The impact of migration, race and ethnic diversity on healthcare delivery and clinical outcomes in the UK

Polly Clayden, HIV i-Base

Three oral presentations and a number of posters highlighted issues of ethnic diversity in the UK and the impact of this on both healthcare delivery and clinical outcome.

Newly diagnosed women in Leicester

Dr Chapman from the GUM department at Leicester Royal Infirmary presented the results of an audit of newly diagnosed HIV positive women from January 2000 to December 2002. [1]

He reported that new diagnoses rose by 61% during this period in their area (the government’s policy of ‘dispersal’ of asylum seekers has contributed significantly to this situation), and the aim of this study was to see if the national implementation of antenatal HIV screening has contributed to this rise and the impact it has had on services.

The investigators reported 129 newly diagnosed women during this period – of whom 31 (24%) were pregnant: “As this dispersal continues, more clinics will need to develop care pathways, with access to both healthcare and social-care professionals.”

South Asians in London

South Asia has one of the fastest growing HIV epidemics in the world and to date there have been no data to describe HIV positive South Asians in the UK.

Sethi and colleagues performed a review of all South Asian people (defining their ethnicity as Indian, Pakistani, Bangladeshi or Sri Lankan) presenting at four London hospitals between January 1985 and December 2002. [2]

Of the 116 participants identified 88 were men and 28 women. Their regions of origin included Africa (39%), the Indian subcontinent (35%) and the UK (16%). Mode of transmission included heterosexual 61 (53%), MSM 36 (31%), unknown 13 (11%), IDU 2 (2%) and transfusion 4 (3%) Their median age of diagnosis was 34 years and median CD4 298 cell/mm3, and heterosexuals were more likely to present late than gay men (CD4 214 vs 390 cells mm3 p=0,03) and to have an AIDS defining illness. They were also significantly less likely to be diagnosed in a GUM clinic (2/74, 3% vs 17/36, 47% p<0.001).

The investigators reported 129 newly diagnosed women during this period – of whom 31 (24%) were pregnant and antenatal screening identified 15 (12%). Of the 129 women 115 (89%) were infected outside the UK and 109 (95%) of in sub-Saharan Africa. 60 (55%) of these women are seeking asylum.

The investigators also noted that a large number of these women presented with advanced HIV disease, and that they required HAART either for themselves or to prevent mother to child transmission. And they added “ As this dispersal continues, more clinics will need to develop care pathways, with access to both healthcare and social-care professionals.”

HIV and black Caribbeans in the UK

Likewise, prevalence rates in the Caribbean are high. The UK has an estimated black Caribbean population of 612,000 and continuing immigration so inevitably the numbers of black Caribbeans living with HIV in the UK are increasing (almost six-fold since 1995).

Dougan and colleagues, on behalf of the Communicable Disease Surveillance Centre (CDSC), London, looked at data on new diagnoses received by the CDSC until 30 September 2002 and on diagnosed prevalent infections from the Survey of Prevalent Diagnosed HIV Infections (SOPHID). [3]

They reported 759 diagnoses of black Caribbeans since the beginning of the epidemic, the majority since 1998. Of these 531 (70%) were men and 228 (30%) women. Median ages at diagnosis were 33.7 years for men and 32.9 years for women. Regions of infection (recorded for 530 people) included 270(37%) probably infected in Latin America and the Caribbean and 194 (37%) in the UK. 297 (39%) were infected through sex between men and 407(53%) through heterosexual sex (of which 195 were men).

They also reported that SOPHID 2001 recorded 705 black Caribbeans receiving HIV-related treatment and care in England Wales and Northern Ireland, a 57% increase since 1999. In 2001 they recorded that 538 (76%) black Caribbeans with HIV lived in London.

In addition to reporting this increase the investigators stressed that “Targeted and culturally sensitive prevention methods are required to address this issue”, and we would add targeted and culturally sensitive treatment information.

Another study evaluated subtypes, and other demographics, of black Caribbean people at London’s Kings College Hospital. [4] Aggarwal and colleagues collected data for 169 black Caribbean people and 42 were subtyped using an in house assay.

They reported that 121 (72%) of the participants were men, 56 (46%) MSM and 41/48 (85%) of the women were infected heterosexually. Regions of origin included 73 (53%) Jamaica, 53 (39%) UK, and 11 (8%) elsewhere in the Caribbean. The median age at diagnosis was 31.5 years and the median CD4 count 316 cells/mm3; 18 (11%) had an AIDS diagnosis at presentation. The investigators noted that this is similar to the CD4 at presentation among their white participants (median 312 cells/mm³) but higher than their African participants (median 227 cells/mm³ p<0.05).

They report that 57.5% were subtype B, which was strongly associated with infection acquired through sex between men (60% vs 23% p<0.05). Non B subtypes included: five subtype C (four born in UK, one in Jamaica), two A (one UK, one Jamaica), two D (one UK, one Jamaica), one F (Jamaica), one H (Trinidad and Tobago), one CRFO2_AG (UK) and two B/C mosaics.

Non-B subtypes were therefore common among their cohort and the investigators pointed to the urgency for “in-depth studies into the emerging HIV epidemic among black Caribbeans in the UK.”

