AIDS Behav (2015) 19:890–898 DOI 10.1007/s10461-014-0954-1

ORIGINAL PAPER

Foreign-Born Persons Diagnosed with HIV: Where are They From and Where Were They Infected? Ellen W. Wiewel • Lucia V. Torian • David B. Hanna • Angelica Bocour • Colin W. Shepard

Published online: 19 December 2014 Ó Springer Science+Business Media New York 2014

Abstract We sought to calculate rates of HIV diagnoses by area of birth among foreign-born persons in a highincidence US city with many immigrants, and determine probable place of HIV acquisition. Data from the New York City HIV surveillance registry and American Community Survey were used to calculate HIV diagnosis rates by area of birth and determine probable place of HIV acquisition among foreign-born diagnosed in 2006–2012. HIV diagnosis rates varied by area of birth and were highest among African-born persons; absolute numbers were highest among Caribbean-born persons. Probable place of acquisition was a foreign country for 23 % (from 9 % among Middle Easterners to 43 % among Africans), US for 61 % (from 34 % among Africans to 76 % among South Americans), and not possible to estimate for 16 %. HIV prevention and testing initiatives should take into account variability by foreign area of birth in HIV diagnosis rates and place of acquisition.

Data in this manuscript were presented in part at the 14th annual Conference on Retroviruses and Opportunistic Infections, Montreal, Canada, February 2009.

Electronic supplementary material The online version of this article (doi:10.1007/s10461-014-0954-1) contains supplementary material, which is available to authorized users. E. W. Wiewel (&)  L. V. Torian  A. Bocour  C. W. Shepard HIV Epidemiology and Field Services Program, New York City Department of Health and Mental Hygiene, 42-09 28th Street, 22nd Floor, Long Island City, New York, NY 11101, USA e-mail: [email protected] D. B. Hanna The Albert Einstein College of Medicine, Bronx, NY, USA

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Resumen Intentamos calcular los niveles de diagno´sticos de VIH por lugar de nacimiento entre personas nacidas en el extranjero en una ciudad de los Estados Unidos de alta incidencia de infeccio´n del VIH y con muchos inmigrantes, y determinar el lugar probable de contagio. Se utilizaron los datos del registro de vigilancia del VIH de la ciudad de Nueva York y los datos de la Encuesta de la Comunidad Estadounidense para calcular los niveles de diagno´stico de VIH por lugar de nacimiento y determinar el lugar probable de contagio entre las personas nacidas en el extranjero y diagnosticadas durante el periodo del 2006 al 2012. Los niveles de diagno´stico del VIH variaron por lugar de nacimiento y fueron ma´s altos entre personas de origen africano; los nu´meros absolutos fueron ma´s altos entre personas de origen cariben˜o. El lugar probable de contagio del VIH fue para el 23 % otro paı´s (de 9 % entre personas del Medio Oriente hasta 43 % entre personas de origen africano), para el 61 % los Estados Unidos (de 34 % entre personas de origen africano hasta 76 % entre sudamericanos), y para el 16 % no fue posible estimar. Las iniciativas de prevencio´n del VIH y promocio´n de la prueba del VIH deben tomar en cuenta la variedad por lugar de nacimiento en los niveles de diagno´stico del VIH y el lugar de contagio. Keywords HIV  Epidemiology  Epidemiologic surveillance  Emigrants and immigrants  Place of birth

Introduction One in every six people newly diagnosed with HIV in the United States (US) was born in another country [1]. There have been few large-scale, population-based calculations of HIV diagnosis rates based on region and country of origin, or estimation of where US foreign-born newly diagnosed with

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HIV may have acquired the infection [1, 2]. This information would be useful for guiding HIV prevention and testing in light of the high number of immigrants in the US. New York City (NYC) has been an immigration gateway for centuries and the center of the US HIV epidemic for decades. Almost one-third of HIV diagnoses in NYC are attributable to foreign-born persons, who nonetheless have a lower diagnosis rate than non-foreign-born [3]. Using data from NYC HIV surveillance and the American Community Survey, we calculated rates of HIV diagnosis by region and country of birth among foreign-born persons in a high-incidence US city with many immigrants, and determined probable place of HIV acquisition.

