BBVs and Migration: the Scottish policy context

1. BBVs and Migration: the Scottish policy context Gareth Brown – Scottish Government

2. About Me • Head of Blood, Organ Donation and Sexual Health Team, within the CMOs Public Health Division • Involved in hepatitis C work since 2007 (responsible for Hepatitis C Phase 2 Action Plan) • Responsible for HIV and sexual health since 2010. • Until late 2012 also responsible for vaccination and immunisation, including hepatitis B vaccination policy • Responsible for developing the Sexual Health and BBV Framework, published 2011

3. BBVs and Migration: the Scottish policy context Gareth Brown – Scottish Government

4. BBVs and Migration: the Scottish Policy Context BBVs

5. BBVs • Viral hepatitis – HBV and HCV • HIV Why? • Diseases of global significance.

6. Viral Hepatitis • Hepatitis C – 150 million chronically infected worldwide. High rates of chronic infection in Egypt (15%), Pakistan (4.8%) and China (3.2%). The main mode of transmission is injecting. • Hepatitis B – estimated 2 billion people globally have been infected. Endemic in China and other parts of Asia. High rates of chronic infections are also found in the Amazon and the southern parts of eastern and central Europe. In the Middle East and Indian subcontinent, an estimated 2–5% of the general population is chronically infected. (source: WHO)

7. HIV • Globally, ~34 millionPLWHIVat the end of 2011. • Burden of the epidemic continues to vary considerably between countries and regions. • Sub-Saharan Africa remains most severely affected, with nearly 1 in every 20 adults (4.9%) living with HIV and accounting for 69% of the people living with HIV worldwide. • Almost 5 million people are living with HIV in South, South-East and East Asia combined. • After sub-Saharan Africa, the regions most heavily affected are the Caribbean, Eastern Europe and Central Asia, where 1.0% of adults were living with HIV in 2011. (source: 2012 UNAIDS Report on Global AIDS Epidemic)

8. BBVs • Viral hepatitis – HBV and HCV • HIV Why? • Diseases of global significance. • Of public health importance for Scotland given prevalence, impact, size of undiagnosed populations, and who is usually affected (marginalised etc). • But also, because we can do better. We have the tools to prevent every infection. We have the treatments to improve the health of those infected. We have a healthcare system capable of delivering the best quality integrated health care.

9. BBVs and Migration: the Scottish Policy Context Migration

10. Migration and Scotland • Under the Scotland Act 1998 immigration and nationality are reserved to the UK Parliament. • No powers for Scottish Ministers to change immigration and nationality policy – set by UK Government. • Post 2014: In a new independent Scotland what would Scotland’s policy on immigration and nationality be? Would there be an increase or a decrease in inward migration?

11. Migration and Scotland • Migration patterns (countries of origin, rates of migration) to the UK have varied over time for various reasons – changes to EU membership for example. • Impact of migration on Scotland as a whole may be different than in other parts of the UK; and impact within Scotland may vary from area to area (urban/rural, north/central). • Useful to look briefly at the immigration data available at UK and Scottish level.

12. Long-term international migration estimates of non-EU Citizens, UK, 2002–2012 (Source: Office for National Statistics)

13. Long-term international migration estimates of EU8 citizens, UK, 2004–2012 (Source: Office for National Statistics)

14. Why Is EU8 Relevant? Just looking at HIV – • HIV treatment coverage is low in Eastern Europe – 25% among those eligible • Many countries (including the Baltic states and Poland) report low coverage of needle and syringe programmes • Estonia reports HIV prevalence of over 50% in PWIDs • Low domestic spending on HIV prevention programmes. External donors finance at least 60% of prevention programmes for PWID in ALL Eastern European countries. Domestic public sector sources provide only 15% of spending on these programmes. (Source: UNAIDS Regional Fact Sheet 2012)

15. UK Entry clearance visas issued (excluding visitor and transit visas), by world area, 2005–2012 (Source: Home Office)

16. Scottish Population • Last published census from 2001 (2011 census not yet published) • 2001 data showed 97.99% of Scottish population was white. Main non-white ethnicities: • Pakistani – 0.63% (32,000) • Chinese – 0.32% (16,000) • Indian – 0.30% (15,000) • Mixed – 0.25% (13,000) • Will this have changed significantly by 2011? We await the updated census. Of course – BBVs and migration is not just an issue about ethnicity – EU8.

