Gaps in the HIV diagnosis and care cascade for migrants in Australia, 2013–2017: A cross-sectional study

Autoři: Tafireyi Marukutira aff001;  Richard T. Gray aff003;  Caitlin Douglass aff001;  Carol El-Hayek aff001;  Clarissa Moreira aff001;  Jason Asselin aff001;  Basil Donovan aff003;  Tobias Vickers aff003;  Tim Spelman aff001;  Suzanne Crowe aff001;  Rebecca Guy aff003;  Mark Stoove aff001;  Margaret Hellard aff001
Působiště autorů: Public Health Discipline, Burnet Institute, Melbourne, Australia aff001;  School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia aff002;  The Kirby Institute, UNSW Sydney, Sydney, Australia aff003;  School of Population and Global Health, University of Melbourne, Melbourne, Australia aff004;  Sydney Sexual Health Centre, Sydney, Australia aff005;  Department of Infectious Diseases, Monash University, Melbourne, Australia aff006
Vyšlo v časopise: Gaps in the HIV diagnosis and care cascade for migrants in Australia, 2013–2017: A cross-sectional study. PLoS Med 17(3): e32767. doi:10.1371/journal.pmed.1003044
Kategorie: Research Article



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.


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.

Klíčová slova:

Antiretroviral therapy – Asia – Australia – HIV – HIV diagnosis and management – HIV epidemiology – HIV prevention – Medicare


1. UNAIDS. Fast-Track: Ending the AIDS epidemic by 2030. Geneva, Switzerland: UNAIDS; 2014 [cited 2019 May 30. Available from:

2. UNAIDS. Fast-track commitments to end AIDS by 2030. Geneva, Switzerland: UNAIDS; 2016 [cited 2019 Jun 9]. Available from:

3. UNAIDS. UNAIDS Data 2018. Geneva, Switzerland: UNAIDS; 2018 [cited 2019 Jun 14]. Available from:

4. Scott N, Stoové M, Kelly SL, Wilson DP, Hellard ME. Achieving 90-90-90 HIV targets will not be enough to achieve the HIV incidence reduction target in Australia. Clin. Infect. Dis. 2018;66(7):1019–26. doi: 10.1093/cid/cix939 29099920

5. UNAIDS. Global AIDS Update: MILES TO GO: Closing gaps, breaking barriers, righting injustices. Geneva, Switzerland: UNAIDS; 2018 [cited 2019 Jun 9]. Available from:

6. Kirby Institute. HIV, viral hepatitis and sexually transmissible infections in Australia: Annual surveillance report 2018. Sydney, Australia: Kirby Institute, UNSW Sydney; 2018.

7. Australian Bureau of Statistics (ABS). Migration, Australia. Canberra, Australia: ABS; 2018 [cited 2019 Jun 4]. Available from:

8. Reyes-Urueña J, Campbell C, Hernando C, Vives N, Folch C, Ferrer L, et al. Differences between migrants and Spanish-born population through the HIV care cascade, Catalonia: an analysis using multiple data sources. Epidemiol. Infect. 2017;145(08):1670–81.

9. Diaz A, del Romero J, Rodriguez C, Alastrue I, Belda J, Bru FJ, et al. Effects of region of birth, educational level and age on late presentation among men who have sex with men newly diagnosed with HIV in a network of STI/HIV counselling and testing clinics in Spain. Euro Surveill. 2015;20(14):21088. doi: 10.2807/1560-7917.es2015.20.14.21088 25884148

10. Agu J, Lobo R, Crawford G, Chigwada B. Migrant Sexual Health Help-Seeking and Experiences of Stigmatization and Discrimination in Perth, Western Australia: Exploring Barriers and Enablers. Int. J. Environ. Res. Public Health. 2016;13(5):1–22.

