HIV outcomes among migrants from low- and middle-income countries living in high-income countries: a review of recent evidence

Abstract

Purpose of review

Migrants living in high-income countries are disproportionately affected by HIV infection and frequently have characteristics associated with poor HIV clinical outcomes. HIV epidemiology among migrants is influenced by changes in migration patterns and variations in transmission risk behaviors. Here we review the recently published literature on known HIV outcomes among migrants from low- and middle-income countries living in high-income countries.

Recent findings

High proportions of migrants acquire HIV after migration, and this group frequently presents to care late. Once established in care, migrants are often more likely to experience worse HIV treatment outcomes compared to native populations. Multiple individual and structural factors influence HIV diagnosis and treatment outcomes among migrants, including disruption of social networks, increased sexual risk behaviors, communication barriers, limited access to care, and stigma. Few studies have examined interventions targeted at improving HIV outcomes among migrants.

Summary

Stigma and limited access to care appear to be primary drivers of poor HIV outcomes among migrants in high-income countries. Addressing these disparities is limited by difficulties in identifying and monitoring this population as well as a lack of evidence regarding appropriate interventions for migrants living with HIV. Improving outcomes for this group requires interventions that are specifically targeted at this marginalized and growing population.

Introduction

Worldwide, there are an estimated 244 million migrants, defined as people living temporarily or permanently outside their country of birth [1]. While 75% of migrants were born in low and middle-income countries, over half reside in high-income countries in Europe, North America and Australasia [1]. Migrants in high-income countries face particular circumstances associated with poor health outcomes, including restricted access to healthcare, poverty, limited education, linguistic and cultural barriers to accessing care, and stigma [2–5]. These factors place migrants at risk for acquiring HIV infection and experiencing poor HIV-related outcomes.

Migrants living in high-income countries are disproportionately affected by HIV infection. The proportion of new HIV diagnoses who are migrants exceeds the percentage of foreign-born persons in the general population in nearly all high-income countries, and is as high as 70% in some European countries [6–8] (Figure 1). Migrant persons living with HIV (PLWH) frequently have characteristics associated with poor HIV clinical outcomes [11–18]. Migrants are also more likely than non-migrants to die from HIV [19].

Figure 1.

Map showing the percentage of migrants among new HIV diagnoses in high-income countries, based on surveillance data. (A) Canada, 2015 (migrants defined based on heterosexual contact and born in an HIV-endemic country) [9]; United States, 2010–2014 [10], (B) Australia, 2016 [Surveillance Evaluation and Research Program, Kirby Institute, University of New South Wales Sydney, personal communication, September 2017], (C) European Union/European Economic Area, 2015 [8].

Legend: Percent migrants among new HIV diagnoses in high-income countries

The epidemiology of HIV among migrants is influenced by characteristics of the migrating population, motivations for relocation, and environments of both the origin and host countries. Furthermore, these factors may change over time given political and economic conditions [6, 10, 20, 21]. A current understanding of HIV outcomes among migrants and the factors driving them is necessary to target interventions to improve health outcomes of these important and growing populations. Here, we summarize information published since 2015 on known HIV outcomes among migrants, focusing on persons from low- and middle-income countries who are living in high-income countries.

Place of HIV acquisition

Prior research based largely on self-report or CD4 testing suggested that most migrants living with HIV were infected prior to migration [22–24]. Recent investigations from Europe utilizing more robust methods indicate that high proportions of migrants acquire HIV infection after migration. Alvarez-Delarco, et al, estimated place of acquisition among migrants in 9 European countries diagnosed with HIV in the preceding 5 years. Using Bayesian models incorporating migration history, HIV risk factor and clinical characteristics, the authors estimated that 63% of patients studied acquired HIV after migration [25**]. Similarly, in the ANRS PARCOURS study, French investigators used survey data, medical records and laboratory data to assess place of HIV acquisition for African PLWH in Paris, determining that 49% had been infected after migration [26].

Data from North America regarding place of acquisition are similar, though more limited. A large, nationally representative transmission network analysis of HIV-1 polymerase sequences reported to the U.S. National HIV Surveillance System between 2001–2013 found that among foreign-born persons linked to at least one other person in the network, 62% had partners who were born in the U.S [27*]. Wiewel, et al., analyzed interview data from persons newly diagnosed with HIV in New York City, estimating that 61% of migrants were infected after arrival in the United States (US) [28]. Small phylogenetic studies of migrant groups in the US have provided additional evidence for local HIV transmission [29, 30].

In both the European and North American studies cited, post-migration infection was highest among migrants from Latin America and the Caribbean and lowest among Africans. Place of acquisition also varied by HIV risk factor, with post-migration infection highest among injection drug users and men who have sex with men (MSM), and lowest among persons who reported heterosexual sex as their primary HIV risk factor. Other predictors of post-migration HIV acquisition include young age, male sex, and longer duration of residence in host country as predictors of post-migration HIV acquisition [25, 26, 31].

The disproportionate risk of acquiring HIV infection that migrants face in their host countries likely results from a combination of factors, including stigma, increased risk behaviors, and limited access to HIV prevention services. Qualitative research with migrant communities in Canada and New Zealand found that migrants understood how HIV is transmitted and ways to prevent infection, yet expressed reluctance to use condoms or undergo HIV testing because of the high degree of stigma surrounding HIV in their communities [32, 33]. Zhang, et al., conducted a study conducted at the US-Mexico border examining sexual practices of male migrants at various stages of migration. Compared to participants in the pre-departure phase of migration, those in transit or returning from the US were more likely to report sex with casual female partners, sex with female sex workers, unprotected vaginal or anal sex, and substance use before or during sex [34**]. Additionally, migrants face isolation, disruption of social networks, hostility, and unique social and legal circumstances, all of which may act as barriers to accessing HIV prevention services [35–37, 38*]. For example, a recent study of MSM in the US found that, compared to those born in the US, migrant MSM were less likely to use pre-exposure prophylaxis for HIV prevention [39].

Entry into HIV care

Regardless of place of acquisition, migrants present late to care. In two very large, multi-country European cohort studies, the median CD4 count at entry to care was substantially lower among migrants compared to European natives [6, 40**]. In both studies, migrants from sub-Saharan Africa – who comprised over half of migrants in each analysis – were more likely to be diagnosed with AIDS and had the lowest median CD4 counts. In the Netherlands from 1996–2014, the proportion of late presenters (defined as CD4 count < 350 cells/mm3) among migrants ranged from 63–79%, depending on region of origin [41]. More worrisome, in a German national cohort from 1999–2013, while median CD4 count at HIV diagnosis increased for native Germans and migrants from Central Europe, it did not change for other migrant groups over this time period [42].

Limited information on disease stage at diagnosis among migrants is available from regions outside of Europe. A cross-sectional, nationally representative survey of over 12,000 PLWH in medical care in the US found no differences between migrants and native-born persons in terms of current disease stage, but did not report on CD4 count or disease stage at entry to care [43**]. In single cohort studies in several US states, migrants were more likely than non-migrants to be diagnosed with AIDS within 3 month of HIV diagnosis [44, 45]; migrants also entered care with lower CD4 counts [46, 47]. Among patients enrolled in the Australian HIV Observational Database cohort, median CD4 count at diagnosis was lower among migrants than among native Australians [48].

Several reasons likely contribute to migrants’ late presentation to care. Migrant PLWH may not know they are infected. Nationally representative studies of Africans in Belgium and African and Caribbean migrants in the Netherlands estimated that 73% and 48% of migrants did not know their HIV status [49*, 50], compared to 20% and 34% of the general populations, respectively [49*, 51]. In a representative sample in the US, 49% of Black and Hispanic migrants had never been tested for HIV [52**], despite these groups being at disproportionately high risk [53, 54].

Multiple individual, structural and cultural barriers limit access to HIV testing, including lack of insurance, cost of medical care, being undocumented, stigma surrounding testing itself and potentially positive results, and lack of social support [32, 55–59**]. In a qualitative study exemplifying many of these themes, East African women living in the US endorsed feeling that HIV testing implied they had engaged in ‘bad’ behavior, that their community would judge them negatively for getting tested, that getting tested might signal distrust or infidelity, and that information regarding HIV diagnosis is not confidential [59**].

HIV outcomes once in care

Once established in care, there is mixed evidence with respect to migrants’ clinical outcomes. In Europe, migrant PLWH tend to fare worse than native-born persons. In the Netherlands, African migrants were nearly three times as likely to not attend clinic visits as Dutch natives [60]. Despite having access to medical insurance, undocumented migrants with HIV infection in Italy were eight times more likely to be lost to follow-up than persons born in Italy [61]. Recently published data from the COHERE collaborative demonstrate that, depending on region of origin, migrant men were 25–45% less likely to initiate antiretroviral therapy (ART) even when adjusting for baseline CD4 count [40, 62]. In several European studies, migrants were also more likely than native-born persons to experience virologic failure [63, 64].

Data from regions outside of Europe are fewer and inconsistent. In a Medical Monitoring Project study comparing migrant and US-born PLWH, migrants had equal rates of ART prescription (91%) and slightly higher rates of viral suppression (77% vs. 73%) [43**]. In several single-cohort studies from Florida, migrant PLWH were less likely to be retained in care or virally suppressed compared to native-born persons [65, 66]. However, in studies conducted in Massachusetts and New York, migrants – including undocumented migrants – had similar rates of retention in care and viral suppression compared to native-born PLWH [46, 67]. In a single study from 10 clinics in Ontario, Canada, migrant status was predictive of retention in care [68]. In an Australian study, no significant differences were found between migrants and native Australians with respect to viral suppression, loss to follow up, or progression to AIDS [48].

Linguistic and cultural barriers, poverty, poor health literacy, lack of social support, and lack of HIV disclosure are major barriers for migrants to accessing HIV services (69, 70*, 71–75). Differences in care outcomes may also be secondary to variability in social service availability; even when present, migrants may lack familiarity with available social services, and may be hesitant to seek out these services if they are undocumented [76]. HIV outcomes may be influenced by multiple barriers migrants face in accessing mental health care [77], however, the burden of psychiatric disease among migrants living with HIV has not been well-characterized. A study in France found lower prevalence of depression among African migrants living with HIV compared to other PLWH [78], and several U.S. studies have demonstrated a lower prevalence of substance use disorders among migrants compared to non-migrants [43**, 47]. Additionally, some geographical differences in HIV outcomes among migrants are likely related to policies affecting their access to HIV services. Considerable differences exist among countries in Europe with regards to provision of ART to migrants, particularly undocumented migrants [79, 80], and medical insurance coverage for migrant PLWH in the US varies substantially between states [81].

Once in care, migrants also face unique barriers to retention in care, adherence to ART and viral suppression. Migrants’ high level of mobility is predictive of poor engagement in HIV care and ART disruption [82, 83]. Lack of social support, which is associated with poor adherence to ART and medical appointments among general populations [84], may be particularly influential in migrant communities, where many rely on support from their social networks for daily survival [85]. Although depression has been identified as a risk factor for poor treatment adherence, a Canadian study found no association between symptoms of depression and ART adherence for migrants, while native Canadians with depression had worse adherence to medications [86]. A large, representative multi-country survey in Europe is currently underway that should provide additional insight about clinical, structural, cultural and financial barriers to HIV diagnosis and access to care [87].

Interventions to improve outcomes and gaps in the literature

The literature reviewed suggests that migrant PLWH migrants are increasingly acquiring HIV infection after migration, that they are presenting to care late, and that being a migrant is frequently a predictor of poor engagement in care (Table 1). These findings hint at important targets for interventions to improve HIV outcomes for migrants; however, few studies have evaluated interventions to improve these outcomes among migrants.

Table 1.

Important HIV outcomes and selected determinants of outcomes among migrants from low- and middle-income countries living in high-income countries.

Important HIV outcomes	Major findings among migrants	Selected determinants of outcomes	Key references
HIV acquisition	High proportions acquire HIV post-migration	Disruption of social networks Increased risk behaviors Limited access to HIV prevention services	25–28; 34; 36–38
Entry into care	Limited HIV testing Often unaware of diagnosis Enter care late	Lack of health insurance Limited access to/knowledge of testing Fear of immigration authorities Stigma related to HIV and immigration status Lack of social support	6; 41; 44–45; 48–51; 52; 55–59
Clinical outcomes once established in HIV care	At risk of: Loss to follow-up Poor adherence to ART Lack of viral suppression	Stigma related to HIV and immigration status Lack of social support Linguistic and cultural barriers in health care settings Limited access to HIV care and social services	40; 43; 62; 64; 67–68; 70

