'Hidden epidemic' of HIV amongst African migrants in the United States

There is a “hidden epidemic” of HIV amongst African migrants living in the United States, according to investigators writing in the September 12^th edition of the Journal of Acquired Immune Deficiency Syndromes. The researchers found that African-born individuals in the US had a disproportionately high prevalence of HIV – although they comprised only 0.6% of the study population, almost 4% of HIV diagnoses were amongst African-born individuals. Furthermore, the investigators found that in one health area approximately 50% of HIV infections amongst black people were amongst individuals originating in Africa.

Because current US surveillance data do not routinely include information on individuals’ country of origin, it is probable that a significant number of HIV infections currently classified as being amongst African-Americans are likely to involve recent migrants from Africa.

Failure to acknowledge the scale of the HIV epidemic amongst African-born individuals, could, the investigators argue, mean that the HIV prevention and care needs of African-born US residents are being neglected. The investigators call on the US government and health authorities to target information about the availability of HIV testing and care to individuals from Africa, and for the gathering of accurate surveillance data about the country of origin of individuals diagnosed with HIV.

In 2005, almost two-thirds of the world’s HIV infections were located in sub-Saharan Africa. It is estimated that 25% or more of total HIV infections in western Europe are amongst migrants from southern Africa. Although the total number of African migrants in the US increased by 130% between 1990 and 2000, there is little information about the number of HIV infections amongst this community, and few HIV prevention or care services are targeted at individuals in this group.

US immigration law requires that all persons applying to become lawful permanent residents in the country have an HIV test. Infection with HIV is normally a bar to even temporary entry to the US (although this may change), but this prohibition is waived for refugees and in other special cases.

To try and find out what contribution African-born individuals were making to the epidemiology of HIV in the US, investigators contacted health authorities in nine areas where African-born individuals comprised 0.5% or more of the total population. Six states (California, Georgia, Ohio, Massachusetts, Minnesota and Ohio) were included in the study, as were Washington DC, New York City and King County, Washington State.

The health authorities in these areas provided information on the total number of HIV infections within their district in 2003-04, as well as the place of birth of individuals diagnosed with HIV, and the HIV risk activity of these individuals.

A total of 459,000 African-born individuals were resident in the eight areas included in the study – some 47% of all African-born individuals living in the US according to figures from the US census.

Although African migrants comprised just 0.6% of the total population of the districts participating in the study, they accounted for 4% of all HIV diagnoses. But there was considerable variation between the participating areas, with African migrants contributing just over 1% of HIV diagnoses in Minnesota, but 20% of infections in California.

Further analysis of this surveillance data showed that African-born individuals constituted 16% of all HIV infections in black people due to heterosexual sex (or where the risk was unknown), and in every area except New Jersey well over one-third of black heterosexual HIV infections amongst African migrants.

“African-born persons account for a substantial proportion of HIV diagnoses in selected areas of the United States with large African-born populations”, write the investigators.

They believe their study has a number of implications:

• The failure of HIV surveillance methods to record the place of birth of individuals means that the needs of foreign-born individuals are being neglected.
• US surveillance data are currently being misinterpreted. For example, the increase in HIV infections amongst black people in King County, Washington, was originally thought to be due to new HIV infections amongst American-born black people. This could mean that prevention efforts are misdirected.
• By failing to properly estimate the full contribution of African-born individuals to the US HIV epidemic, current surveillance data may be underestimating the importance of heterosexual transmission to the ongoing epidemiology of HIV in the country.

The investigators call on US federal, state and local authorities and health departments to develop resources targeted at African-born individuals that provide information about the availability of HIV testing and care. The authors also note that there are unanswered questions about the “societal commitment to noncitizens residing in the United States”, particularly “to what extent will HIV-infected residents be eligible for medical care and how will testing HIV-positive affect their residency?”