Restricted access to antiretroviral treatment for undocumented migrants: a bottle neck to control the HIV epidemic in the EU/EEA

In populations with high HIV prevalence and high rates of undiagnosed infection, such as in many migrant African communities, assortative sexual mixing may unwittingly increase the probability of HIV exposure [18‐20]. A study among individuals who were born in a Sub-Saharan African country and who had migrated to France provided evidence of sexual relations amongst Africans from different countries of origin. This intra-African mixing leads to sexual contacts between migrants coming from low HIV-prevalence and high-prevalence countries and can contribute to the transmission of HIV among African migrants in Europe [21].

One online survey among MSM living in Britain observed that the vast majority of ethnic minority MSM reported unprotected sex with partners from ethnic groups other than their own, particularly with white partners [22]. Central and Eastern European MSM in the United Kingdom were also more likely to have partners from other countries than their heterosexual counterparts. This non-assortative sexual mixing may increase risk of HIV acquisition for migrant MSM moving from low prevalence communities into high prevalence settings such as the London gay scene [23].

Migrants may engage in sexual practices that put them at risk of HIV in their country of residence, but also in their country of origin while visiting family and friends. As such, travellers may act as a bridge population for cross-border transmission of STI including HIV [24‐26].

While undocumented migrants are a sub-population of the migrant population in general, structural discrimination against people on the basis of their migration or residence status, and against undocumented migrants in particular puts them at further risk. Exclusion from essential services, protection and justice undermines undocumented migrants’ control over their sexual health. For example, undocumented women are placed at greater risk of enduring sexual violence by factors such as their inability to seek protection and justice from the police without risking arrest, and exclusion from victim’s support and homelessness services. Undocumented women may also practice transactional sex in the context of income and housing insecurity and homelessness, or as sex workers [27, 28]. Further, laws and practices that restrict access to health care services for undocumented migrants can reduce their access to contraception and information on sexual and reproductive health issues, particularly on HIV prevention [28, 29]. A study among a limited population of undocumented migrants–mostly young, Latin-American, single, well-educated and currently working women who accessed services from a community mobile care unit in Geneva, Switzerland–found that women reported multiple sex partners with suboptimal use of STI prevention strategies [30].

In EU/EEA countries, a considerable number of individuals remain undiagnosed until they present with an advanced stage of HIV disease [31, 32]. Migrants in Europe experience a disproportionate diagnostic delay and late entry in care (Fig. 1) [4, 33‐35]. Many studies have uncovered barriers to HIV testing in the general population as well as in specific sub-populations as for example migrants [36, 37].

At the policy level, barriers concern the actual availability and accessibility of HIV testing services for undocumented migrants [33, 38]. A recent legal analysis showed that only 15 EU Member States entitle them access to HIV testing services [39].

At the provider level, barriers consist primarily of discomfort when approaching the subject of sexual health and HIV, lack of training to increase health care providers’ competence in conducting HIV testing, lack of knowledge about symptoms of undiagnosed HIV infection and logistical barriers such as cost and time constraints [33, 40, 41]. Health care providers and administrators may also be unaware of undocumented migrants’ entitlements to access testing services or face complex procedures for the provision and the reimbursement of these services [38].

At the patient level, barriers include fear of stigma and discrimination–in particular fear of exclusion from one’s own ethnic community–and fear of the disease and the potential for death [42, 43]. Additional barriers are related to risk perceptions with some people not testing due to lack of perceived risk [33, 44‐46]. Another barrier to testing is lack of awareness or uncertainty as to where to get an HIV test and undocumented migrants may not be aware that they are entitled to an HIV test [33, 47]. Numerous practical barriers also exist, such as discretionary and inappropriate refusals of care or demands for payment, administrative and financial obstacles [38]. These may have an impact on health seeking behaviour, and the ability to benefit from HIV testing services [47]. Undocumented migrants also express concern that confidentiality will not be respected by medical staff regarding their migration status, and that they may face immigration enforcement as a result of utilising health services [33, 38].

Several studies have highlighted that stigma and discrimination against MSM, migrants, sex workers and against people living with HIV, continues to hamper efforts to prevent new infections and engage people in HIV treatment, care and support programmes [48]. In Europe, there is evidence that HIV-related stigma and discrimination manifests itself within the family, community, workplace, health care system, and within the affected individual. In case of migrants, HIV-related stigma is often exacerbated by marginalisation and restricted entitlements to care [49, 50].

High levels of perceived, anticipated or internalized stigma have been found to yield lower levels of HIV status disclosure; denying the individual the beneficial impact of disclosure in terms of greater social support, the adoption of preventive behaviours and the involvement in HIV care [51, 52].

A qualitative study among HIV positive Black Africans living in the United Kingdom revealed that many feel unable to access community and social support services due to fear of disclosure and related negative consequences [53]. Fear of stigma may deter African and Afro-Caribbean people from disclosing their HIV status to sexual partners [54, 55].

Undocumented migrants are amongst the most impoverished and socially excluded populations in Europe [56]. The mainstream discourse is that irregular migration is an unlawful or even criminal activity which should be controlled and countered. Policy responses increasingly seek to do so by denying undocumented migrants the core elements which constitute a basic standard of living. Their lack of access to adequate housing, education, health care and fair working conditions usually causes poverty and destitution [38]. The poor living and working conditions associated with living in an irregular migration situation, in particular, can have negative impacts on physical and mental health [57‐61].

Undocumented migrants mainly seek health care when they are severely ill [38, 62]. The fear of being detected as an irregular migrant, based on the real or perceived exchange of data between health care providers and immigration enforcement, on many occasions prevents and delays migrants from accessing the care they need. Migrants may lack knowledge of the national language, be unfamiliar with the health system, face complicated bureaucracy and be subject to direct and indirect discrimination [38, 63‐66].

When necessary health care is denied, delayed or avoided, including HIV testing and treatment, it can prolong periods of poor health and foster chronic health conditions which can lead to further socio-economic exclusion [67].

Since the 1946 Constitution of the World Health Organization (WHO) and the 1948 Universal Declaration of Human Rights (UDHR) the enjoyment of the highest attainable standard of health has been established as a fundamental right of every human being. The human right to health applies universally and was codified into binding law by the International Convention on Economic, Social and Cultural Rights (ICESCR) and the International Covenant on Civil and Political Rights (ICCPR) in 1966.

In 2000, the UN Committee on Economic, Social and Cultural Rights (CESCR) issued “General Comment 14”, an authoritative and binding explanation of Article 12.1 on the right to health of the ICESCR. It states in § 12(b) that governments have legal obligations to ensure that “health facilities, goods and services are accessible to all, especially the most vulnerable of marginalized sections of the population, in law and in fact, without discrimination on any of the prohibited grounds”, defined as “race, colour, sex, language, religion, political or other opinion, national or social origin, property, birth, physical or mental disability, health status (including HIV/AIDS), sexual orientation, civil, political, social or other status”.

In addition, the CESCR specified that States have an obligation to respect the right to health by refraining from denying or limiting equal access for all persons, including asylum seekers and irregular immigrants, to preventive, curative and rehabilitative health services.

All EU countries have ratified the “International Bill of Human Rights” (which is comprised of the UDHR, ICESCR and ICCPR), and thus acknowledge migrants’ equal right to health. Migrants’ access to health care is simultaneously enshrined in other legal instruments. The EU Charter of Fundamental Rights (2000) for example sets out in article 35 that “everyone has the right of access to preventive health care and the right to benefit from medical treatment under the conditions established by national laws and practices”. While this provision is linked to the conditions established in national law, it must be read together with article 21, which prohibits discrimination. Article 11 and 13 of the European Social Charter, on which the provision is based, are also relevant as they guarantee respectively the right to benefit from any measures to enjoy the highest possible standard of health and the right to social and medical assistance for anyone without adequate resources, and the Committee of Social Rights has found this to include undocumented migrants.

A number of policy documents at European level are also relevant. The EU Council Conclusions on Common Values and Principles in European Union Health Systems of 22 June 2006 (C/146) endorsed a joint statement from the Ministers of Health of the EU MS, considering that universality, access to good quality of care, equity and solidarity are the overarching common values and principles, underpinning Europe’s health systems. The EU Council Conclusions on Equity and Health in All Policies of 8 June 2010 urges all Member States to consider policies to “ensure that citizens, and all children, young people and pregnant women in particular, can make full use of their rights of universal access to health care, including health promotion and disease prevention services” [81].

On 8 March 2011, the EU Parliament adopted a resolution ‘Reducing health inequalities in the EU’ (2010/2089 INI), in which it calls on Member States to tackle health inequalities in access to health care for undocumented migrants. The EU Parliament has also adopted the following resolutions which call for improvements in the provision of health care for undocumented migrants: resolution of 4 July 2013 “Impact of economic crisis on access to care for vulnerable groups” (2013/2044 INI) and resolution of 4 February 2014 on undocumented women migrants in the EU (2013/2115 INI). While health is an area of shared competence between the EU and Member States, and health policies are not defined at EU level, these European policy documents reflect political recognition that equity in access to health services for all residents, regardless of status, is necessary both in terms of human rights and health system principles.

Against this background, the European Union Agency for Fundamental Rights recommends that migrants in irregular situation should, as a minimum be entitled by law to access necessary health care services which should not be limited to emergency care only. The same rules for payment of fees and exemption should apply to irregular migrants as to nationals. Finally, the European Union Agency for Fundamental Rights urges EU Member States to disconnect health care from immigration-control policies [56, 82].

Restricting access to HIV care not only hampers a state’s compliance with human rights obligations, but it also impacts on the quality of life and survival of HIV infected patients and fuels onward HIV transmission.

