Non UK-born migrants are 'largely hidden' from NHS and have high burden of HIV, TB and malaria

Some groups of migrants living in the UK carry a high burden of HIV, tuberculosis (TB) and malaria according to the first report into migrant health from the Health Protection Agency (HPA), Migrant health: infectious diseases in non-UK born populations in England, Wales & Northern Ireland. Since many migrants are often disenfranchised, and unable to access healthcare, the report recommends that NHS services must include, and reflect the needs of, those most affected.

Many migrants 'largely hidden' from NHS

The report estimates that in 2001, 7.5% of all people living in the British Isles were non-UK born. To put this into perspective, in 2001 nine other EU countries - including Austria, Germany, Sweden and Greece - had a higher percentage of residents who were not born there.

Most of the 542,000 people who migrated to England and Wales in 2004 were work permit holders (130,700) and students (127,700) - primarily from countries in the Americas and Asia.

Although fewer individuals (30,700, a decrease from previous years) were seeking asylum - primarily from countries in Africa and Asia - the report notes that “the health of asylum seekers is likely to be of greater concern than other groups of migrants.”

However, there are estimated to be 430,000 irregular or undocumented migrants in the UK who “may have significant health needs but have very limited entitlement to health care within the National Health Service due to their irregular status and for most, no financial resources to fund alternative treatment.”

The report adds that “despite probable increased health needs undocumented migrants are largely hidden to health services and public health initiatives.”

High burden, but 'low overall prevalence'

The report pulls together previously published data from 2004 regarding the three main infectious diseases currently affecting the globe and says that around 70% of individuals diagnosed with HIV, TB and malaria in England, Wales and Northern Ireland were non-UK born.

However, some data regarding country of birth are missing or incomplete (for example, country of birth was only reported for approximately 62% of HIV diagnoses), and consequently, the authors note that 70% “may not truly reflect the contribution of non-UK born cases to the total case load, however, since it is unknown whether cases with no country of birth recorded are more or less likely to have been born abroad than those with this information.”

The report highlights that the increased burden of HIV, TB and malaria in some non-UK born populations is primarily related to the higher prevalence of these infections in their countries of origin.

Although these infectious diseases disproportionately affect certain non-UK born communities the authors of the report are keen to stress “that the fact that the major burden falls on some of the non-UK born, does not mean that these groups overall have a very high prevalence of infectious diseases.”

As an example, they point out that “HIV prevalence in heterosexuals born in sub-Saharan Africa attending genitourinary medicine clinics in England, Wales and Northern Ireland is only four percent, and two percent in women born in sub-Saharan Africa attending a sample of antenatal clinics.”

This compares with an 0.2% HIV prevalence for UK-born heterosexuals in both GUM and antenatal clinics.

No significant risk of transmission

Although the report concedes that all three infectious diseases are likely to have been acquired prior to arrival, it does note that “there is evidence for some acquisition in the UK", although this is primarily occuring within the non UK-born communities already disproportionatley affected.

Looking specifically at HIV it notes that "higher proportions of heterosexual cases born in Asia and the Caribbean than those born in Africa probably acquired their infection in the UK. This demonstrates that HIV risk may continue after migration to the UK, perhaps as a result of sexual mixing patterns within at risk communities in the UK, or related to travel back to high incidence areas.”

The authors stress, however, that there is “little evidence that the wider UK population is at risk of significant levels of transmission of disease from affected migrants, especially during normal social contact.”

They note that this information “needs to be conveyed to the general public since the fear of a perceived health threat can lead to prejudice which increases stigma and may have untoward public health consequences.”

In particular, the report suggests that “the general public need to be reassured that they cannot acquire HIV through normal social contact with affected individuals. This will help to avoid the misconception that the non-UK born pose a health threat to the general population which can lead to prejudice that is unlikely to contribute to overall HIV control.”

Britain's most widely read tabloid newspaper, The Sun, however, chose to ignore this recommendation in today's story on the report entitled, 'Migrants' AIDS epidemic threat'.

The story claims that “Britain is facing an AIDS epidemic after the revelation that two thirds of all new cases are in immigrants. Almost none of these foreigners seeks treatment and could be infecting the rest of the population, medics warned last night.”

In an accompanying editorial, 'Killer plagues', the newspaper claimed that “we risk an explosion in both these killer diseases [TB and HIV], thanks to infected immigrants,” and that “we will soon have to choose between acting as Good Samaritan to the world's sick. And protecting our own citizens against a deadly epidemic.”

Yusef Azad, Director of Policy and Campaigns at the National AIDS Trust (NAT) nevertheless notes that "this important report makes clear how untrue it is to claim migrants pose any health risk to the UK population.”

Health services must reflect the needs of those most affected

One of the key recommendations of the report is that “health services for infectious diseases need to reflect the needs of the population groups most affected by these diseases, and that health care professionals require support to meet those needs.”

Specific HIV-focused recommendations include providing the non-UK born with “access to appropriate HIV services which include language support and an understanding of their health beliefs about, and cultural attitudes towards, the disease. Women are disproportionately affected,” the report notes, “so services need to reflect the particular needs of women with HIV.”

The report also stresses how important is it that health care practitioners working within affected communities “should be aware of their risk of infectious disease, not just at the time of arrival in the UK but as part of an ongoing process”.

The report highlights the role of primary care, noting that GPs are “likely to be particularly important in this regard, since [they are] ideally placed to consider the range of possible health needs of a migrant.”

Other recommendations include the need for “innovative approaches” to allow migrant groups to become more engaged with diagnostic services, and suggest that “community organisations may be invaluable in this regard.”

Government response must 'promote rather than undermine' migrants' health

One of the final recommendations of the report is that “HIV in migrants to the UK occurs against a background of a global pandemic of the disease. It would therefore be useful to review the current UK contribution to HIV control programmes in source countries for migrants, and to consider how this contribution might be enhanced.”

NAT's Yusef Azad agrees. “The Government must look again at all its immigration processes in the light of this report to ensure they promote rather than undermine the health of migrants in the UK,” he says.

Professor Pat Troop, Chief Executive of the Health Protection Agency, says that the report “will play a vital role in the planning and provision of health services. Many organisations will be involved in taking forward the report's recommendations and we will work closely with our partners, particularly within the NHS, to determine the best public health response."

The full report can be downloaded from the HPA website.

Need to investigate further the HIV/TB overlap

The report notes that around 45% of non-UK born tuberculosis cases originated from South Asia and 39% from sub-Saharan Africa. “Although the highest rate of tuberculosis occurred in those who had recently arrived in the country,” it says, “most tuberculosis cases were diagnosed two years or more after arrival.”

The report also noted that “UK born minority ethnic groups were at increased risk of [TB] and there was some evidence for recent transmission in this group.”

The report also highlights that in 2004, 17% of non-UK born individuals had an AIDS-defining illness at the time of their HIV diagnosis, and that pulmonary TB was the most prevalent AIDS-defining illness.

However, the most recent data cited in the report for TB/HIV coinfection come from 1998, when 3.3% of individuals diagnosed with TB cases were found to be coinfected with HIV.

The report says that the HPA is currently estimating the extent of TB and HIV overlap in more recent years and recommends that where HIV and TB coexist “joined up care between specialities is important.”