Perinatal HIV in Migrant Families

1. Perinatal HIV in Migrant Families Janak A. Patel, M.D. Professor of Pediatrics Director, Pediatric Infectious Diseases and Immunology Director, Maternal-Child HIV Program University of Texas Medical Branch Galveston, Texas

2. East Europe and Central Asia 53,000 E. Europe Central Asia 420,000 BA C D G H B BA C D F O W. Europe 520,000 B,E BC N. America 900,000 N. Africa Middle East 220,000 BE East Asia and Pacific 530,000 CBE HIV-2 B Caribbean 360,000 E/A,B BOD G H E/AB C A DE/A South and SE Asia 5.6 million BF C C A D B Latin America 1.3 million BE Sub-Saharan Africa 24.5 million Australia and New Zealand 15,000 Global Molecular Epidemiology of HIV Infection Global Total : 42 million of HIV-infected Adults and Children Source: UNAIDS/WHO 2002, Weniger B, et al 1994

3. HIV in Migrant Families Problems of surveillance • No systematic national or local data • Impacts varies from region to region • Legal and illegal migration status often not reported in publications

4. HIV in Migrant Families • Areas facing migrant families with HIV • Southern US border states • International airports • Ethnic neighborhoods • Refugees

5. Analysis of the Enhanced Perinatal Surveillance ProjectState of Texas: Report Year 2003 (J. Patel et al) (0.97%) (37.79%) (31.27%) (20.03%) (9.93%)

6. Each case is located on the map by the county of residence in the respective public health regions

7. Country of Mother’s Birth J. Patel et al. Texas-EPS Report 2003

8. Proportion of Foreign-Born WomenJ. Patel et al. Texas-EPS Report 2003

9. UTMB, Galveston2006 • 5 (17%) out of 30 women were from foreign countries • Mexico = 2 • El Salvador = 1 • Zimbabwe = 1 • Zambia = 1

10. The Face of HIV in Migrant Populations The situation varies in different communities

11. Female Public STD Clinic Attendees: Los Angeles County, 1993–1999 * Harawa NT et al, Am J Public Health. 2002;92:1958–1963

12. Seattle, WA

13. MMWR October 15, 2004 / Vol. 53 / No. 40

14. States that Identified Immigrants as an Emerging Concern (N = 11 States): CDC HIV/AIDS Special Surveillance Report: 2004 Ancestry as specified by respondents Africans Minnesota, Wisconsin Indiana (East African) South Dakota (Sudanese and Ethiopian) Hispanics Mississippi, Missouri Kentucky (Migrant workers) Hmong Minnesota Immigrant-related issues Oregon (care and treatment of undocumented workers) Iowa (250% increase in diagnoses since 1999) Illinois (Chicago suburbs) Ancestry or immigrant-related issue not specified Alabama

15. Where do migrants acquire HIV? • South/Central America: • Younger age, male • Most acquired in the United States • Africans • Older age, female • Most likely acquired in Africa

16. Challenges for Migrants’ HIV Care • Translators needed in HIV programs • South/Central Americans usually not fluent in English • Africans are more fluent in English • Adds significant expenses to clinical programs • Poverty • No insurance (<60% in Los Angeles) • Low income (<$25,000) • Access to HIV medications • Dependent on insurance • Some state ADAP programs may be more accommodative (eg. Texas) • Lack of family support • Poor psychosocial support • Use of sex workers

17. Testing of HIV+ Migrant Pregnant Women • Most illegal migrants do not seek voluntary HIV testing • At pregnancy and delivery, almost all HIV+ women are tested • Texas State Law

18. US vs. Foreign Birth of Mother J. Patel et al. Texas EPS Report 2003 Data in parenthesis are column percentages

19. Access to HIV Care for Illegal Migrant HIV+ Pregnant Women in Texas • State has provided access to prenatal care through Title V funding • Provides funds for OBGYN, genetic testing, delivery services • No specific HIV care reimbursement to HIV specialist • No medication benefits • The new Perinatal CHIP program (February 2007) replaces Title V funding • Provides the same services as Title V (increased number of OB visits) • No reimbursement for specialists care of hospitalization not related to delivery • No HIV medication benefits

