Perinatal HIV in Perinatal HIV in Migrant FamiliesMigrant Families

Janak A. Patel, M.D.Professor of Pediatrics

Director, Pediatric Infectious Diseases and ImmunologyDirector, Maternal-Child HIV ProgramUniversity of Texas Medical Branch

Galveston, Texas

Global Molecular Epidemiology of HIV InfectionGlobal Molecular Epidemiology of HIV Infection

Global Total : 42 million of HIV-infected Adults and Children

Source: UNAIDS/WHO 2002, Weniger B, et al 1994

Latin America1.3 million

Latin America1.3 million

Sub-Saharan Africa24.5 million

Sub-Saharan Africa24.5 million

South and SE Asia

5.6 million

South and SE Asia

5.6 million

East Asia and Pacific530,000

East Asia and Pacific530,000

E. EuropeCentral Asia

420,000

E. EuropeCentral Asia

420,000

W. Europe520,000

W. Europe520,000

N. AfricaMiddle East

220,000

N. AfricaMiddle East

220,000

Caribbean360,000

Caribbean360,000

N. America900,000

N. America900,000

BB

B F CB F C

B EB E

B A C D G HB A C D G H

B CB CB EB E

E/A,BE/A,BC B E

C B E

B A C D F OB A C D F O

HIV-2HIV-2B O D G HB O D G H

BBCC

A D E/AA D E/A

C A DC A D

B, EB, E

E/A BE/A B

BBAustralia and New

Zealand15,000

Australia and New Zealand15,000

East Europe and Central Asia

53,000

East Europe and Central Asia

53,000

HIV in Migrant FamiliesHIV 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

• Areas facing migrant families with HIV– Southern US border states– International airports

• Ethnic neighborhoods• Refugees

HIV in Migrant FamiliesHIV in Migrant Families

Analysis of the Enhanced Perinatal Surveillance ProjectAnalysis of the Enhanced Perinatal Surveillance ProjectState of Texas: Report Year 2003 (J. Patel et al)

Number of Births/Year(EPS)

6

232

192

123

61

0

50

100

150

200

250

Year of Birth

Nu

mb

er

of

Birth

s

1998 1999 2000 2001 2002 (0.97%) (37.79%) (31.27%) (20.03%) (9.93%)

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

Country of Birth of Mothers Frequency Percentage (617 = 100%)

United States 434 79.93%

Mexico 34 6.26

Honduras 11 2.03

Zimbabwe 6 1.1

Kenya 4 0.74

El Salvador 3 0.55

Nigeria 2 0.37

Malawi 2 0.37

India 2 0.37

Guadaloupe 1 0.18

Congo 1 0.18

Liberia 1 0.18

South Africa 1 0.18

Tanzania 1 0.18

Uganda 1 0.18

Unknown 39 6.32

Country of Mother’s BirthCountry of Mother’s BirthJ. Patel et al. Texas-EPS Report 2003

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

Africa27%

Asia3%

South/Central

America/Carribean

70%

UTMB, Galveston2006

• 5 (17%) out of 30 women were from foreign countries– Mexico = 2– El Salvador = 1– Zimbabwe = 1– Zambia = 1

The Face of HIV in Migrant The Face of HIV in Migrant PopulationsPopulations

The situation varies in different communities

Harawa NT et al, Am J Public Health. 2002;92:1958–1963

Female Public STD Clinic Attendees: Female Public STD Clinic Attendees: Los Angeles County, 1993–1999Los Angeles County, 1993–1999

*

Seattle, WA

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

States that Identified Immigrants as an Emerging ConcernStates that Identified Immigrants as an Emerging Concern (N = 11 States): CDC HIV/AIDS Special Surveillance Report: 2004

Ancestry as specified by respondents

AfricansMinnesota, WisconsinIndiana (East African)South Dakota (Sudanese and Ethiopian)

HispanicsMississippi, MissouriKentucky (Migrant workers)

HmongMinnesota

Immigrant-related issuesOregon (care and treatment of undocumented workers)Iowa (250% increase in diagnoses since 1999)Illinois (Chicago suburbs)

Ancestry or immigrant-related issue not specifiedAlabama

Where do migrants acquire HIV?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

Challenges for Migrants’ HIV CareChallenges 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

• Most illegal migrants do not seek voluntary HIV testing

• At pregnancy and delivery, almost all HIV+ women are tested– Texas State Law

Testing of HIV+ Migrant Pregnant WomenTesting of HIV+ Migrant Pregnant Women

US-born Foreign-born Unknown Total

Health insurance

Insured 105 (94.6) 56 (90.3) 13 (100) 174

Uninsured 6 (5.4) 6 (9.7) 0 (0) 12(missing = 431)

HIV medication

None 1 (0.7) 2 (2.8) 0 (0) 3

Mono 19 (12.7) 14 (19.7) 1 (6.3) 34

Dual 51 (34) 20 (28.2) 5 (31.3) 76

3 or more 79 (52.7) 35 (49.3) 10 (62.5) 124(missing = 380)

US vs. Foreign Birth of MotherUS vs. Foreign Birth of MotherJ. Patel et al. Texas EPS Report 2003

Data in parenthesis are column percentages

Access to HIV Care for Illegal Migrant HIV+ Access to HIV Care for Illegal Migrant HIV+ Pregnant Women in TexasPregnant 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

Access to HIV Care for Illegal Migrant Access to HIV Care for Illegal Migrant HIV+ Pregnant Women in TexasHIV+ 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

US-born Foreign-born Unknown Total

Infected 17 (4) 12 (8.5) 1 (2.6) 30

Uninfected 215 (50.7) 74 (52.1) 17 (43.6) 306

Indeterminate 192 (45.3) 56 (39.4) 21 (53.9) 269(missing = 348)

US vs. Foreign Birth of MotherUS vs. Foreign Birth of MotherJ. Patel, et al. Texas EPS Report 2003

Perinatal HIV transmission

Data in parenthesis are column percentages

Legal Migration and HIVLegal 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

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.”

Unique HIV Care Issues for Unique HIV Care Issues for Migrant PopulationsMigrant 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

Unique HIV Care Issues for Unique HIV Care Issues for Migrant PopulationsMigrant 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

Global Molecular Epidemiology of HIV InfectionGlobal Molecular Epidemiology of HIV Infection

Global Total : 42 million of HIV-infected Adults and Children

Source: UNAIDS/WHO 2002, Weniger B, et al 1994

Latin America1.3 million

Latin America1.3 million

Sub-Saharan Africa24.5 million

Sub-Saharan Africa24.5 million

South and SE Asia

5.6 million

South and SE Asia

5.6 million

East Asia and Pacific530,000

East Asia and Pacific530,000

E. EuropeCentral Asia

420,000

E. EuropeCentral Asia

420,000

W. Europe520,000

W. Europe520,000

N. AfricaMiddle East

220,000

N. AfricaMiddle East

220,000

Caribbean360,000

Caribbean360,000

N. America900,000

N. America900,000

BB

B F CB F C

B EB E

B A C D G HB A C D G H

B CB CB EB E

E/A,BE/A,BC B E

C B E

B A C D F OB A C D F O

HIV-2HIV-2B O D G HB O D G H

BBCC

A D E/AA D E/A

C A DC A D

B, EB, E

E/A BE/A B

BBAustralia and New

Zealand15,000

Australia and New Zealand15,000

East Europe and Central Asia

53,000

East Europe and Central Asia

53,000

• 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

Effect of Genetic Diversity on HIV CareEffect of Genetic Diversity on HIV Care

Test Subtype Detection Range (copies/mL)

bDNA (Quantiplex HIV-1 3.0) A - F 50-500,000

NASBA (NucliSens HIV-1 ZT) A - F 80-10,000,000

RT-PCR (Amplicor HIV-1 Monitor 1.0; Ultraquant)

A - F, but unreliable for A and E

400-750,000Ultrasensitive: 50-75,000

RT-PCR (Amplicor HIV-1 Monitor 1.5; Ultraquant)

A - G 400-750,000Ultrasensitive: 50-75,000

HIV-1 Genetic Diversity in HIV-1 Genetic Diversity in Antenatal Cohort, CanadaAntenatal 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

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

END