11. Ledoux C, Pilot E, Diaz E, Krafft T. Migrants' access to healthcare services within the European Union: a content analysis of policy documents in Ireland, Portugal and Spain. Globalization and Health. 2018;14(1):57. doi: 10.1186/s12992-018-0373-6 29903036

12. Perez-Urdiales I, Goicolea I, Sebastian MS, Irazusta A, Linander I. Sub-Saharan African immigrant women's experiences of (lack of) access to appropriate healthcare in the public health system in the Basque Country, Spain. Int. J. Equity Health. 2019;18(1):59. doi: 10.1186/s12939-019-0958-6 31014337

13. Davis A, Terlikbayeva A, Terloyeva D, Primbetova S, El-Bassel N. What Prevents Central Asian Migrant Workers from Accessing HIV Testing? Implications for Increasing HIV Testing Uptake in Kazakhstan. AIDS Behav. 2017;21(8):2372–80. doi: 10.1007/s10461-017-1713-x 28155038

14. Keen P, Gray RT, Telfer B, Guy R, Schmidt HM, Whittaker B, et al. The 2016 HIV diagnosis and care cascade in New South Wales, Australia: meeting the UNAIDS 90-90-90 targets. J. Int. AIDS Soc. 2018;21(4):e25109. doi: 10.1002/jia2.25109 29676000

15. van Sighem A, Nakagawa F, De Angelis D, Quinten C, Bezemer D, Op de Coul E, et al. Estimating HIV Incidence, Time to Diagnosis, and the Undiagnosed HIV Epidemic Using Routine Surveillance Data. Epidemiology. 2015;26:653–60. doi: 10.1097/EDE.0000000000000324 26214334

16. The Australasian Society for HIV Medicine (ASHM). National HIV Testing Policy. Sydney, Australia: ASHM; 2017 [cited 2019 Jun 8]. Available from:

17. Communicable Diseases Network of Australia (CDNA). Human Immunodeficiency virus (HIV): CDNA National Guidelines for Public Health Units 2014. Canberra, Australia: Department of Health, Australian Government; 2014 [cited 2019 Jun 4]. Available from:

18. Callander D, Moreira C, El-Hayek C, Asselin J, van Gemert C, Watchirs Smith L, et al. Monitoring the Control of Sexually Transmissible Infections and Blood-Borne Viruses: Protocol for the Australian Collaboration for Coordinated Enhanced Sentinel Surveillance (ACCESS). JMIR Res Protoc. 2018;7(11): e11028. doi: 10.2196/11028 30459142

19. McManus H, Callander D, Donovan B, Russell DB, O'Connor CC, Davies SC, et al. Early initiation of antiretroviral therapy for people newly diagnosed with HIV infection in Australia: trends and predictors, 2004–2015. Med. J. Aust. 2019;210(6):269–75. doi: 10.5694/mja2.50006 30773651

20. Centre for Population Health, NSW Government. NSW HIV Strategy 2016–2020: Quarter 4 & Annual 2018 Data Report. Sydney, Australia: Centre for Population Health, NSW Government; 2019 [2019 Jun 4]. Available from

21. Department of Human Services, Australian Government. Medical care for visitors to Australia. Canberra, Australia: DHS, Australian Government; 2019. Available from:

22. Bretaña NA, Gray R, Law M, Guy R. Aging of the HIV Population in Australia: A Modeling Study. J. Acquir. Immun Defic. Syndr. 2018;79(5):e115–6.

23. Gray RT, Bretana NA. leftygray/Cascade_calculations: Version used for Migrant HIV Cascade Manuscript (Version v4.1_migrant_cascade_paper) [software]; 2017 [2019 Jun 10]. Available from: Updated code available from:

24. van Buuren S, Groothuis-Oudshoorn K. mice: Multivariate Imputation by Chained Equations in R. J. Stat. Softw. 2011;45(3):1–67.

25. The R Team Core: A Language and Environment for Statistical Computing [software]. R Foundation for Statistical Computing, Vienna, Austria. 2017 [2019 Jun 10]. Available from:

26. Brown AE, Attawell K, Hales D, Rice BD, Pharris A, Supervie V, et al. Monitoring the HIV continuum of care in key populations across Europe and Central Asia. HIV Med. 2018;19:431–9.

27. Edwards JK, Arimi P, Ssengooba F, Mulholland G, Markiewicz M, Bukusi EA, et al. The HIV care continuum among resident and non-resident populations found in venues in East Africa cross-border areas. J. Int. AIDS Soc. 2019;22(1):e25226. doi: 10.1002/jia2.25226 30675984

28. Saracino A, Lorenzini P, Lo Caputo S, Girardi E, Castelli F, Bonfanti P, et al. Increased risk of virologic failure to the first antiretroviral regimen in HIV-infected migrants compared to natives: data from the ICONA cohort. Clin. Microbiol. Infect. 2016;22(3):288 e1–8.

