Migrants being left behind by the HIV response in Europe

Although half of new HIV diagnoses are in people born in another country, migrants have less access to HIV prevention, testing and treatment services across Europe. Many European countries have no data on migrants’ engagement with the HIV care continuum, which is likely to leave any barriers to care unaddressed, data from the European Centre for Disease Prevention and Control (ECDC) show.

Rather than declining, new HIV diagnoses are increasing in gay and bisexual men born overseas. In many countries, migrants have limited access to the HIV prevention medication PrEP.

Across the European Economic Area (which includes all members of the European Union, plus Norway, Iceland and Liechtenstein – but not Switzerland or the United Kingdom), 42% of new diagnoses in 2021 were in people born in another country. This included 14% born in sub-Saharan Africa, 11% born in Latin America and the Caribbean, 8% born in other countries in central and eastern Europe, and 3% from other countries in western Europe.

Following Russia’s invasion of Ukraine in 2022, the share of new diagnoses in migrants jumped to 52%. The proportions of diagnoses in people coming from other parts of the world barely changed from 2021 to 2022, but the proportion born in central and eastern Europe increased from 8% to 23%.

Most, but not all, of this increase was in people born in Ukraine. In 2021, just 1.2% of new diagnoses in the European Economic Area were in people born in Ukraine, jumping to 10.2% (or 2338 people) in the following year. This has particularly affected countries such as Poland, Estonia and Slovakia.

But the HIV prevention needs of migrants were going unmet long before the Ukrainian refugee crisis, and across the continent. Looking at data from 2012 to 2021, new diagnoses in gay and bisexual men living in their country of birth fell by 34%. Over the same time period, diagnoses increased in foreign-born gay and bisexual migrants by 36%. (This divergence according to country of birth was not seen in heterosexual men and women.)

Over the past decade, numerous studies have shown that a significant proportion of newly diagnosed migrants probably acquired HIV in their host country, rather than their country of birth. Dates of infection have been estimated from CD4 counts at diagnosis, medical records and what people say about their sexual behaviour before and after migration. Most recently, a study of foreign-born gay and bisexual men living with HIV in France concluded that 62% acquired HIV after moving to the country. Men from north Africa and Asia were more likely than men from elsewhere in the world to acquire HIV in France.

The implication is that HIV prevention services need to be accessible to migrants in European countries, especially those who have recently arrived (a period of increased vulnerability). Rather than just screening new arrivals, programmes also need to provide ongoing access to HIV prevention.

But ECDC reports that of 22 countries in the whole of Europe which provided or reimbursed PrEP (regular medication to prevent HIV infection) through their healthcare system in 2022, only eight could share any data on uptake by migrants specifically. The UK had the largest number of foreign-born PrEP users (4641) but this represented only 7.6% of PrEP users in the country. The Netherlands did much better, with 3306 foreign-born PrEP users, accounting for a third of those taking the tablets. Figures were much smaller in Portugal (168), Czechia (89) and Cyprus (4). Kyrgyzstan, Moldova and Ukraine each reported zero PrEP users born outside the country, while the relatively large PrEP programmes in France, Germany, Spain and Belgium did not monitor uptake by migrants.

Similarly, experts in only ten countries could tell ECDC that they thought over 30% of people born overseas had been reached by condom programmes, with 18 countries reporting that level of coverage for testing of sexually transmitted infections. There were more countries where no data were available.

Hardly any countries track progress through the HIV care continuum according to migration status. Of the 55 countries reporting to ECDC, only four had data on the whole continuum, with another seven countries having data on some stages.

The UK is one country which has data and appears to be meeting the 95-95-95 targets for migrants. It’s estimated that 96% of migrants living with HIV have been diagnosed, 99% of those diagnosed are on treatment and 97% of those on treatment are virally suppressed.

In contrast, Czechia has a real problem with undiagnosed infection, but does better on access to treatment – its results are 65-91-98. Neighbouring Austria appears to have challenges maintaining viral suppression, with scores of 94-90-67.

In seven countries undocumented migrants can’t obtain PrEP, in six countries they can’t get an HIV test and in nine countries they can’t access HIV treatment. Countries restricting access to HIV treatment include Austria, Czechia, Finland and Greece.

“Universal access to HIV prevention, testing and treatment services is important to end new transmissions by 2030,” concludes the European Centre for Disease Prevention and Control.

It recommends better data and monitoring; prevention and medical services that are accessible to recently arrived migrants, people who have been in the country for some time and people who are undocumented; targeted campaigns; and reflecting on how general attitudes and legislation around migrants may impact their willingness to seek out medical care.