Methods Data Sources NYC has conducted population-based AIDS surveillance since 1981 and HIV surveillance since 2000 [4]. The surveillance registry, which includes information on place, date and stage of illness at diagnosis, vital status, demographic characteristics, HIV-related laboratory tests and place of birth, was the primary data source for this analysis. Place of birth was collected via medical record reviews, provider report forms, and/or patient interviews, and recorded by the name of the country or categorized by region if more specific data were not available. Countries were aggregated to regions largely consistent with groupings in the US Census-based American Community Survey (ACS) [5], to maximize comparability across data sources. Data from the 2006–2010 ACS were used for population denominators overall and by place of birth [5]. ACS is an ongoing household survey of a random sample of the US population [6]. It is conducted by the US Census Bureau to provide population size estimates and information about population characteristics such as place of birth. The UNAIDS Report on the Global AIDS Epidemic—2012 provided HIV incidence estimates for 2011 by country and region [7]. Because ACS and UNAIDS regional groupings differed, incidence rates for mostly comparable regions were applied, i.e., the incidence rate for Latin America was applied to Central and South America, for Sub-Saharan Africa to Africa, and for Western and Central Europe to Europe. A subset of persons newly diagnosed with HIV was interviewed by the DOHMH’s HIV Field Services Unit (FSU), which assists HIV providers with the provision of partner services and linkage to care [8]. FSU was established in 2006, with staff providing assistance to eight hospitals providing HIV diagnosis and care in NYC, and has expanded to include over 100 sites affiliated with 37 facilities in the city in 2011. FSU attempts to interview all HIV-positive

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persons at these facilities who are newly diagnosed, previously diagnosed and have known or suspected unnotified partners or a newly diagnosed sexually transmitted infection, or, since 2008, out of care C9 months. For this subset of persons included in this analysis (i.e., persons interviewed by the FSU), the interview provided data on length of time in US, country of previous HIV diagnosis, and where the respondent believed that HIV infection was acquired. The analytic dataset included all diagnoses made between January 1, 2006, and December 31, 2012, and reported to the registry as of June 30, 2013. Population The analysis included the entire population of persons newly diagnosed with HIV and reported by an NYC provider between June 1, 2006, and December 31, 2012, regardless of patient place of residence. A further analysis was conducted among the subset of these persons that was interviewed by the FSU between March 1, 2007, and January 31, 2012. Variable Definitions Country of birth was grouped into regions and used to divide the population into two subpopulations: foreignborn or non-foreign-born. Non-foreign-born included persons born in the US, US dependencies (e.g., Puerto Rico) and missing country of birth, on the assumption that country of birth was less likely to be recorded in the medical record if the person was born in the US and because some demographic and clinical characteristics of persons missing country of birth were more similar to those born in the US than those known to be foreign-born. We developed a composite measure describing the place of acquisition of HIV. It was primarily based on a person’s answer to the question, ‘‘Where do you think you were infected with HIV?,’’ for which answer options included ‘‘In NYC,’’ ‘‘In US, outside NYC,’’ ‘‘Outside US,’’ or ‘‘Don’t know.’’ It was also based on country of previous HIV diagnosis (if any), length of time residing in the US at interview, and concurrent HIV/AIDS diagnosis, to balance the possibility that patient belief about place of infection was not accurate. Residence for 10 years in the US at the time of interview was used as a cut point because this was considered sufficient time to develop symptoms in the absence of treatment, suggesting possible time and place of infection [9–11]. Information about HIV risk behaviors was not available by country of occurrence and therefore was not used in this composite measure. Place of acquisition was categorized as ‘‘probable foreign acquisition,’’ ‘‘probable US acquisition,’’ and ‘‘unknown place of acquisition.’’ Probable foreign acquisition was defined as HIV believed to be acquired outside or diagnosed outside and believed to be

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Table 1 HIV diagnoses and foreign-born population in New York City (NYC) by area of birth, and UNAIDS-estimated HIV incidence in foreign regions, 2006–2012 Area of birtha

2006–12 HIV diagnoses in NYCb

2006–10 NYC populationc

Annual HIV diagnosis rate per 100,000 population in NYC (95 % CI)b,c

HIV diagnoses as percent of all newly diagnosedforeignborn persons in NYCb (%)

Population as percent of all foreign-born persons in NYCc (%)