29. Tanser F, Barnighausen T, Vandormael A, Dobra A. HIV treatment cascade in migrants and mobile populations. Curr. Opin. HIV AIDS. 2015;10(6):430–8. doi: 10.1097/COH.0000000000000192 26352396

30. Medland NA, Chow EPF, Read THR, Ong JJ, Chen M, Denham I, et al. Incident HIV infection has fallen rapidly in men who have sex with men in Melbourne, Australia (2013–2017) but not in the newly-arrived Asian-born. BMC Infect. Dis. 2018;18(1):410. doi: 10.1186/s12879-018-3325-0 30126355

31. Medland NA, Mao L, Crooks L, de Wit J. Obstacles to prescribers' initiation early antiretroviral therapy: a barrier to achieving 90-90-90 goals. Lancet HIV. 2016;3(12):e559–e60. doi: 10.1016/S2352-3018(16)30172-2 27884374

32. Gunaratnam P, McManus H, Watchirs-Smith L, McGregor S, Callander D, Brown G, et al. People Born in Non-Main English Speaking Countries Are Less Likely to Start HIV Treatment Early in Australia: A National Cohort Analysis, 2014–15. J. Acquir. Immun Defic. Syndr. 2018;77(3):e31–4.

33. Alvarez-del Arco D, Monge S, Azcoaga A, Rio I, Hernando V, Gonzalez C, et al. HIV testing and counselling for migrant populations living in high-income countries: a systematic review. Eur. J. Public Health. 2013;23(6):1039–45. doi: 10.1093/eurpub/cks130 23002238

34. Ridolfo AL, Oreni L, Vassalini P, Resnati C, Bozzi G, Milazzo L, et al. Effect of Legal Status on the Early Treatment Outcomes of Migrants Beginning Combined Antiretroviral Therapy at an Outpatient Clinic in Milan Italy. J. Acquir. Immun Defic. Syndr. 2017;765:315–321.

35. Gray C, Lobo R, Narciso L, Oudih E, Gunaratnam P, Thorpe R, et al. Why I Can't, Won't or Don't Test for HIV: Insights from Australian Migrants Born in Sub-Saharan Africa, Southeast Asia and Northeast Asia. Int. J. Environ. Res. Public Health. 2019;16(6):2–18.

36. Petoumenos K, Watson J, Whittaker B, Hoy J, Smith D, Bastian L, et al. Subsidized optimal ART for HIV-positive temporary residents of Australia improves virological outcomes: results from the Australian HIV Observational Database Temporary Residents Access Study. J. Int. AIDS Soc. 2015; 18:1–8.

37. Gray RT, Watson J, Cogle AJ, Smith DE, Hoy JF, Bastian LA, et al. Funding antiretroviral treatment for HIV-positive temporary residents in Australia prevents transmission and is inexpensive. Sex. Health. 2017;15:13–19.

38. International Organization for Migration (IOM). World Migration Report 2018. Geneva, Switzerland: IOM; 2018 [cited 2019 Jun 4]. Available from:

Článek vyšel v časopise

PLOS Medicine

2020 Číslo 3
Nejčtenější tento týden
Nejčtenější v tomto čísle

Zvyšte si kvalifikaci online z pohodlí domova

Jak na primární i sekundární osteoporózu − prakticky a v kostce
nový kurz
Autoři: MUDr. Jan Rosa

Léčba roztroušené sklerózy

Důležitost adherence při depresivním onemocnění
Autoři: MUDr. Eliška Bartečková, Ph.D.

Koncepce osteologické péče pro gynekology a praktické lékaře
Autoři: MUDr. František Šenk

Sekvenční léčba schizofrenie
Autoři: MUDr. Jana Hořínková, Ph.D.

Všechny kurzy
Kurzy Podcasty Doporučená témata Časopisy
Zapomenuté heslo

Zadejte e-mailovou adresu, se kterou jste vytvářel(a) účet, budou Vám na ni zaslány informace k nastavení nového hesla.


Nemáte účet?  Registrujte se