Refugees and family-reunified immigrants have a high incidence of HIV diagnosis and late presentation compared with Danish born: a nationwide register-based cohort study

IgE and Eosinophilia in Newly Arrived Refugees in Denmark: A Cross-Sectional Study of Prevalence and Clinical Management in Primary Care

Refugees have different disease patterns than the population in receiving countries. Furthermore, refugees face barriers to accessing health care services and treatment. The purpose of this study was to describe the prevalence of eosinophilia and elevated IgE levels in refugees and assess the clinical follow-up. Using a cross-sectional study design, we offered health assessments, including eosinophil count and IgE level measurements, to all newly arrived refugees in a Danish municipality from January 2016 to November 2018. In a subgroup, we assessed the clinical follow-up. The study population consisted of 793 refugees, all of whom had eosinophil counts measured, with 411 also having IgE levels measured. Notably, 48.6% were female and most participants originated from Syria, Eritrea, Iran or Afghanistan, with smaller representation from several other countries. Notably, 6.8% had eosinophilia and 32.1% had elevated IgE levels. Syrian origin was associated with a lower prevalence of both biomarkers, and Eritrean origin with a higher prevalence. In a subgroup of 116 participants with abnormal results, general practitioners brought attention to the elevated levels in 50.9% of the cases, and 31.0% of these received a diagnosis related to the findings. In total, 98.3% (114) of patients in the subgroup had contact with their GP following the health assessment. In refugees, eosinophilia and elevated IgE levels are common conditions, and underlying causes are often not diagnosed, potentially leading to inadequate treatment and worse health outcomes.

Rate estimation and trend analysis of new HIV infections among the international migrant population in Chile from 2013 to 2022

Background

International migrants are central to HIV research, but comparative data on their infection rates versus resident populations, including in Chile, are scarce. This study compares HIV incidence rates between international migrants and Chileans.

Methods

A longitudinal study was conducted. Crude and standardized rates of new HIV infections reported by the Institute of Public Health of Chile (ISP) were calculated for the period 2013 to 2022, using data from public and private health facilities nationwide. Population estimates for international migrants and Chileans were obtained from the National Institute of Statistics (INE) and the National Migration Service (SERMIG). Rates were adjusted for age and sex using the direct method.

Results

A total of 51,513 validated new HIV infections were analyzed, of which 14,936 (29.0 %) occurred in international migrants and 36,577 (71.0 %) in Chileans. International migrants showed an increase in incidence rates between 2013 and 2022 (adjusted rate from 22.6 [95 % CI: 18.3 - 27.0] to 115.6 [95 % CI: 110.5 - 120.7] new HIV infections per 100,000 population). Throughout the study period, the ratio of adjusted incidence rates between international migrants and Chileans increased from 1.0 [95 % CI: 0.9 - 1.2] to 7.6 [95 % CI: 7.2 - 8.0].

Conclusions

HIV incidence rates were higher in international migrants than in Chileans and increased over the study period. This may be influenced by various exogenous factors, including social determinants of health and the COVID-19 pandemic. It is crucial to focus on HIV diagnosis, prevention, and control strategies for international migrants in Chile.

Trends of late HIV presentation and advance HIV disease among newly diagnosed HIV cases in Jiangsu, China: A serial cross-sectional study from 2008 to 2020

Background

This study aimed to assess the trends and determine the factors associated with late presentation (LP) and advanced HIV disease (AHD) among newly diagnosed people living with HIV (PLWH) from 2008 to 2020 in Jiangsu, China.

Methods

Newly diagnosed PLWH registered in the HIV surveillance system from 2008 to 2020 were included. Multivariable logistic regression models were used to analyze the factors associated with LP and AHD. The LP and AHD trends were assessed using Joint-point analysis.

Results

Of 37,251 newly diagnosed PLWH identified, 30,251(81.2%) patients met the inclusion criteria. Among those, 16,672 (55.1%) were considered LP, and 8,691 (28.7%) had AHD. LP trends steadily increased from 2008 (39.0%) to 2020 (59.4%), but AHD trends decreased visibly from 2016 (32.3%) to 2020 (23.4%). The overall median CD4 trends decreased slowly from 389 to 305 cells/mm³ between 2008 and 2020. Married patients and those older than 35 years were more likely to be LP and have AHD. Patients infected via heterosexual transmission had a higher risk of being classified as AHD (aOR: 1.13, 95%CI: 1.06-1.21) than patients infected via homosexual transmission. Patients that were diagnosed at sexually transmitted infections (STIs) clinics (aOR: 1.10, 95%CI: 1.01-1.20) and in hospitals (aOR: 1.69, 95%CI: 1.59-1.79) were more likely to be classified as LP compared with patients diagnosed at voluntary counseling and testing (VCT) centers. Similar, patients diagnosed at STIs clinics (aOR: 1.23, 95%CI: 1.11-1.36) and hospitals (aOR: 2.27, 95%CI: 2.12-2.43) were more likely to have AHD than patients diagnosed in VCT.

