1. EATG, 2014 Borderless Strategies for MSM and Migrants within Western Europe 1/24 Borderless Strategies for MSM and Migrants within Western Europe

2. EATG, 2014 Borderless Strategies for MSM and Migrants within Western Europe 2/24  HIV in Europe and Western Europe  Prevention  Testing  Treatment and Care  Future steps

3. EATG, 2014 Borderless Strategies for MSM and Migrants within Western Europe 3/24 HIV in Europe  Key populations at higher risk including injecting drug users (IDUs) MSM, transgender people, prisoners, sex workers, migrants and their sexual partners  Large differences accross countries in HIV testing rates, time of diagnosis, accessibility to care and treatment, moment when people present to care, retention rate etc  Important social inequalities  Stigma and discrimination  A fairly stable HIV epidemic with HIV prevalence that changed little since 2004  Relatively small number of people living with HIV and AIDS in the region when compared to areas such as Asia and sub-Saharan Africa  AIDS-related deaths significantly decreased since ART  relative wealthy economies, stable infrastructures and developed healthcare systems Western Europe

4. EATG, 2014 Borderless Strategies for MSM and Migrants within Western Europe 4/24  HIV in Europe and Western Europe  Prevention  Testing  Treatment and Care  Future steps

5. EATG, 2014 Borderless Strategies for MSM and Migrants within Western Europe 5/24 Despite prevention efforts in the past :  still a high number of new HIV diagnoses  increasing rates of HIV transmission particularly among MSM  disproportionate and increasing number of migrants from countries with a high prevalence of HIV/AIDS sub-Saharan Africa predominant way of transmission in Western Europe (prevalence from 0,5 to 17,7%) MSM Account for majority of heterosexuall y acquired HIV infections migrants increasing criminalisation, stigma and discrimination of vulnerable populations across Europe Why do we need cross border actions for MSM and migrants?

6. EATG, 2014 Borderless Strategies for MSM and Migrants within Western Europe 6/24 MSM Resurgence of risky sexual behaviour Sense of complacency since arrival of ART Use of social media and mobile applications Sex while abroad CONTRIBUTING TO ONGOING AND INCREASING HIV TRANSMISSION

7. EATG, 2014 Borderless Strategies for MSM and Migrants within Western Europe 7/24 Migrants Increased HIV vulnerability Social marginalization and exclusion Legal barriers and obstacles Language problems Problems related to employment Health care barriers Low condom use Migrant MSM higher prevalence of HIV higher prevalence of sexually transmitted infections

8. EATG, 2014 Borderless Strategies for MSM and Migrants within Western Europe 8/24 Migrant MSM High vulnerability MSM are often invisible in discussions about HIV prevention among migrants Migrant MSM are at particular risk of HIV acquisition and transmission post- migration: need for targeted (prevention) programmes Surveillance data do not routinely report on migrant MSM (difficult to develop proper prevention programmes) Difficulties accessing HIV and STI testing facilities and also to report some behaviour associated with an increased risk of HIV Stigma and violence related to homophobia and xenophobia

9. EATG, 2014 Borderless Strategies for MSM and Migrants within Western Europe 9/24 Nearly a third (31%) of people in viral 'clusters' were connected to at least one diagnosis in another country SPREAD 14% of migrant MSM men reported unprotected anal sex (UAS) with a steady partner in the previous twelve months; 15% reported UAS with a casual partner in the previous year Migrant MSM men were more likely than non-migrants to report the use of drugs associated with sex and parties A substantial number of gay men in Europe had their last high-risk sex while not in their own country (Spain, Berlin, Paris and London most frequently cited locations) EMIS

10. EATG, 2014 Borderless Strategies for MSM and Migrants within Western Europe 10/24 Prevention needs Specific groups need to be targeted with prevention campaigns in order to maintain high levels of safer sex practices (including new information) Need for better knowledge on risk behaviour of specific groups, including injecting drugs, international (sex) tourism and involvement in commercial sex Need for better knowledge on influence of social networking websites or social networking phone apps (e.g. Facebook, Gaydar, Grindr, etc.) Need for interventions, based on research, that take into account the evolving dynamics of people’s behaviour and sexual lives Adapt prevention, treatment, and care interventions to reach migrant populations Need to remove structural barriers and inequalities e.g.: PEP in Belgium: cost is 25 EUR for people with insurance and 100 EUR without

11. EATG, 2014 Borderless Strategies for MSM and Migrants within Western Europe 11/24  HIV in Europe and Western Europe  Prevention  Testing  Treatment and Care  Future steps

12. EATG, 2014 Borderless Strategies for MSM and Migrants within Western Europe 12/24 In most countries the total number of HIV tests increased since 2004 but: The number of PLHIV unaware of their status is high Rates of late diagnosis have remained high at 49 percent of all new HIV infections People who are most at risk of late diagnosis (migrants, people living in low prevalence areas and older, heterosexual men with stable partners …) are those who are least likely to be targeted or reached by testing programmes Structural barriers to access prevent people at risk from being tested need to be removed

13. EATG, 2014 Borderless Strategies for MSM and Migrants within Western Europe 13/24 MSM (higher testing level) Most new infections come from those unaware - as many as half may happen during primary (or acute) HIV infection Legal barriers: e.g. MSM living in hostile social environments more likely to have negative feelings about sexuality, less likely to test for HIV Migrants (overall late presentation) Cultural, socio-economic, linguistic, and administrative barriers Legal barriers: e.g. problem of compulsory testing (e.g. Greek government)

