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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