نبذة مختصرة : Background Globally, few studies compare progress toward the Joint United Nations Program on HIV/AIDS (UNAIDS) Fast-Track targets among migrant populations. Fast-Track targets are aligned to the HIV diagnosis and care cascade and entail achieving 90-90-90 (90% of people living with HIV [PLHIV] diagnosed, 90% of those diagnosed on treatment, and 90% of those on treatment with viral suppression [VS]) by 2020 and 95-95-95 by 2030. We compared cascades between migrant and nonmigrant populations in Australia. Methods and findings We conducted a serial cross-sectional survey for HIV diagnosis and care cascades using modelling estimates for proportions diagnosed combined with a clinical database for proportions on treatment and VS between 2013–2017. We estimated the number of PLHIV and number diagnosed using New South Wales (NSW) and Victorian (VIC) data from the Australian National HIV Registry. Cascades were stratified by migration status, sex, HIV exposure, and eligibility for subsidised healthcare in Australia (reciprocal healthcare agreement [RHCA]). We found that in 2017, 17,760 PLHIV were estimated in NSW and VIC, and 90% of them were males. In total, 90% of estimated PLHIV were diagnosed. Of the 9,391 who were diagnosed and retained in care, most (85%; n = 8,015) were males. We excluded 38% of PLHIV with missing data for country of birth, and 41% (n = 2,408) of eligible retained PLHIV were migrants. Most migrants were from Southeast Asia (SEA; 28%), northern Europe (12%), and eastern Asia (11%). Most of the migrants and nonmigrants were males (72% and 83%, respectively). We found that among those retained in care, 90% were on antiretroviral therapy (ART), and 95% of those on ART had VS (i.e., 90-90-95). Migrants had larger gaps in their HIV diagnosis and care cascade (85-85-93) compared with nonmigrants (94-90-96). Similarly, there were larger gaps among migrants reporting male-to-male HIV exposure (84-83-93) compared with nonmigrants reporting male-to-male HIV exposure (96-92-96). Large gaps were also found among migrants from SEA (72-87-93) and sub-Saharan Africa (SSA; 89-93-91). Migrants from countries ineligible for RHCA had lower cascade estimates (83-85-92) than RHCA-eligible migrants (96-86-95). Trends in the HIV diagnosis and care cascades improved over time (2013 and 2017). However, there was no significant increase in ART coverage among migrant females (incidence rate ratio [IRR]: 1.03; 95% CI 0.99–1.08; p = 0.154), nonmigrant females (IRR: 1.01; 95% CI 0.95–1.07; p = 0.71), and migrants from SEA (IRR: 1.03; 95% CI 0.99–1.07; p = 0.06) and SSA (IRR: 1.03; 95% CI 0.99–1.08; p = 0.11). Additionally, there was no significant increase in VS among migrants reporting male-to-male HIV exposure (IRR: 1.02; 95% CI 0.99–1.04; p = 0.08). The major limitation of our study was a high proportion of individuals missing data for country of birth, thereby limiting migrant status categorisation. Additionally, we used a cross-sectional instead of a longitudinal study design to develop the cascades and used the number retained as opposed to using all individuals diagnosed to calculate the proportions on ART. Conclusions HIV diagnosis and care cascades improved overall between 2013 and 2017 in NSW and VIC. Cascades for migrants had larger gaps compared with nonmigrants, particularly among key migrant populations. Tracking subpopulation cascades enables gaps to be identified and addressed early to facilitate achievement of Fast-Track targets.
Tafireyi Marukutira and colleagues study the cascade of diagnosis and care for migrants with HIV infection in Australia.
Author summary Why was this study done? Reaching the end of the AIDS epidemic by achieving the Joint United Nations Program on HIV/AIDS (UNAIDS) Fast-Track targets requires tracking progress across all population groups. Fast-Track targets entails reaching 90-90-90 (90% of people living with HIV diagnosed, 90% of those diagnosed on treatment, and 90% of those on treatment with viral suppression) by 2020 and 95-95-95 by 2030. Migrants often face barriers to healthcare access because of their migration status, sociocultural influence, financial constraints, and stigma. There are limited data on HIV diagnosis, care, and treatment among migrants, which is required in order to streamline the HIV response. What did the researchers do and find? We developed HIV diagnosis and care cascades for migrants and nonmigrants in Australia between 2013 and 2017. The overall cascade was high in New South Wales and Victoria (i.e., 90-90-95). Migrants had inferior cascades (85-85-93) compared with nonmigrants (94-90-96), including migrants reporting male-to-male HIV exposure (84-83-93) compared with nonmigrants (96-92-96). Between 2013 and 2017, subpopulation cascades improved, except for females, irrespective of migration status and migrants from Southeast Asia. What do these findings mean? In our study, although the overall HIV diagnosis and care cascades improved over time in Australia, migrants lagged behind. Failure to develop subpopulation cascades may lead to gaps going unnoticed. To address gaps, there is need for streamlined strategies, especially among migrant populations, to ensure timely HIV testing and linkage to care.
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