17. Scottish Migration Data Recent Migration Into Scotland: the Evidence Base (Scottish Government Social Research 2009) • Statistical sources of data on migration into Scotland have a number of limitations: estimates below UK level are not robust; available sources measure migration flows rather than stocks; and there is little data on characteristics, outcomes, intentions and attitudes of migrants. • There is little evidence of any increased demand on health services as a result of increased migration into Scotland. This is explained with reference to characteristics of the migrant population and their reported use of health services in their home countries.

18. Scottish Migration Data • Scotland has attracted migrants from many parts of the world in the past, notably from Pakistan, India, Italy, Poland and China. • The accession of the EU8 countries - has resulted in an increase in migration to Scotland, with particularly large in-migration from Poland. • Low rates of registration and use of primary care services among EU8 migrants… in Glasgow only 58 per cent of respondents had registered with a GP and only 32 per cent had used health services in the city.

19. Reported Eastern European HIV Infection in Scotland (SHIVAG) 122 Total Cases (since 2005?) • 97 persons of Eastern European origin presumed infected in Eastern Europe. • 10 persons of Eastern European origin presumed infected in Scotland. • Relatively even distribution of cases across main risk groups - MSM 29%, Het 34%, PWID 28%. • EE cases generally present at a slightly more advanced stage than Scots. Source: HPS/Scottish National HIV Database

20. BBVs and Migration: the Scottish Policy Context The scottish policy context

21. Sexual Health and BBV Framework • Outcome 1: Fewer newly acquired blood borne virus and sexually transmitted infections; fewer unintended pregnancies. • Outcome 2: A reduction in the health inequalities gap in sexual health and blood borne viruses. • Outcome 3: People affected by blood borne viruses lead longer, healthier lives • Outcome 4: Sexual relationships are free from coercion and harm • Outcome 5: A society where the attitudes of individuals, the public, professionals and the media in Scotland towards sexual health and blood borne viruses are positive, non-stigmatising and supportive All relevant to minority populations – and issue of minority populations is threaded throughout the Framework.

22. HIV • “Those most at risk of HIV in Scotland are MSM and those from areas of high prevalence, notably African countries.” • “Multi-agency partners should work together to ensure…engagement, support and involvement of those most at risk of HIV transmission, notably MSM and those from areas of high prevalence, particularly African countries…” • “The inequality gap seen in HIV manifests in relation to race and sexual identity, more so than socio-economic status. This is, for example, pertinent to those living with HIV in Scotland in black and minority ethnic (BME), particularly African, communities.”

23. Hepatitis C • “All partners are asked to work together with individuals living with or affected by hepatitis C to implement effective strategies that encompass… awareness raising and other initiatives among migrant populations to encourage test uptake among people who have come from areas of high prevalence for hepatitis C such as Pakistan and other South Asian countries.”

24. Hepatitis B • “While precise estimates of the number of people living in Scotland with chronic hepatitis B infection are unavailable, preliminary work indicates that the number lies within the 5000-15,000 range and the majority of infected individuals will be of Asian, African or East European ethnicity, areas with a high prevalence of hepatitis B infection.” • “Multi-agency partners should work together to ensure that prevention, treatment and care pathways for hepatitis B consider the language, literacy and/or cultural challenges to risk populations accessing these services in Scotland to optimise their uptake.”

25. Standards and Quality Assurance

26. Other Sources of Information Policy context is not only set by Government: • I want to be like the others. A cross sector needs assessment of children infected and affected by HIV in Scotland. (University of Edinburgh, 2009) • With the exception of health services, HIV agencies in Scotland are focused on adults; where services for children exist, these have to be accessed through adults first.

27. NICE Guidance: Increasing Testing Among Black Africans What are other countries doing about this? • Increasing the uptake of HIV testing among black Africans in England (NICE public health guidance 33, March 2011) • “Recruit, train and encourage members of local black African communities to act as champions and role models…” • “Gather the views and experiences of local black African communities to understand their specific concerns and needs…”

28. Finally….

29. Healthcare Quality The most important elements of all of the documents I have referenced echo the NHS Scotland Quality Strategy principles: • Services will be Patient-based: reflecting the uniqueness of the individual, their experience of their health, illness and healthcare, and enabling them to share in decision- making about their care.

30. Healthcare Quality Populations or individuals? • Subpopulations are no more homogenous than the indigenous population - there is wide variations in needs, expectations and understanding. • We do need to think about populations in designing our services and our responses to these infections, but we need to deliver our services to individuals and individual needs.

31. Healthcare Quality Designed for or designed with? • We need to make sure we engage with those people we are trying to reach. • Sexual Health and BBV Framework emphasises the importance of designing services in partnership with communities and patients. • In the context of Minorities, Communities and BBVsthis is of particular importance.

32. Thank You Gareth.Brown@scotland.gsi.gov.uk