment options
e.Costs-effectiveness of screening and treatment
2. Review national and international policies, practices
and guidelines on screening for ID among migrants
3. Consult key experts in countries working with
prevention of infectious diseases among migrants
4. Draft evidence-based guidance on screening and prevention of
infectious diseases among migrants

Target audience of the guidance
 National and sub-national policy makers in EU/EEA Member States
 Health practitioners
 NGOs and patient organisations working with migrant
communities

Evidence-based guidance for prevention of infectious
diseases among newly arrived migrants in the EU/EEA
1st Scientific panel
meeting (Nov 2015)
2nd Scientific panel
meeting (Oct 2016)
Reports available from: https://www.researchgate.net/profile/Teymur_Noori

Pre-meeting survey – Sept 2015
Report available from: https://www.researchgate.net/publication/287197954_Meeting_report_Evidence-based_guidance_--
_Prevention_of_Infectious_Diseases_Among_Newly_Arrived_Migrants_to_the_EUEEA

Are newly arrived migrants having an impact on
infectious disease epidemiology in your country?

Does your country have national guidelines on
screening for infectious diseases among migrants?

Which infectious diseases are migrants
screened for in your country?

Which conditions would you want ECDC to
prioritise when developing guidance?

Would European guidance on screening for
infectious diseases among migrants be useful?

Priority conditions in ECDC guidance –
systematic reviews
Active TB Latent TB HIV
Hepatitis B Hepatitis C
Intestinal parasites
• Schistosomiasis
• Strongyloidiasis
Routine vaccinations
•Measles • Diphtheria
•Mumps • Tetanus
•Rubella • Pertussis
•Hib • Polio

Methods
 Phase 1: conduct a systematic
review of reviews and
guidelines
 Phase 2: conduct a systematic
search and selection for
economic evaluations on
resource use, costs and cost-
effectiveness
 Phase 3: update systematic
reviews of effectiveness
 Phase 4: supplement with de
novo systematic reviews
 Evidence on screening for infectious diseases among
migrants is limited
 Therefore the certainty of the recommendations we are
able to make are weak
 Very challenging task to develop guidance in the area of
migrant health

DRAFT evidence-based statements: HIV
Condition Evidence-based statement Strength of opinion;
certainty of evidence (GRADE)
HIV Offer testing for HIV to migrants who
have lived in communities with high
prevalence of HIV (≥1%)
Conditional recommendation based
on prevalence of HIV in country of
origin (>1%)
Certainty of evidence: moderate
Offer testing for HIV to all
adolescents and adult migrants at
high risk for exposure to HIV
Conditional recommendation based
on prevalence of HIV in migrants’
community in host country
Certainty of evidence: low
Source: ECDC. Public health guidance on screening and vaccination for infectious diseases in newly arrived migrants within the EU/EEA. Stockholm: ECDC; 2018.
Under review.

Table: HIV screening recommendations for migrants in selected low
HIV prevalence countries
Country When, how and who to test
Ireland (25) Offer test for HIV Ag/Ab to:
 All women attending antenatal services
 All those with risk factors for HIV including but not limited to:
- From high HIV prevalence countries (>1%)
- Concurrent sexually transmitted infection
- People who inject drugs (PWID)
- Sex workers and those who have been trafficked
- Men who have sex with men (MSM)
 Concurrent TB infection
 Refer all positive cases to specialist services for review
Italy (30) During the second phase of reception, offer all migrants culturally-sensitive counselling for HIV
Offer HIV test to:
 all migrants aged ≥ 16 years coming from high prevalence (1%) Countries
 pregnant and lactating migrant women
 those exposed to high risk (blood transfusions in origin country, sexual abuse or multiple
sexual partners)
 concomitant presence of active TB or IST
Migrants < 16 years should be offered HIV test if:
 born from HIV positive mother
 early sexual activities
 history of sexual abuse
 concomitant presence of active TB or IST
UK (180, 181) HIV testing in the UK is recommended in selected specialist services, in certain clinical, community and
home settings, where there is risk of transmission to others, and for high risk groups.
High risk groups include, among others, people born in a country of high diagnosed HIV prevalence
(>1%), those reporting sexual contact with people from countries of high HIV prevalence and black
African populations.
For all high risk groups, routine testing is recommended annually if negative.
Source: ECDC. Public health guidance on screening and vaccination for infectious diseases in newly arrived migrants within the EU/EEA. Stockholm: ECDC; 2018.
Under review.

Conclusions
 Most migrants entering the EU/EEA are healthy and do not represent a threat to
Europe with respect to infectious diseases
 Some sub-groups of migrants carry a disproportionate burden of infectious
diseases, including HIV
 A significant proportion of migrants get infected with HIV post-migration
 From both a clinical and public health perspective, it is therefore crucial to:
1. Tailor and target testing/screening programmes so as to diagnose early and reduce
the fraction of people living with undiagnosed infectious disease
2. Link people to care as early as possible
3. Provide equitable treatment
4. Improve health outcomes and further reduce onward transmission
 ECDC to launch guidance on screening for infectious diseases among newly
arrived migrants to the EU/EEA in the autumn 2018

Thank you
teymur.noori@ecdc.europa.eu

Latest epidemiology on migrants in the European Union - ECDC

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