Conclusion

Our findings indicate an alarming burden of LP in Jiangsu, suggesting the need for more attention toward HIV diagnosis at early CD4 stages. National HIV control programs must strengthen comprehensive interventions for HIV prevention and promote HIV services. Also, strategies for HIV prevention (PrEP and PEP), testing, and treatment must be extended, especially among the general population.

HIV prevalence ratio of international migrants compared to their native-born counterparts: A systematic review and meta-analysis

BACKGROUND

People on the move, including international migrants, may face health inequities that expose them to a higher risk for HIV than native-born populations. We conducted a systematic review to calculate the HIV prevalence ratio of international migrants compared with native-born populations.

METHODS

We searched five databases between January 2010 and March 2022. Using random-effects meta-analysis, we calculated the pooled HIV prevalence ratios (PR) by comparing the HIV prevalence of migrants with native-born populations. Our research protocol is registered in the International prospective register of systematic reviews (PROSPERO, CRD42021250867).

FINDINGS

In total, 5,121 studies were screened, and 38 were included in the final analysis: 7,121,699 migrants and more than 270 million natives were included in the analysis. The pooled PR for any foreign-born migrants was 1·70 (95% CI 1·11 - 2·61, I² =99·67%, n = 33 studies), refugees was 2·37 (95% CI 0·33-16·99, I² =99·5%, n = 5), undocumented people was 3·98 (95% CI 0·11-143·01, I² =94·6%, n = 3), whilst asylum seekers was 54·79 (95% CI 17·23-174·23, I² =90·2%, n = 2). Meta-regression revealed that population type (adjusted R-squared 11.5%), region of origin (11.3%) and migrant type (10.8%) accounted for heterogeneity more than country-income (2.4%) and study setting (2.3%).

INTERPRETATION

Although it was not possible to assess if HIV infection occurred in the country of origin or destination, the HIV prevalence ratio was higher among migrants than in native-born populations. Inclusive health policies and strategies for delivering HIV testing, prevention and treatment services for migrant populations tailored to their needs are urgently needed.

FUNDING

J.J.O. and E.P.F.C. are supported by the Australian National Health and Medical Research Council (NHMRC) Emerging Leader Fellowship (GNT1193955 and GNT1172873, respectively).

Migration health research in the Nordic countries: Priorities and implications for public health

The past 50 years have witnessed an increase in immigration to the Nordic countries from and beyond neighbouring countries in Europe. Diversity implies variations and differences in health status and health outcomes both within and across populations. Migrant health research has not been prioritized and health policies and practice, especially long-term national plans, often exclude migrants. In this article, we briefly trace the history, the groups, reasons for migration and the road to migrant health research in Norway, Sweden, Finland and Denmark. We discuss the case for data and research including needs, basis for data collection and the methodological challenges. We provide a brief snapshot of migrant health research, identify current gaps and discuss the implications for research. We recommend a regional Nordic strategy to promote intercountry exchange, sharing and learning. Finally, we reflect on the larger picture, implications for policy and practice that could enable societal conditions to reduce avoidable health inequalities.

Cost of non‐communicable diseases in people living with HIV in the Central Denmark Region

OBJECTIVE

To estimate the economic burden of non-communicable diseases (NCDs) in people living with HIV (PLWH) in Denmark.

METHODS

We conducted a cohort study using population-based Danish medical registries including all adult residents of the Central Denmark Region registered with a first-time HIV-diagnosis during the period 2006-2017. For each PLWH, we matched 10 persons without HIV from the background population by birth year, sex and municipality of residence. Information on healthcare utilization and costs for the PLWH and non-HIV cohorts was retrieved from register data. For each cohort, we estimated the annual costs for major disease categories (HIV care, other somatic care, and psychiatric care) in the period from 3 years before to 9 years after diagnosis/matching date.

RESULTS

We identified 407 PLWH and 4070 persons from the background population. The total healthcare costs during the study period were approximately three times higher for PLWH compared to the non-HIV cohort (€76 198 vs. €23 692). Average annual cost of hospital care, primary care and selected prescription medicine was estimated to be €6987 per year in the years after the diagnosis compared to €2083 per year in the non-HIV cohort. In PLWH, the cost of NCDs and psychiatric care was approximately two times higher than the cost of HIV care.