Risk behaviour and the meaning of “resistance” in African people in central London

Davidson and colleagues reported findings from the Padare project on behalf of the Mortimer Market Centre and African HIV Policy Network, London. [5] This study, conducted in the form of a questionnaire, aimed to assess risk knowledge, attitudes and behaviour in a group of HIV-positive African migrants living in London.

The questionnaire, distributed through two clinics and seven community groups elicited response from 214 HIV-positive Africans. Seventy-four per cent reported having had penetrative sex in the past month and of these 40% reported occasional or no condom use. Sixty-one per cent of respondents reported having had unprotected sex in the past year.

As an example of HIV knowledge, the investigators reported that only 18% were sure that they knew what “drug resistance“ meant and 20% were unsure if “resistance’ meant they could not transmit HIV to their partners. They continued: “Sixteen per cent claimed they had been told they had developed resistance, with another eight per cent unsure whether they had been told this.” And 45% of the sexually active study participants who had been told they had resistance reported inconsistent or no condom use in the previous month.

These findings suggest that healthcare workers and community groups, such as ours, need to do a better job concerning HIV information and misinformation…

Subtype, disease progression and response to treatment

Finally two studies from King’s College and St Thomas’ hospitals in London addressed some clinical aspects of an ethnically diverse cohort. [6, 7]

Philippa Easterbrook and colleagues compared the rate of immunological progression prior to antiretroviral therapy, on initiation of HAART and on virological rebound in people with B vs non-B subtypes.

A group of 867 HIV-positive people were subtyped using an in house assay. It found that 47.5% were subtype B and 34.5% non-B, 5.5% were of mixed reactivity and 12.5% were either non reactive or below detectable limits of the assay (env gene sequencing was used to confirm exact distribution of non-B subtypes and mosaic strains).

CD4 count was recorded to determine disease progression and response to HAART. Response to HAART was assessed on time to viral load <50 copies/mL and rebound as time to >50 copies/mL.

Analyses of the subtypes revealed that 457 were B and 317 were non-B subtype. Of these 60 (19%) were A, 114 (36%) were C, 30 (9%) were D and 14 (4.4%) were infected with recombinant strains. Some 82.2% of recombinant strains were Africans from Sub-Saharan Africa (mostly Uganda, Zimbabwe, Nigeria, Ivory Coast and Ghana).

The investigators reported a similar rate of pretreatment CD4 decline and similar time to undetectable viral load across all subtypes.

Response to tenofovir in a highly drug experienced ethnically diverse cohort

McDonald and colleagues evaluated 48-week response to tenofovir containing salvage regimens in a group of 44 ethnically diverse and highly drug experienced participants.

The study group was 44 HIV-positive people (28 men and 16 women) of which 38% were black African, 68% white and 45 black Caribbean with a median CD4 count of 224 cells/mm³. The mean number of previously used antiretroviral drugs was eight, mean number of regimen failures was four and mean number of months on HAART was 47. In addition the mean number of NRTI mutations with thymidine analogue mutations (TAMs) at baseline was two.

At 48 weeks 18 participants had a viral load <50 copies/mL (41%), two had a viral load >50 copies/mL but <400 copies/mL (5%), five viral load >400copies/mL (11%), eight were lost to follow up (18%) and 11 (25%) discontinued therapy. By ITT analysis virological control (viral load <400) was achieved in 46% at 48 weeks. CD4 counts increased by mean 118 cell/mm³ in people who remained on treatment at week 24. The investigators noted that their results were “…despite a high prevalence of RT mutations known to affect tenofovir susceptibility.”

References:

All references are to abstracts presented at 9th BHIVA Conference, 24-26 April 2003,Manchester.

Chapman C and Dhar J. Migration and HIV: impact on service delivery. Abstract O6.
Sethi, G, Fox E, Williams et al South Asians with HIV infection in London: a growing epidemic? Abstract O29.
Dougan S, Payne l, Fenton K et al. HIV and black Caribbeans in the UK. Abstract O30.
Aggarwai I, Smith M, Geretti AM et al. HIV-1 infection among black Caribbeans in southeast London. Abstract P17.
Davidson O, Chinouya M, Ndawula L et al. Risk behaviour and the meaning of ‘resistance’ in a sample of HIV positive Africans accessing services in central London; clinicians be aware. Abstract P20.
Easterbrook PJ, Smith M, Mullen J et al. Relationship between HIV-1 viral subtype, disease progression and response to antiretroviral therapy. Abstract P59.
McDonald C, Kulasegaram R, Smith M et al. The impact of antiretroviral resistance on responses to tenofovir in an ethnically diverse population of highly antiretroviral drug-experienced HIV-infected patients in South London Abstract P1.

Comment

The UK government’s ill-conceived and inhumane policy of dispersing asylum seekers around the country, on the basis that NHS care is supposedly equal across the UK, has contributed considerably to their often woefully inadequate standard of care.

This results in interrupted treatment, ruptured patient-professional relationships and people being sent to areas that have limited or no experience of HIV treatment, with no account taken for necessary social support.