Table 1.

Summary of WHO and ECDC guidance and recommendations relating to TB, HIV, HBV and HCV infection and refugees and migrants to the WHO European Region

TB	HIV	HBV/HCV
Action plans, guidance, recommendations and strategies
Action plans/strategies for TB control in WHO European Region9–14 Roadmap to implement TB action plan for WHO European Region 2016–2011: divides recommendations for TB management in refugees and migrants into three pillars which form part of the End TB Strategy: refugee and migrant-sensitive care and prevention bold intersectoral policies and systems supportive of refugees and migrants operational research WHO evidence-based guidance/recommendations for implementing the End TB Strategy14–16: Active TB screening: systematic screening in subpopulations with very high TB rates or very poor access to healthcare, such as some refugees and migrants residing in, or coming from, settings with a high TB prevalence85,b LTBI managementc: systematic testing and treatment of LTBI for refugees and migrants according to TB epidemiology and resource availability16 Either IGRA or TST should be usedd Global framework towards TB elimination in low-incidence countries:21,i Interventions for refugees and migrants: Ensure healthcare services are accessible to all refugees and migrants, with individual follow-up Detailed surveillance including disaggregated data on refugee and migrant groups to identify those at highest risk Empower refugee and migrant communities Systematic active TB screening Systematic LTBI screening focussing on groups at high risk of exposures and of progressing to active TB Screening should observe human rights principles and safeguard against stigma, discrimination and deportation Cross-border referral systems with contact tracing and information sharing	WHO Action Plan for the Health Sector response to HIV in the WHO European Region (2017)17: Guiding principle: universal health coverage ensuring all PLWH can access the full range of healthcare services they need Targets covering all areas of HIV management to achieve goals of reducing HIV incidence Eliminate HIV-related discrimination Provide universal treatmente WHO: ART to be initiated in all adult PLWH regardless of clinical stage and CD4 count18 WHO recommends use of PrEP for individuals with ≥3% risk per year of acquiring HIV65,f ECDC recommendations for refugees and migrants19: Offer HIV screening to refugees and migrants who have lived in communities with high HIV prevalence (≥1%) If HIV positive, link to care and treatment as per clinical guidelines Offer testing for HIV to all adolescents and adult refugees and migrants at high risk for exposure to HIV ECDC priority action20: reduce legal and policy barriers in place for undocumented migrants to receive ART	WHO: first action plan for viral hepatitis for the WHO European Region adopted by all 53 Member States in 201621 Action plan goal: eliminating viral hepatitis as a public health threat in the WHO European Region by 2030 through reducing transmission, morbidity and mortality. Global targets of 80% reduction in new chronic infections and 65% reduction in mortality from the 2015 levels. Recommendations to reach these targets that relate to refugees and migrants: Improved data are necessary both within a country’s health system to integrate with broader HIS and in cross-border systems to enable better continuity of care 50% of all people living with chronic hepatitis B and C to be diagnosed by 2020 through improved testing and screening Prevention of mother-to-child transmission through screening pregnant women from countries not implementing universal HBV vaccination and access to post-exposure prophylaxis for newborns, where needed Reducing sexual transmission: ensuring access to dedicated sexual and reproductive health services Strengthening human resources using community-based organizations and peer-support workers for vulnerable populations such as refugees and migrants ECDC recommendations for refugees and migrants19: HBV screening and treatment to be offered to refugees and migrants from intermediate- and high-prevalence countries (≥2 and ≥5% HBsAg positivity, respectively)h HBV vaccination to be offered to all refugee and migrant children and adolescents from intermediate- and high-prevalence countries who do not have evidence of vaccination or immunity HCV antibody screening to be offered to refugee and migrant populations from HCV-endemic countries (≥2% positivity) Refugees and migrants with anti-HCV antibodies to undergo RNA testing and those testing positive to be linked to care and treatment
ECDC recommendations for refugees and migrants19: Offer active TB screening (CXR) soon after arrival for refugees and migrants from high TB incidence countries. Offer LTBI screening (TST/IGRA) soon after arrival for all refugee and migrant populations from high TB incidence countries and link to care and treatment where indicated ECDC recommendations for vulnerable populations, including refugees and migrants:18,a   Outreach teams and mobile units for testing and treatment Involvement of key partners to support patients with their treatment and find contacts Directly observed and video-observed treatment Reminders to improve patient attendance and medication uptake Integration of services Promoting awareness and education to tackle stigma and misconceptions
Discrimination
Refugees and migrants are protected under international law from blanket restrictions on entry, stay and residence based solely on their TB status.22 WHO additional guidance to ensure that sound ethics underpin implementation of the End TB Strategy: screening and testing of refugees and migrants may only be justified with the objective to provide adequate medical care and never to discriminate14	WHO, UN and UNAIDS strongly advise against restricting movement of PLWH.17,18,23 Such restrictions are discriminatory, unjustified and not supported by public health evidence62,g ECDC and WHO strongly advise against mandatory HIV testing of refugees and migrants, although ECDC recommends that refugees and migrants from countries with a high HIV prevalence (≥1%) should be offered an HIV test.17,19 HIV testing should be voluntary and confidential, with informed consent

ART, antiretroviral therapy.

^aFurther details of the ECDC recommendations⁹ are summarized in Table 2, WHO Health Evidence Network synthesis report 74.²⁴

^bBased on very low-quality evidence due to lack of available data. No threshold for high-prevalence is provided; WHO recommends that it must be adapted to the local context and may also change over time.

^cIn high- or upper-middle-income countries with a low TB burden (incidence < 100 cases/100 000 population per year).

^dConditional recommendation, based on low to very low quality of evidence, Appendix Table A6.

^eSee Appendix Box A1, Appendix, for details. The Plan advocates for interventions for key populations (including refugees and migrants) which are tailored to the local context, capacity and resources and ensures that services are relevant, acceptable and accessible. One fast-track action is for improved information with the need to expand cross-border sharing of information to ensure continuity of care of mobile populations, including migrants.

^fThe main obstacles are inability to identify high-risk subgroups of refugees and migrants who would benefit from PrEP and the lack of refugee and migrant-specific services to provide it.²⁵

^gThese policies emphasize the discrimination and stigmatization faced by PLWH, which may cause them to conceal their diagnosis, thereby preventing them accessing the healthcare services they require.²⁶

^hDifferent thresholds of HBsAg positivity were used in the guidelines and policies identified in the search to categorize countries as of low, intermediate and high prevalence.

ⁱFramework authored by multiple WHO employees, including corresponding author. Further details are summarized in Table 1, WHO Health Evidence Network synthesis report 74.²⁴