CONCLUSION

PLWH have higher healthcare costs stemming from three areas: excess cost due to the HIV infection, the treatment of NCDs, and psychiatric care.

Length of stay in Denmark before HIV diagnosis and linkage to care: a population-based study of migrants living with HIV, Denmark, 1995 to 2020

BackgroundMigrants face an increased risk of HIV infection and late presentation for HIV care.AimTo examine delays in HIV diagnosis, linkage to care (LTC), and risk of late presentation for migrants living with HIV in Denmark.MethodsWe conducted a population-based, nationwide study of adult migrants (n = 2,166) presenting for HIV care between 1 January 1995 and 31 December 2020 in Denmark. Time from immigration to HIV diagnosis and from diagnosis to LTC, and late presentation were assessed, stratified by migrants' geographical regions of origin, using descriptive statistics.ResultsThe demographics of the migrant population changed over time. Overall, migrants diagnosed with HIV after immigration to Denmark resided a median of 3.7 (IQR: 0.8-10.2) years in Denmark before diagnosis. Median time from HIV diagnosis to LTC was 6 (IQR: 0-24) days. Migrants diagnosed with HIV infection before immigration had a median of 38 (IQR: 0-105) days from arrival in Denmark to LTC. The corresponding median times for 2015-20 alone were 4.1 (IQR: 0.9-13.1) years, 0 (IQR: 0-8) days, and 62 (IQR: 25-152) days, respectively. The overall proportion of late presentation among migrants diagnosed with HIV after immigration was 60%, and highest among migrants from sub-Saharan Africa and East and South Asia.ConclusionHIV diagnosis is still substantially delayed in Danish migrants, while LTC is timely. The proportions with late presentation are high. These results call for targeted interventions to reduce the number of migrants with undiagnosed HIV infections and of late presenters.

A Mental Health Profile of 900 Newly Arrived Refugees in Denmark Using ICD-10 Diagnoses

(1) Background: Recognizing mental health problems in newly arrived refugees poses a challenge. Little is known of the mental health profile of refugees currently arriving in Northern Europe. (2) Method: In total, we included 900 adult (≥18 years old) refugees arriving in Aarhus, Denmark, between 1 January 2014 and 1 January 2020. All participants accepted an offer of a voluntary systematic health assessment from the municipality in Aarhus, including a mental health screening. (3) Results: Within this cohort, 26% (237/900) of the participants were referred to the Department of Psychiatry, Aarhus University Hospital, 24% (212/900) were in contact with the department and 21% (185/900) received ≥1 psychiatric diagnosis. Within the subpopulation referred (n = 237), 64% (152/237) were diagnosed with post-traumatic stress disorder (PTSD) (DF431), 14% (34/237) with neurotic, stress-related and somatoform disorders (F40–F48) and 13% (30/237) with major mood disorders (F30–F39). Among the participants referred to the Department of Psychiatry and participants receiving a diagnosis, we found an overrepresentation of participants originating from the Southern Asian region (Pakistan, Afghanistan and Iran) and with an age above 44 years. (4) Conclusion: We found a high prevalence of both referrals and psychiatric diagnoses in newly arrived refugees. Attention to psychiatric conditions in refugees and systematic health assessments during resettlement are needed.

Understanding the needs and use of sexual and reproductive health services among Thai women: a descriptive cross-sectional study in Sweden

Background Immigrants are at increased risk of HIV infection in Europe and at risk of delayed diagnosis. In Sweden, Thailand belongs to one of the three most common countries of origin among immigrants diagnosed with HIV. This study investigated the need and use of sexual and reproductive health (SRH) services among Thai women residing in Sweden. Use of contraceptives and HIV testing in Thailand was also investigated to understand if this influences utilisation of SRH services in Sweden.

METHODS

A cross-sectional study using postal questionnaire to all Thai-born women (age 23-60) in Stockholm, residing in Sweden since 2014. The response rate was 52.3% (n= 266). Bivariate and multivariate logistic regression analyses were used.

RESULTS

The majority reported a significant need for information related to SRH services. Most of the women using contraception (70%) bought their contraceptives in Thailand. In total, 60% of the women had been HIV-tested at some point in their lives; the majority were tested in Thailand. Women who had been HIV-tested in Thailand were more likely to also have been tested in Sweden. Significant differences in contraception use, participation in contraceptive counselling and having had an HIV test were found between groups of younger and older women.

CONCLUSIONS

Our findings imply that age is an important factor to understand women's need and use of SRH services in Sweden versus Thailand. Furthermore, women's lack of knowledge and reported need for SRH information needs to be considered when making policies and strategies to increase access to SRH services.

Tuberculosis incidence among migrants according to migrant status: a cohort study, Denmark, 1993 to 2015

Background

Migrants account for the majority of tuberculosis (TB) cases in low-incidence countries in western Europe. TB incidence among migrants might be influenced by patterns of migration, but this is not well understood.

Aim

To investigate differences in TB risk across migrant groups according to migrant status and region of origin.

Methods

This prospective cohort study included migrants ≥ 18 years of age who obtained residency in Denmark between 1 January 1993 and 31 December 2015, matched 1:6 to Danish-born individuals. Migrants were grouped according to legal status of residency and region of origin. Incidence rates (IR) and incidence rate ratios (IRR) were estimated by Poisson regression.

Results

The cohort included 142,314 migrants. Migrants had significantly higher TB incidence (IR: 120/100,000 person-years (PY); 95% confidence interval (CI): 115–126) than Danish-born individuals (IR: 4/100,000 PY; 95% CI: 3–4). The IRR was significantly higher in all migrant groups compared with Danish-born (p < 0.01). A particularly higher risk was seen among family-reunified to refugees (IRR: 61.8; 95% CI: 52.7–72.4), quota refugees (IRR: 46.0; 95% CI: 36.6–57.6) and former asylum seekers (IRR: 45.3; 95% CI: 40.2–51.1), whereas lower risk was seen among family-reunified to Danish/Nordic citizens (IRR 15.8; 95% CI: 13.6–18.4) and family-reunified to immigrants (IRR: 16.9; 95% CI: 13.5–21.3).

Discussion

All migrants had higher TB risk compared with the Danish-born population. While screening programmes focus mostly on asylum seekers, other migrant groups with high risk of TB are missed. Awareness of TB risk in all high-risk groups should be strengthened and screening programmes should be optimised.

Phylogenetic clustering networks among heterosexual migrants with new HIV diagnoses post-migration in Australia

Background

It is estimated that approximately half of new HIV diagnoses among heterosexual migrants in Victoria, Australia, were acquired post-migration. We investigated the characteristics of phylogenetic clusters in notified cases of HIV among heterosexual migrants.

Methods

Partial HIV pol sequences obtained from routine clinical genotype tests were linked to Victorian HIV notifications with the following exposures listed on the notification form: heterosexual sexual contact, injecting drug use, bisexual sexual contact, male-to male sexual contact or heterosexual sexual contact in combination with injecting drug use, unknown exposure. Those with heterosexual sexual contact as the only exposure were the focus of this study, with the other exposures included to better understand transmission networks. Additional reference sequences were extracted from the Los Alamos database. Maximum likelihood methods were used to infer the phylogeny and the robustness of the resulting tree was assessed using bootstrap analysis. Phylogenetic clusters were defined on the basis of bootstrap and genetic distance.

Results

HIV pol sequences were available for 332 of 445 HIV notifications attributed to only heterosexual sexual contact in Victoria from 2005–2014. Forty-three phylogenetic clusters containing at least one heterosexual migrant were detected, 30 (70%) of which were pairs. The characteristics of these phylogenetic clusters varied considerably by cluster size. Pairs were more likely to be composed of people living with HIV from a single country of birth (p = 0.032). Larger clusters (n≥3) were more likely to contain people born in Australian/New Zealand (p = 0.002), migrants from more than one country of birth (p = 0.013) and viral subtype-B, the most common subtype in Australia (p = 0.006). Pairs were significantly more likely to contain females (p = 0.037) and less likely to include HIV diagnoses with male-to-male sexual contact reported as a possible exposure (p<0.001) compared to larger clusters (n≥3).

Conclusion

Migrants appear to be at elevated risk of HIV acquisition, in part due to intimate relationships between migrants from the same country of origin, and in part due to risks associated with the broader Australian HIV epidemic. However, there was no evidence of large transmission clusters driven by heterosexual transmission between migrants. A multipronged approach to prevention of HIV among migrants is warranted.

Clinical features of tuberculous lymphadenitis in a low-incidence country

BACKGROUND

Tuberculous lymphadenitis (TBLA) is the most common extrapulmonary manifestation of tuberculosis (TB) in Denmark. However, the clinical features of patients with TBLA have never been systematically studied in this setting.

METHODS

Patients treated for TBLA in Central Region Denmark from 2007 to 2016 were identified using the national TB surveillance register and The Danish Hospital Patient Registry. Data of clinical characteristics and treatment were extracted from hospital records.

RESULTS

Eighty-three TBLA patients were identified. The median age was 32 years (IQR 23-42); 71 (85.5%) were migrants; 58 (69.9%) presented with cervical lymphadenopathy; and 45 (54.2%) had one or more systemic TB symptom such as fever, chills, night sweats, fatigue, and weight loss. Sixty-five patients had no comorbidities (78.3%). HIV co-infection was seen in five (7.2%) of the 69 who were tested for HIV. Abscesses and/or draining sinuses were noted in 13 (15.7%) patients and 15 (18.1%) had concurrent pulmonary infection. The median time from first hospital contact to treatment initiation was 42 days (IQR 16-82) and admitted patients were hospitalised for a median of 7 days (IQR 3-13.5). For 24 patients (28.9%), lymph node material was not sent for mycobacterial culture and 52 (62.7%) had microbiologically confirmed TB. Treatment outcome was successful for 70 patients (84.3%).

CONCLUSION

In Denmark, TBLA is mainly seen among young and previously healthy migrants presenting with cervical lymphadenopathy and sparse systemic symptoms. The diagnosis is often considerably delayed and not microbiologically verified, implying diagnostic difficulties. Treatment outcome needs to be improved.

Immediate versus deferred antiretroviral therapy in HIV-infected patients presenting with acute AIDS-defining events (toxoplasmosis, Pneumocystis jirovecii-pneumonia): a prospective, randomized, open-label multicenter study (IDEAL-study)

BACKGROUND

To evaluate clinical outcomes after either immediate or deferred initiation of antiretroviral therapy in HIV-1-infected patients, presenting late with pneumocystis pneumonia (PCP) or toxoplasma encephalitis (TE).

METHODS

Phase IV, multicenter, prospective, randomized open-label clinical trial. Patients were randomized into an immediate therapy arm (starting antiretroviral therapy (ART) within 7 days after initiation of OI treatment) versus a deferred arm (starting ART after completing the OI-therapy). All patients were followed for 24 weeks. The rates of clinical progression (death, new or relapsing opportunistic infections (OI) and other grade 4 clinical endpoints) were compared, using a combined primary endpoint. Secondary endpoints were hospitalization rates after completion of OI treatment, incidence of immune reconstitution inflammatory syndrome (IRIS), virologic and immunological outcome, adherence to proteinase-inhibitor based antiretroviral therapy (ART) protocol and quality of life.

RESULTS

61 patients (11 patients suffering TE, 50 with PCP) were enrolled. No differences between the two therapy groups in all examined primary and secondary endpoints could be identified: immunological and virologic outcome was similar in both groups, there was no significant difference in the incidence of IRIS (11 and 10 cases), furthermore 9 events (combined endpoint of death, new/relapsing OI and grade 4 events) occurred in each group.

CONCLUSIONS

In summary, this study supports the notion that immediate initiation of ART with a ritonavir-boosted proteinase-inhibitor and two nucleoside reverse transcriptase inhibitors is safe and has no negative effects on incidence of disease progression or IRIS, nor on immunological and virologic outcomes or on quality of life.

Investigation of the Proportion of Diagnosed People Living with HIV/AIDS among Foreign Residents in Japan

Foreign residents represent an increasing proportion of newly diagnosed human immunodeficiency virus (HIV) infections and acquired immunodeficiency syndrome (AIDS) cases in Japan, though scant research has addressed this. This study aimed to estimate the diagnosed proportion of people living with HIV/AIDS (PLWHA) among foreign residents in Japan, covering 1990–2017 and stratifying by geographic region of the country of origin. A balance equation model was employed to statistically estimate the diagnosed proportion as a single parameter. This used published estimates of HIV incidence and prevalence, population size, visit duration, travel volume, as well as surveillance data on HIV/AIDS in Japan. The proportion varied widely by region: People from Western Europe, East Asia and the Pacific, Australia and New Zealand, and North America were underdiagnosed, while those from sub-Saharan Africa, South and South-East Asia, and Latin America were more frequently diagnosed. Overall, the diagnosed proportion of PLWHA among foreign residents in Japan has increased, but the latest estimate in 2017 was as low as 55.3%; lower than the estimate among Japanese on the order of 80% and far below the quoted goal of 90%. This finding indicates a critical need to investigate the underlying mechanisms, including disparate access to HIV testing.