Epidemiology of HIV among black Africans in the UK: impact of migration

1
Epidemiology of HIV among black Africans in the
UKimpact of migration a highlight of gender
inequalities

• Dr Valerie Delpech
• Health Protection Agency
• March 2008

2
OutlineHighlighting gender differences

• Migration data
• Global impact of HIV
• European perspective
• UK focus
• New diagnoses of HIV
• Persons late diagnosed
• Persons seen for HIV care/ ARV uptake
• Conclusions

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Adults and children estimated to be living with
HIV, 2007
Total 33.2 (30.6 36.1) million
4
Over 6800 new HIV infections a day in 2007

• More than 96 are in low and middle income
  countries
• About 1200 are in children under 15 years of age
• About 5800 are in adults aged 15 years and older
• of whom
• almost 50 are among women
• 61 in sub-Saharan Africa
• 35 in western Europe
• 40 in Eastern Europe

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Migration
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Migration

• Definition
• a migrant is a person who enters a country other
  than that of which he/she is a citizen for at
  least 12 months (UN 1998)
• Data sources
• UK census 2001 by COB
• immigration border control data shows around
  half a million migrants enter UK per year
• The international passenger survey
• Diverse reasons for migrating
• Official - work, study, accompany/join loved
  ones, asylum seeking
• Many others including non-official reason that
  my be violation to rights of individual- eg sex
  slavery trade

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UK population by world region of birth 2001
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Migrants to the UK by country of birth and sex
2005
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Lack of good data on migration and its impact on
HIV
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HIV infections newly diagnosed by transmission
group, western Europe, 1995-2005
Persons infected heterosexually (HC)
Homo/bisexual men
HC from country with generalised epidemic
Risk not reported
Injecting drug users
EuroHIV
Belgium, Denmark, Finland, Germany, Greece,
Iceland, Ireland, Israel, Luxembourg, San
Marino, Sweden, Switzerland, United Kingdom
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Persons diagnosed in UK
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Annual number of HIV-infected black African and
black Caribbean persons accessing care in E, W
NI and newly diagnosed in the UK

• 1 Numbers of new HIV diagnoses from 2003 onwards
  are adjusted for reporting delays.
• Annual survey of HIV-infected persons accessing
  care, HIV/AIDS and death reports

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Prevalence
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HIV-infected persons accessing care by
prevention group, UK 2006
Annual survey of HIV-infected persons
accessing care
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Black African individuals accessing HIV treatment
and care services by exposure category
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Percentage of ethnic groups living with
HIV, England 2006
diagnosed
To gain overall prevalence estimate need to add
1/3 undiagnosed
As a comparison, for example, estimated
prevalence in many North and West African
countries with ties with the UK lt4
Better understand implications for UK
black-African populations of a relatively high
prevalence of HIV within the UK

• Annual survey of HIV-infected persons accessing
  care

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HIV prevalence among women giving birth by
women's world region of birth, England 2006

• 1 Includes previously diagnosed, those diagnosed
  through antenatal screening and those remaining
  undiagnosed.
• 2 Enhanced unlinked anonymous newborn infant
  dried blood spot data is available for
  approximately 35 of births in England.
• Unlinked anonymous surveillance of newborn infant
  dried blood spots

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Late diagnoses and earlier testing
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Late diagnosis of HIV infection among Black
Africans diagnosed in the UK 2006
46
41
39
13
10
11
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Median CD4 cell count at HIV diagnosis by
prevention group, E, W NI
1 Data on pregnancy status only from
2000 HIV/AIDS diagnoses and death reports, and
surveillance of CD4 cell counts in HIV-infected
persons
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Outcome of HIV testing policy for sub-Saharan
African
born and UK born heterosexuals attending clinics
in the UK
of previously undiagnosed HIV infected UK
100
born heterosexuals remaining undiagnosed
of previously undiagnosed HIV infected SSA
90
born heterosexuals remaining undiagnosed
of all SSA born GUM clinic attendees who
were HIV tested
80
of all UK born GUM clinic attendees who were
HIV tested
70
60
50
One third of black Africans remain undiagnosed
40
30
20
10
0
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
Unlinked anonymous serosurvey
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MAYISHA II HIV testing and service use
2004 Community based sexual health survey among
black-African populations
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Summary

• There had been a increase in HIV infection rates
  among women worldwide
• Migration is a major cause of late diagnosis and
  reduced access to testing and treatment in many
  countries
• Following earlier steep increases in UK, there is
  a levelling off in diagnoses among black-African
  individuals largely due to changes in
  immigration patterns
• Small but important increases in number of
  heterosexually acquired infections acquired in
  the UK, particularly among black-African
  individuals
• HIV prevalence in the UK amongst black-African
  populations greatly exceeds that amongst other
  ethnicity groups.

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Summary continued

• Despite similar migration patterns for men and
  women, there is a 21 FM ratio among new
  diagnoses
• women tend to be tested earlier after arrival
  into the UK and at a younger age mostly as a
  result of antenatal screening
• Similarly to other prevention groups, there is a
  good uptake of ARV among black African men and
  women who access HIV care.
• Two in five black Africans present late, and
  almost half of all men. Late diagnoses results in
  high risk of early death. New settings and
  opportunities for offering HIV testing to black
  Africans are urgently needed.

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Thank you!

• Thank you to my HIV team at the HPA,
• in particular Brian Rice, Tim Chadborn, Sam
  Lattimore, Ruth Smith, Sonia Ribeiro, Celia
  Penman and Jorgen Engmann

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AcknowledgementsThe continuing collaboration
of clinicians, nurses, microbiologists, health
advisors and data managers who contribute to HIV
surveillance in the UK is gratefully
acknowledged. Without their generosity, time and
effort, the current level of understanding of the
epidemic could not have been attained.