14. Migrant MSM were 26% more likely than non-migrant MSM men to report difficulty accessing HIV testing Migrant MSM were 32% more likely to state they had encountered problems obtaining STI services EMIS Rates of late presentation were especially high among heterosexual men (66%), individuals originating from Africa (65%) and patients receiving care in southern Europe (57%) COHERE

15. EATG, 2014 Borderless Strategies for MSM and Migrants within Western Europe 15/24 Testing needs Provide accessible HIV testing services for migrants/MSM, e.g. through community organisations and outreach (e.g. support community based testing) Increase awareness among migrant and MSM populations Involve migrant/MSM communities in the design and implementation of interventions or utilise peer support Ensure coherence and define best practice across Western and Central Europe Offer voluntary counselling and testing and provide health information leaflets in a number of foreign languages and adapted to specific groups Performance research Remove legal and other barriers to access testing (e.g. demedicalise testing)

16. EATG, 2014 Borderless Strategies for MSM and Migrants within Western Europe 16/24  HIV in Europe and Western Europe  Prevention  Testing  Treatment and Care  Future steps

17. EATG, 2014 Borderless Strategies for MSM and Migrants within Western Europe 17/24 Antiretroviral treatment is widely available for PLHIV in Western Europe and number of people dying from AIDS was significantly reduced but: Failure to ensure access to HIV treatment for all persons in need could prove detrimental to efforts to ameliorate the HIV epidemic Restrictive treatment policies Unclear return policies for migrants in need of treatment A high number of late diagnoses leading to less well response to ART Challenges of ageing and disease progression Poor surveillance of HIV and other STIs A lack of harmonized definitions of behavioural indicators, stigmatization, discrimination

18. EATG, 2014 Borderless Strategies for MSM and Migrants within Western Europe 18/24 Treatment and care General gaps and barriers: Service delivery Knowledge Funding and sustainability Stigma, discrimination, xenophobia and racism, social exclusion Policies and legislation Migrants Legal status — lack of residence status and health insurance — are a major barrier to HIV treatment In Europe, 16 countries do not provide ART to undocumented migrants Cultural, socio-economic, linguistic, and administrative barriers Problems in service delivery and gaps in information Inconsistency of policies: Lack of a legal framework and standardisation MSM Knowledge gaps, problems accessing services for MSM in several countries (especially on new preventive methods, co-infections etc) Wide variation in quality of sexual health screening across Europe; countries with specialised clinics do better Stigmatization of and discrimination against MSM remain at unacceptable levels MSM and migration: international sex scene MSM migrants leaving countries for increasing homophobia A lack of political will conceals the extent of the MSM HIV epidemic and makes targeted prevention very difficult

19. EATG, 2014 Borderless Strategies for MSM and Migrants within Western Europe 19/24 Treatment needs Governments and international bodies should commit resources for surveillance and research that is standardized, covers relevant behaviours and prevention efforts, and incorporates training of the health providers who collect the raw data More (sexuality) education, public awareness campaigns, community mobilization and implementation of international commitments such as the Dublin Declaration are needed Need to improve sexually transmitted infection screening for MSM in Europe Remove legal, social, economical, cultural … barriers to access

20. EATG, 2014 Borderless Strategies for MSM and Migrants within Western Europe 20/24  HIV in Europe and Western Europe  Prevention  Testing  Treatment and Care  Future steps

21. EATG, 2014 Borderless Strategies for MSM and Migrants within Western Europe 21/24 Specific actions are needed at both European and national levels in the areas of policy, funding, research, networking and services Remove financial barriers to accessing prevention, treatment and care Establish policies on universal access Establish a legal framework protecting MSM and migrants Increase / support the involvement of communities in policy processes Consider post-migration programs on HIV acquisition/transmission Strengthen EU-wide and bilateral prevention campaigns and interventions Cross border level EU should: Remove barriers to HIV testing, treatment, care and prevention: stigma within society criminalisation of specific behaviour and groups (MSM, sex workers …) discriminatory rules and regulations inequalities within health (financial, social, cultural, ethnic …) Ensure continued investment in treatment, care, prevention despite the crisis National level Member states should:

22. EATG, 2014 Borderless Strategies for MSM and Migrants within Western Europe 22/24 At service level we need: culturally appropriate materials and interventions; related training for health and community workers greater involvement of migrant communities in service delivery primary prevention and treatment programs targeting these communities We need campaigns that: that target specific groups in order to maintain high levels of safer sex practices promote HIV testing to increase the number of people who are aware of their status and to ensure early testing and access to antiretroviral treatment At research level we need: HIV/AIDS surveillance to become a priority in all European countries in order to allow for the sharing of best practice better understanding of migration patterns, the impact of European laws and policies on treatment access evaluations of the costs and benefits of universal access to treatment, and of the impact of interventions Studies (behavioural, scientific) to obtain data

23. EATG, 2014 Borderless Strategies for MSM and Migrants within Western Europe 23/24 Governments should collaborate to: create a European-wide network of organizations and individuals working in HIV and migration sharing resources and information increase cooperation with international bodies e.g. IOM. increase cooperation with countries of origin: methods and materials in countries of origin could help develop interventions in host countries Governments should support the development of capacity building programs that: provide culturally adapted information to communities provide guidance on training and clinical practice for health professionals in provision of culturally- sensitive prevention, treatment and care services, and for development of culturally appropriate materials

24. EATG, 2014 Borderless Strategies for MSM and Migrants within Western Europe 24/24 Thanks Koen Block Executive Director European AIDS Treatment Group www.eatg.org New research: