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IAS 2023 Eastern Europe
Key Takeaways From IAS 2023 on Diagnosis, Linkage to Care, and Treatment of Migrant and Refugee Populations in Eastern Europe

Released: August 31, 2023

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Key Takeaways
  • Social networks provide a key to linkage and care among migrant populations.
  • Virologic suppression with INSTI-based ART maintained in Ukranian refugees coinfected with HIV and latent TB and treated with short-course rifapentine plus isoniazid.

Central and Eastern Europe, my area of practice, remains disproportionately affected by the HIV epidemic, and delayed testing results in an increased burden of late HIV diagnoses. In this context, tuberculosis is the most common opportunistic infection. A substantial proportion of individuals who are diagnosed late during HIV infection are among populations who experience major obstacles to accessing healthcare, often due to challenging life circumstances, including migrants and refugees. The migrant and refugee population has grown rapidly in several regions of Europe, particularly Eastern Europe, because of the Russian invasion of Ukraine as well as political unrest and military actions in other regions. Therefore, there is considerable clinical interest in implementing strategies to increase HIV testing and linkage to care and to improve treatment of key opportunistic infections including multidrug-resistant tuberculosis among migrant and refugee groups.

Using Social Networks to Increase Testing and Linkage to Care

At IAS 2023, there were highly interesting data presented related to social network HIV testing. This approach involves a key person becoming the “seed” and providing motivation to others in the network to be tested. A large-scale systematic review and meta-analysis of the literature including >18,000 reports indicated that implementation of this social network approach resulted in an increase in uptake of HIV testing services in general and first-time testing in particular translating into a >2-fold higher proportion of people among social networks being diagnosed with HIV.

Another presentation reported the results of a randomized trial in Kenya of “promoters” (key players in the social network) who, with identification and training, were given HIV self-tests to distribute to others in their group, along with transport vouchers and a small monetary incentive. When compared with a control group whose leader only had information and referrals for testing, the groups with trained promoters had higher rates of both self-testing (60% vs 10%, P<.001) and any modality HIV testing (47% vs 27%, P<.001). These interventions also resulted in a higher rate of linkage to ART or PrEP (70% vs 17%, P<.001).

Partly as a result of these data, the World Health Organization has issued new recommendations that social network testing approaches may be offered as an additional HIV testing strategy as part of a comprehensive package of care and prevention. One might predict that a social network testing approach may be useful among refugee and migrant populations in Eastern Europe.

Short Course TB Treatment + INSTI-Based ART in Ukranian Refugees

The Russian invasion of Ukraine has shifted the clinical characteristics of HIV infection further, increasing numbers and the risk of late diagnosis in refugee populations. In addition, Ukraine has a high rate of incident tuberculosis (71 per 100,000 in 2021 with 31%-45% of those being multidrug resistant), and high TB mortality rates (8.3 per 100,000 population in 2021). Approximately 22% of persons with TB in Ukraine are coinfected with HIV. For this reason, data on maintenance of virologic suppression during short-term treatment of latent tuberculosis sparked special interest for me. A retrospective study by Lin and colleagues included 456 people with HIV and positive or indeterminate  interferon-gamma release assay who received either 3 months of once weekly rifapentine plus isoniazid or 1 month of daily rifapentine plus isoniazid. Most (97.6%) also received dolutegravir- or bictegravir-based ART. Virologic suppression rates (HIV-1 RNA <200 copies/mL) 3 to 6 months following completion of latent TB treatment were excellent (96.7%-100%) regardless of the ART/TB combination with mostly mild or moderate adverse events, indicating high virologic efficacy and clinical safety. Data such as these can give us confidence in this approach, even among this highly at-risk population.

Your Thoughts?

Are you working with migrant groups in your practice? What are your particular concerns and challenges related to HIV and opportunistic coinfection care in this population? Leave a comment to join the conversation.