The introduction of ART in 1996 was a substantial advance in HIV care. The provision of ART can stop HIV replication on a sustained basis and, as a result, plasma viral load becomes undetectable. Viral suppression allows immune reconstitution to take place, leading to long-term disease remission and prolonged survival. Clinical studies have indicated that maximum benefit in terms of reduced morbidity and mortality is obtained when HIV infection is diagnosed and treated early. Large observational cohort studies such as D:A:D (Data Collection on Adverse Events of Anti-HIV drugs), SMART (The Strategies for Management of Antiretroviral Therapy) and the Collaboration of Observational HIV Epidemiological Research Europe (COHERE) have given convincing evidence that early start and continued treatment with ART not only reduces the classic AIDS defining illnesses, but also non-AIDS defining illnesses linked to HIV such as cardiovascular and renal disease [83‐87]. The recent findings from the randomized clinical trial START (Strategic Timing of AntiRetroviral Treatment) have confirmed that earlier ART benefits all HIV-infected individuals [88].

Plasma viral load has also been shown to be a marker of infectiousness. Persons living with HIV with a plasma viral load below the detectable limit are likely to have lower levels of viral load in cervix, rectum, vagina and breast milk. The association between high plasma viral load and high risk of HIV transmission has long been documented [89]. As the highest viral loads are noted immediately after infection, people with acute infection are the most infectious [90]. Observational studies in different populations and mathematical modelling work have demonstrated the secondary benefit of ART in preventing HIV transmission [91].

Reductions in both vertical and heterosexual transmission have been shown to be associated with the receipt of antiretroviral therapy and subsequent reductions in individual viral load [92]. Similarly, reduction in community viral load as result of ART was shown to be a key determinant of decreasing HIV incidence in a cohort of injecting drug users in Vancouver, Canada [93]. In British Colombia, the number of individuals actively receiving ART increased by 54 % between 1996 and 2009 and during the same period, the number of new HIV diagnoses decreased by 52 % [94]. In San Francisco, a decrease in both the mean and total community viral load between 2004 and 2008 was accompanied by decreases in new HIV diagnoses from 798 (2004) to 434 (2008). The mean viral load and total community viral load were significantly associated with new HIV cases [95].

A 92 % reduction in HIV transmission rate was reported in a randomized controlled trial of HIV serodiscordant heterosexual couples in Sub-Saharan Africa in whom the index partner was treated with ART [96]. The real breakthrough for the use of ART as prevention came with the publication of the HPTN052 trial results. HPTN052 was a randomized controlled trial study showing a 96 % reduction in transmission from an infected partner to his or her uninfected stable sexual partner in a heterosexual relationship when the infected partner was put on ART immediately after diagnosis in comparison to couples where the infected partner received treatment only when he or she fulfilled the criteria for initiation of the medication [97]. Similar results have been reported in serodiscordant heterosexual couples in Madrid, Spain [98]. A large observational study, PARTNER, provided preliminary data that support the findings of HTPN052 both for heterosexuals and MSM. The primary aim of PARTNER is to study the HIV transmission risk through condom-less sex if the HIV positive partner is on suppressive ART. So far, there have been no transmissions within couples from a partner with undetectable viral load, in what was estimated as 16,400 occasions of sex for MSM and 14,000 for the heterosexuals [99, 100].

Recognizing the multiple benefits of ART, the WHO consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection (2015) plead for the further scaling up of treatment. These recommendations, based on the findings of the START trial which provided definitive evidence on the benefits of ART treatment, promote expanded eligibility for ART to be started immediately, irrespective of CD4 cell count [101].

To be effective HIV treatment programs should, however, be integrated within a balanced combination prevention framework, including biomedical, behavioural and structural interventions that address the complex interplay of underlying determinants of HIV transmission. Once infected, people should be diagnosed as early as possible after acquiring HIV and they should be offered appropriate prevention and care services and provided the offer of treatment. All this requires an unrestricted access to a continuum of HIV prevention, testing and care services, implemented through a multi-sectorial and participatory approach, recognizing as such the political, economic and social contexts within which all efforts are positioned [102].

The spectrum of engagement in HIV care–also referred to as the HIV treatment cascade–provides a framework for assessing programme implementation and improving programme management so that optimum outcomes can be achieved at each step. The movement towards treatment as prevention has unmasked gaps in the HIV treatment cascade, including late diagnosis, suboptimum linkage to and retention in care, low ART coverage and poor adherence to treatment [103‐107]. Leakages from the various steps of the cascade lead to programme inefficiencies and missed opportunities for both treatment and prevention [108, 109].

Inevitably, not offering ART to an affected sub-population makes the cascade leakage worse. Persons who are not linked to care or are poorly engaged in care account for the largest proportion of HIV infected individuals with detectable viral load. These people will consequently continue to unwillingly contribute to the on-going transmission of HIV infection [110, 111]. A current challenge of the HIV epidemic is to reach the highest proportion of overall viral suppression among people living with HIV in order to impact on HIV transmission.

Restricting access to ART treatment for undocumented migrants not only adds a complication to lives that are already constrained and beset by multiple problems, it also constitutes a human rights violation that counteracts measures to control HIV incidence. If Europe is to meet internationally agreed targets by 2020 - 90% of all people living with HIV will know their HIV status, 90 % of all people with diagnosed HIV infection will receive sustained antiretroviral therapy, 90 % of people receiving antiretroviral therapy have suppressed viral loads, addressing the barriers facing undocumented migrants’ access to ART is essential.