1. Sexual transmission of HIV amongst migrant populations in Europe: managing change in surveillance, interventions and prevention V.Delpech and Teymur Noori Public Health England, United Kingdom ECDC, Stokholm

2. HIV infections reported EU/EEA, 2006-2012 Transmission mode and origin, adjusted for reporting delay Predominant mode of transmission : men who have sex with men Data were not included or not available from Estonia, Poland, Spain, Italy. Source: ECDC/WHO. HIV/AIDS Surveillance in Europe, 2012 - 52%

3. Strong evidence that migrants are particularly affected by HIV in EU/EFTA countries No Non EU/EEA Yes No data reported 76% of countries identify migrants as an important sub- population in their HIV response ECDC. Monitoring implementation of the Dublin Declaration on Partnership to Fight HIV/AIDS in Europe and Central Asia: 2012 Progress Report. Stockholm: ECDC; 2013.

4. New HIV diagnoses among black Africans born in Africa: UK, 2003 – 2012

5. Issues: How do we track our failures and successes? Quality of data – how to define migrants and collect data without potential for discrimination and stigma? Comparable data – agreeing on standard definitions Lack of registers of death data – NO ONE SHOULD DIE OF AIDS IN 2014 Critical monitors – testing uptake, diagnoses, link to care, retention in care, ARV uptake, viral suppression Need for patient level data – ensure most at risk groups are captured (eg MSM, SW) Data should drive health service response AND public health response including prevention efforts.

6. Proportion of migrants in all diagnosed HIV infections in EU/EEA Member States (2011) Source: Migrant health: Sexual transmission of HIV within migrant groups in the EU/EEA and implications for effective interventions. ECDC (2013) EU/EEA 36%

7. HIV infections reported EU/EEA, 2006-2012 Transmission mode and origin, adjusted for reporting delay Predominant mode of transmission : men who have sex with men Data were not included or not available from Estonia, Poland, Spain, Italy. Source: ECDC/WHO. HIV/AIDS Surveillance in Europe, 2012 - 52%

8. HIV diagnosed persons seen for HIV care by prevention group and ethnicity*: UK, 2003 - 2012 8

9. Percentage of late HIV diagnosis, by geographic origin, EU/EEA, 2007‒2011

10. Late HIV diagnosis by transmission mode EU/EEA, 2012 49% are diagnosed late

11. Late diagnosis of HIV (CD4 <350) among adults in the United Kingdom, 2010 HIV and AIDS Reporting System HIV and STI Department, Health Protection Agency - Colindale

13. Prompt¹ and late² HIV diagnosis in heterosexuals with associated short-term mortality³: United Kingdom, 2001–2010 ¹Prompt diagnosis: CD4 count ≥350 cells/mm³ within 91 days of diagnosis ²Late diagnosis: CD4 count <350 cells/mm³ within 3 months of diagnosis ³Percentage of patients known to have died within 1 year of diagnosis Delpech V, personal communication of unpublished HPA data.

14. Treatment guidelines: Proportion* of adults diagnosed late receiving ART the following year, UK, 2010-2011 14 Delpech et al, HIV medicine, 2013

15. ECDC. Monitoring implementation of the Dublin Declaration on Partnership to Fight HIV/AIDS in Europe and Central Asia: 2012 Progress Report. Stockholm: ECDC; 2013. Availability of ART for undocumented migrants 2012

16. 16 Black MSM vs. Black General Populations by Region/ Country (Millett et al., 2012)

17. 17 U.S. Black MSM vs. U.S. White MSM, U.S. Black Population, and U.S. Population (Millett et al., 2012) 3X 22X

18. Where do migrants acquire HIV infection?

19. Sexual transmission of HIV (2013) ECDC PROJECT HEADED BY UK/ SPANISH TEAM OBJECTIVES OF THE PROJECT*  What is the evidence for ongoing sexual transmission of HIV among migrants after arrival to the EU?  What are the implications for HIV surveillance, policies and prevention programmes? RESULTS  There is evidence to show that some on-going post- migration HIV acquisition is occurring in EU countries  However, it is difficult to quantify the degree to which this is occurring RECOMMENDATIONS  Member States should consider applying an objective method for assigning PCOI  Evidence-based programmes and policies to reduce post- migration HIV acquisition and transmission are needed *PROJECT LED BY FIONA BURNS, IBI FAKOYA, JULIA DEL AMO AND VALERIE DELPECH

20. Estimating UK HIV acquisition – clinic-based method Black Africans born abroad and probably acquiring HIV in the UK 24% 46% 7% 18% Clinic-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

21. 25% 44% 7% 18% Clinic-based estimate CD4-based estimate Estimating UK HIV acquisition – CD4-based method Black Africans born abroad and probably acquiring HIV in the UK

22. Public Health England developed a new objective method for assigning PCOI Method based on modelling rates of CD4 back calculation: cell count decline Necessary variables: ‘Country of birth’ ‘Year of arrival’ ‘CD4 count at time of diagnosis’ Rice B, Elford J, Yin Z, Delpech V (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 Estimates of UK-acquired HIV infection using a CD4 back-calculation

23. 23Monitoring of HIV among migrants in the United Kingdom Estimates of UK-acquired HIV infection by country of birth: UK, 2002-2011

24. New HIV diagnoses by probable country of infection and exposure group: 2001–2010 Delpech V, personal communication of unpublished HPA data. MSM=men who have sex with men

25. Monitoring testing policies and their impact

26. Estimates of the proportion of people living with HIV that remain undiagnosed by risk group: United Kingdom, 2011 26

27. London Less than 1 1-2 >2 Prevalence of diagnosed HIV infection by region of residence among population aged 15-59 years: United Kingdom, 2011 27

28. Countries with necessary variables to assign PCOI using the UK method CountriesCountry of birthYear of arrival CD4 count at time of diagnosis Belgium Denmark France Greece Italy Lithuania Luxembourg Malta Portugal Romania Slovakia Sweden United Kingdom ECDC. Migrant health: Sexual transmission of HIV within migrant groups in the EU/EEA and implications for effective interventions. Stockholm: ECDC; 2013.

29. Pilot testing the UK-method for assigning probable country of HIV infection CountriesCountry of birthYear of arrival CD4 count at time of diagnosis Belgium Denmark France Greece Italy Lithuania Luxembourg Malta Portugal Romania Slovakia Sweden United Kingdom ECDC. Migrant health: Sexual transmission of HIV within migrant groups in the EU/EEA and implications for effective interventions. Stockholm: ECDC; 2013.

30. Retention in HIV care: Proportion* of adults diagnosed seen for care in the following year, UK, 2010-2011, N= 4 940 30 Delpech et al, HIV medicine, 2013

31. Summary Steep decline of reported HIV cases in Europe among heterosexuals from sub-Saharan African countries, however, migrants account for a significant proportion of reported HIV cases per annum (36% in 2011) Migrants are being diagnosed later for HIV than other key populations and more likely to die of AIDS There is evidence that migrants are being infected after arrival to the EU Good surveillance at the patient level which are confidential and adhere to data protection rules (ie preferably donot collect names) are essential in tracking our progress in the HIV response and ensuring resources target the most affected population Death registers are a priority in the 21 st century. Legal barriers and perceived and real stigma must be addressed.