There is a strong social gradient associated with HIV diagnoses in the Netherlands, Dr Vita Jongen from Stichting HIV Monitoring and colleagues report in The Lancet Regional Health – Europe. People who are poorer or are first-generation immigrants are much more likely to be diagnosed with HIV, while intersections between poverty and migration further increase their vulnerability.
Background
The Netherlands has nearly reached the UNAIDS 95-95-95 targets: 95% of people with HIV are diagnosed, 95% of those diagnosed are on treatment and 95% of those on treatment are virally suppressed. Additionally, access to HIV pre-exposure prophylaxis (PrEP) has dramatically reduced HIV transmission, particularly among younger people.
While new HIV diagnoses dropped consistently throughout the 2010s, they’ve stabilised since 2020, at around approximately 500 a year. Gay, bisexual and other men who have sex with men make up around 60% of these new diagnoses, other men around 20%, women around 16% and trans people around 4%.
However, gaps remain – especially for groups such as women and cisgender straight men. Across Europe, there are gaps in coverage of HIV prevention and treatment for migrants. Migrants often lack in-depth knowledge of how to navigate the health system in a new country and may find that language barriers make access to HIV services a challenge.
At a time of decreasing HIV incidence across Europe, when some groups are disproportionately affected by new diagnoses, researchers are interested in the structural and social factors that may make certain people more vulnerable to acquiring HIV. Here, the focus isn’t on risk groups and sexual behaviours – as has been the focus for most of the epidemic – but instead on broader factors, such as poverty or immigration status, and how these cluster together and intersect to create unique and emerging HIV vulnerabilities.
The study
HIV care in the Netherlands is provided by 23 treatment centres who contribute data to the centralised Stichting HIV Monitoring. While the Netherlands has universal healthcare, this is based on mandatory private insurance contributions. HIV testing is free for specific populations, such as gay men and trans women. Documented migrants have access to the healthcare system, but undocumented migrants may have to pay out of pocket for health-related services. However, any care deemed medically necessary – such as HIV testing and care – should not be withheld, even for undocumented people.
Over 97% of all people living with HIV in the Netherlands also contribute their data to a research cohort, AIDS Therapy Evaluation in the Netherlands (ATHENA). This is one of the main data sources for the current study.
Additionally, researchers accessed data from Statistics Netherlands for two purposes. The first was to perform comparisons between age and sex-matched individuals in the general population and people diagnosed with HIV. The second was to match HIV diagnosis data with specific individuals represented in Statistics Netherlands data, to investigate potential associations between being diagnosed with HIV and education, income, immigration status and certain health behaviours, such as using mental healthcare services or antidepressant medication. This was done by matching an individual’s date of birth, the first four digits of the postal code of their last known residence and sex at birth. This allowed for linkage between ATHENA and Statistics Netherlands data. If exact matching was not possible, the data was not used for the results.
All people in the ATHENA cohort over 18 and newly diagnosed with HIV in the Netherlands between January 2012 and December 2023 were included. People who migrated to the Netherlands with known HIV were excluded, as were transgender people – due to small numbers and the possible risk of identification.
Intersecting factors create unique vulnerabilities to HIV
For the study period, 6055 men and 1020 women were newly diagnosed with HIV. Most people diagnosed with HIV were aged between 25 and 49 years old – 64% of all diagnoses for both men and women, with very few diagnoses among those aged 18 to 25. The 25-to-49-year-old group was overrepresented when compared to the general Dutch population, where they comprised 44% of all men and 49% of all women.
Of men diagnosed with HIV, most were neither first- or second-generation immigrants (59%), a large proportion had secondary education or higher (41%) and fell into the middle-to-low-income bracket (43%). However, when compared with the general population, there were many more immigrants among those diagnosed with HIV than generally (40% vs. 23%) and more men living below the poverty line among those diagnosed with HIV (23% vs. 12%). There were also sizable differences in those who used mental health care services and antidepressants among those diagnosed with HIV and the general population (7% vs. 5% and 8% vs. 5%, respectively).
Of women diagnosed with HIV, most were first-generation immigrants (55%), a large proportion had mainly primary and secondary education (44%) and their income fell below the poverty line (45%). Moreover, when compared with the general population, there were many more immigrants among those diagnosed with HIV than generally (64% vs. 25%) and there more women living below the poverty line among those diagnosed with HIV (45% vs. 14%). There was a notable difference in those who used antipsychotic medications among people diagnosed with HIV and the general population (5% vs. 2%).
When considering specific socio-economic categories and health behaviours, first-generation immigrant men were over twice as likely to be diagnosed with HIV than non-immigrants (adjusted Odds Ratio 2.21, 95% Confidence Interval 2.08-2.35). This pattern was much stronger for first-generation immigrant women, who were over four times more likely to be diagnosed with HIV than non-immigrant women (aOR 4.48, 95% CI 3.87-5.19). Statistically significant increases in HIV diagnoses still held true for second-generation immigrants but were not as pronounced, as these people were born in the Netherlands and likely have better healthcare knowledge and access.
The most notable difference for both women and men related to income: women living below the poverty line were over four times more likely to be diagnosed with HIV than high-income women (aOR 4.71, 95% CI 3.8-5.83), while women in the middle to low-income bracket were nearly two and a half times more likely to be diagnosed with HIV than high income women (aOR 2.49, 95% CI 2.05-3.01). For men, this difference was not as dramatic – men living below the poverty line were nearly twice as likely to be diagnosed with HIV than high-income men (aOR 1.75, 95% CI 1.62-1.89). The poverty line is defined as household income less than 120% of the social minimum, or income needed to survive.
Interestingly, men who used antidepressants were more likely to be diagnosed with HIV than those who did not; for women, antipsychotic medications were more likely to be associated with an HIV diagnosis.
When considering combined demographic, socio-economic and health behaviour factors, certain profiles were more likely to have a predicted risk of being diagnosed with HIV than others. A first-generation immigrant man aged 25 to 49, with income below the poverty line and using antidepressants, would have a 12-fold higher risk of being diagnosed with HIV than a man older than 50, with no immigration history and a high income. Similarly, a first-generation immigrant woman aged 25 to 49, with income below the poverty line, receiving social welfare, and using antipsychotic medications, would have a much higher predicted risk of being diagnosed with HIV than women with differing profiles.
Conclusion
“A disproportionally higher burden of new HIV diagnoses was observed for individuals with not only a migration background, but also economic and mental health vulnerabilities,” the authors conclude. “Barriers to HIV prevention and testing need to be reduced if we are to achieve no new HIV infections and end the HIV epidemic.”
This research is a clear indication of the social gradient: those who are poorer and experience the worst consequences of migration, such as first-generation immigrants, are much more likely to see worse health outcomes, such as being diagnosed with HIV. These negative health consequences ease off for low-to-middle income people and second-generation immigrants but are still visible – even in settings with access to HIV testing and prevention.
Intersections between factors such as poverty and migration heighten HIV vulnerability and need to be adequately and actively acknowledged by any public health policies aimed at eliminating new cases of HIV.
