Abstract
BackgroundMigrants represent an increasing proportion of people living with HIV in many developed countries. We aimed to describe the HIV care cascade and baseline genotypic resistance for newly diagnosed asylum seekers referred to the McGill University Health Centre (MUHC) in Montreal, Quebec, Canada.MethodsWe conducted a retrospective cohort study of patients linked to the MUHC from June 1, 2017 to October 31, 2018. We calculated the median time (days; interquartile range (IQR)) from: 1) entry into Canada to immigration medical examination (IME) (i.e. HIV screening); 2) IME to patient notification of diagnosis; 3) notification to linkage to HIV care (defined as a CD4 or viral load (VL) measure); 4) linkage to HIV care to combination antiretroviral therapy (cART) prescription; and 5) cART prescription to viral suppression (defined as a VL < 20 copies/mL). We reviewed baseline genotypes and interpreted mutations using the Stanford University HIV Drug Resistance Database. We calculated the proportion with full resistance to > 1 antiretroviral.ResultsOverall, 43% (60/139) of asylum seekers were newly diagnosed in Canada. Among these, 62% were late presenters (CD4 < 350 cells/μl), 22% presented with advanced HIV (CD4 < 200 cells/μl), and 25% with high-level viremia (VL > 100,000 copies/ml). Median time from entry to IME: 27 days [IQR:13;55]; IME to notification: 28 days [IQR:21;49]; notification to linkage: 6 days [IQR:2;19]; linkage to cART prescription: 11 days [IQR:6;17]; and cART to viral suppression: 42 days [IQR:31;88]; 45% were linked to HIV care within 30 days. One-fifth (21%) had baseline resistance to at least one antiretroviral agent; the K103 N/S mutation was the most common mutation.ConclusionsWhile the majority of newly diagnosed asylum seekers were late presenters, only 45% were linked to care within 30 days. Once linked, care and viral suppression were rapid. Delays in screening and linkage to care present increased risk for onward transmission, and in the context of 21% baseline resistance, consideration of point-of-care testing and immediate referral at IME screening should be made.
Highlights
Migrants represent an increasing proportion of people living with Human immunodeficiency virus (HIV) in many developed countries
All adult (18 years of age or older) patients living with HIV who were linked to HIV care at the Chronic Viral Illness Service (CVIS) between June 1, 2017 and October 31, 2018, and whose care was covered by the Interim Federal Health Program (IFHP), were included in this retrospective cohort study
43% of asylum seekers were newly diagnosed in Canada with a median CD4 count of 307 cells/μl and viral load (VL) of 32,349 copies/mL at presentation
Summary
Migrants represent an increasing proportion of people living with HIV in many developed countries. Refugee claimants and refugees represent an increasing proportion of people living with HIV in Canada [7]. While the province of Ontario has been the preferential refuge for most asylum seekers, Quebec surpassed Ontario during the past two years having processed approximately 25,000 asylum claims per year [8] This shift is likely due to the higher influx of Haitian and other French-speaking African asylum seekers from the United States, as well as a higher number of irregular or unauthorized ports of entry in Quebec, where the Safe Third Country Agreement between the United States and Canada does not apply [9]. Under this Agreement, requests for refugee protection are required to be made in the first country of arrival (either Canada or the United States) [9]
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