Interventions for HIV prevention and testing

The limited research on interventions to prevent HIV and diagnose HIV early among migrants has largely been conducted in the US. Two studies by Rhodes, et al., examined the effect of training Spanish-speaking peer navigators on HIV prevention and testing behaviors among Latinos in North Carolina. In adjusted analyses, participants in the intervention arm were substantially more likely to report condom use or HIV testing than those in the control arm [88**, 89]. Investigators in Washington State studied an intervention promoting HIV testing in traditional and social media, coupled with free home HIV testing kits. Participants exposed to the intervention reported increased HIV testing, though there was no change in condom use [90]. An intervention targeting African and Caribbean migrants in Philadelphia that bundled HIV testing with diabetes and hypertension screening found very high uptake (92%), compared to prior uptake of stand-alone HIV testing (20%) [91]. Together, these studies suggest methods that reduce stigma surrounding HIV prevention – by utilizing peers, or normalizing testing – can be effective in promoting desired outcomes.

These approaches are promising, although they face potential limitations. Scalability of peer navigator interventions is a concern given their time-intensive nature. Questions also remain regarding generalizability outside the US, given differences in social policies across countries and in the epidemiology of the HIV epidemic among migrants. Despite the higher proportion of PLWH in Europe who are migrants, no published studies from this region have examined interventions that target migrants and focus on HIV prevention and early diagnosis. While European investigators and policy makers have proposed routine, provider-initiated HIV testing or community-based testing as ways to reach patients not in regular medical care [92–94], these approaches have not been rigorously tested in migrants.

Improving access to and engagement in HIV care for migrants

Barriers affecting linkage to and retention in HIV care for migrants include systems-level barriers (e.g. health insurance, lack of migrant-friendly health settings) and individual barriers (e.g. stigma, depression). Few studies have directly evaluated approaches for reducing these barriers. Evidence exists that increasing access to health insurance can promote achievement of health outcomes for migrant PLWH. In New York, where medical insurance is available to undocumented migrant PLWH, one study demonstrated that migrants and non-migrants achieved HIV care cascade outcomes at similar rates [67]. Access to health insurance for undocumented PLWH differs among states in the US, and additional research examining the effect of state policies on HIV outcomes among migrants is needed.

Similarly, few studies have examined interventions promoting engagement in HIV care for migrants. The use of linkage specialists and strength-based counseling to promote re-engagement in HIV care has been successful in reconnecting patients to HIV care [95, 96]. Developing similar programs for migrants might be successful in addressing potential misconceptions about healthcare delivery and reducing stigma. Targeting interventions at HIV care providers could reduce communication barriers for migrants. Two systematic reviews suggest that provider-focused cultural competency interventions increase provider awareness of cultural barriers and change provider behavior [97, 98]. However, few of the studies included in these reviews examined patient outcomes, and none of the studies specifically included migrants with HIV.

Improving our knowledge/understanding of migrant populations

Finally, our understanding of the epidemiology of HIV among migrants is limited by difficulties identifying migrants. our ability to identify them. While HIV surveillance in most European countries accounts for country of origin, migrants may be under-represented even among these data [95]. In North America and Australasia, country of origin is not always systematically collected or available; this may result in improper attributions if data on race/ethnicity are used as a proxy for migrant status [100*]. Migrants may relocate within host countries/regions, and therefore be disproportionately considered lost to care [101]. In all settings, few data are available on undocumented migrants, who frequently avoid interaction with healthcare or public health authorities [102]. Consideration should be given to creative ways to collect data on immigration status and country of origin [47]. Doing so in patient-centric ways that do not further stigmatize migrants would help document and ultimately address inequities in health care and health outcomes for this group.

Conclusion

Migrants from low- and middle-income countries residing in high-income countries are disproportionately affected by HIV. High levels of HIV-related stigma and limited access to care lead to insufficient engagement with HIV prevention and treatment services, placing migrants at risk of poor clinical outcomes. Interventions focused on reducing HIV stigma among migrant populations and expanding access to care are necessary to reduce disparities for this important group.

Key Points.

• High proportions of migrants from low- and middle-income countries living in high-income countries acquire HIV after migration.

• Migrants living in high-income countries consistently present late to care.

• European studies consistently demonstrate poorer HIV outcomes among migrants compared to native-born persons, while data from North America and Australasia are fewer and inconsistent regarding the relative outcomes of these groups.

• Stigma and limited access to care appear to be primary drivers of poor HIV outcomes among migrants in high-income countries, yet few studies have evaluated interventions aimed at addressing these problems.