20. Access to HIV Care for Illegal Migrant HIV+ Pregnant Women in Texas • The state-funded ADAP may provides HIV medication benefits • Occasionally, the benefits can be denied if information on legal status is known to ADAP • Community-based AIDS agencies: Usually provide HIV services without regards to the status of immigration • Limited benefits

21. US vs. Foreign Birth of Mother J. Patel, et al. Texas EPS Report 2003 Perinatal HIV transmission Data in parenthesis are column percentages

22. Legal Migration and HIV • Temporary visitors visa (30 days or less) rule (enacted 1993) • Special waiver granted on a case-by-case basis for a specific purpose • Healthy status, sufficient assets and insurance required • Runs the risk of disclosure and discrimination • Green card • HIV+ person could be banned: a waiver is needed • A physician and private health insurance are needed • Affidavit of support from sponsor is needed • CDC reviews each request

23. US Embassy HIV Policy- Guyana • In a circular dated May 24, 2007 the US Embassy stated: • “a HIV rapid test will be conducted by a current panel physician at the time of visa issuance.” • “All applicants who will be asked to undergo a HIV rapid test have already had a medical examination, HIV test counseling, and HIV rapid test by a previous panel physician.”

24. Unique HIV Care Issues for Migrant Populations • Cultural beliefs and customs • Spouse’s permission for testing • Codom use and family planning • Use of traditional healers and medications • Feeding practices: breastfeeding of infants

25. Unique HIV Care Issues for Migrant Populations • Tuberculosis co-infection common • TB testing and treatment required • Subtypes of HIV-1 vary in different parts of the world (there are 9 clades) • Clade B most common in N. America, Europe and Australia • Clade C now most common globally

26. East Europe and Central Asia 53,000 E. Europe Central Asia 420,000 BA C D G H B BA C D F O W. Europe 520,000 B,E BC N. America 900,000 N. Africa Middle East 220,000 BE East Asia and Pacific 530,000 CBE HIV-2 B Caribbean 360,000 E/A,B BOD G H E/AB C A DE/A South and SE Asia 5.6 million BF C C A D B Latin America 1.3 million BE Sub-Saharan Africa 24.5 million Australia and New Zealand 15,000 Global Molecular Epidemiology of HIV Infection Global Total : 42 million of HIV-infected Adults and Children Source: UNAIDS/WHO 2002, Weniger B, et al 1994

27. Effect of Genetic Diversity on HIV Care • HIV-1, non-subtype B, viral load testing: Performance of commercial kits varies • HIV-1, non-subtype B, treatment: • Effect of salvage therapy not clear • HIV-2 (20% in West Africa), testing and treatment • No commercially available viral load testing • Non-nucleoside reversed transcriptase inhibitors (NNRTIs) not effective

28. HIV-1 Genetic Diversity in Antenatal Cohort, Canada • 127 pregnant women: • 59 (57.3%) infected with clade B • 44 (42.7%) infected with non-clade B • Non-clade B: • 43 ([97.7%] of 44), were newcomers from Africa • 34 (77.3%) asylum seekers • 9 were from West Africa: mostly clade G • 25 were from Central Africa • 4 were from East Africa: mostly clade C • 4 were from Southern Africa: mostly clade C Akouamba BS et al; Emerg Infect Dis. 2005 Aug;11(8):1230-4

29. Summary • HIV among migrant populations may be increasing in Texas and the nation • Epidemiologic surveillance is needed • HIV care of illegal migrants poses challenges for financial resources • Migrant HIV+ pregnant women need access to specialized programs for HIV care and treatment • After-delivery access to HIV programs is a challenge • HIV care of migrant persons requires special considerations for unique genetic properties of the virus

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