2011 HIV incidence per 100,000 persons 15–49 in foreign regionsa,d

Total

26,946

8,078,471

48 (46–49)

N/A

N/A

N/A

Non-foreign-born total Foreign-born total

19,117

5,107,353

53 (51–55)

N/A

N/A

N/A

7,829

2,971,118

38 (35–40)

100

100

N/A

Caribbean

2,984

829,233

51 (47–56)

38

28

60

Central America

1,228

295,896

59 (51–68)

16

10

30

South America

1,216

422,792

41 (35–47)

16

14

30

Africa

1,177

115,181

146 (124–168)

15

4

380

Asia & Middle East

619

802,501

11 (9–13)

8

27

N/A

Europe

505

476,571

15 (12–19)

6

16

\10

North America, not US

30

21,984

19 (13–28)

0

1

N/A

Other or unknown foreign region

70

N/A

N/A

1

N/A

N/A

The first three data rows are italicized to indicate that these are overall totals or subpopulation totals (non-foreign- and foreign-born) a

UNAIDS HIV incidence rate statistics are estimates and include estimated rates of 60 per 100,000 globally and 30 per 100,000 in the United States. Because American Community Survey and UNAIDS regional groupings differed, incidence rates for mostly comparable regions were applied, i.e., the incidence rate for Latin America was applied to Central and South America, for Sub-Saharan Africa to Africa, and for Western and Central Europe to Europe

b

Surveillance data reported to the NYC Department of Health and Mental Hygiene as of June 30, 2013, for HIV diagnoses in 2006–2012

c

American Community Survey 2006–2010 for 2006–2010 NYC population

d

UNAIDS Report on the Global AIDS Epidemic—2012 for 2011 HIV incidence estimates in foreign regions

not acquired in US (i.e., it may have been acquired during residency in, or travel to, the home country); highly likely foreign acquisition was the subset of these in the US 0–9 years. Probable foreign acquisition also included persons who did not state a belief about where they acquired HIV, whose place of diagnosis was the US or unknown, and who were in the US 0–9 years and diagnosed concurrently with AIDS. Probable US acquisition was defined as HIV believed to be acquired and diagnosed in US; highly likely US acquisition was the subset of these in the US C 10 years. Probable US acquisition also included persons not believed to have acquired HIV in a foreign country who resided in the US C 10 years and were not diagnosed concurrently with AIDS. Unknown place of acquisition was assigned for any person that did not meet the above definitions. Statistical analysis Number of diagnoses in 2006–2012 and annualized diagnosis rates per 100,000 population (calculated for countries with at least 15 diagnoses over the 7 years: diagnoses from the NYC registry divided by 7 years, divided by the number of persons living in NYC from that country or

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region of birth per ACS, and multiplied by 100,000) and their corresponding 95 % confidence intervals were calculated for each foreign region and country with a countryspecific population estimate from ACS, and for foreignborn, non-foreign-born, and NYC overall. For regions or countries with fewer than 100 diagnoses over 7 years, confidence intervals were constructed assuming a Poisson distribution; otherwise, a normal distribution was assumed [12]. Persons from each country and region were divided by foreign-born totals, both for HIV diagnoses and for the NYC population overall, to obtain the distributions of foreign-born newly diagnosed with HIV and in the NYC population, respectively. Home-country and home-region HIV incidence rates were provided for context as the estimated number of infections per 100,000 persons 15–49 years old [7]. Place of HIV acquisition was calculated overall and by foreign region and demographic characteristics. Analyses were conducted using SAS 9.2 (SAS Institute, Cary, NC, USA) and Microsoft Excel 2010. We also created maps of (a) the number and (b) the rate of HIV diagnoses in NYC by country of birth, displaying these on the countries of birth, and (c) the incidence of HIV by country per UNAIDS, for visual comparison.

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894 b Fig. 1 a Number of HIV diagnoses in New York City (NYC) by

country of birth, 2006–2012. Number of diagnoses in NYC among foreign-born persons are mapped onto countries of birth. Source: Surveillance data reported to the NYC Department of Health and Mental Hygiene as of June 30, 2013. b Annualized HIV diagnosis rate in New York City (NYC) per 100,000 population, by country of birth, 2006–2012. Rates of diagnoses in NYC among foreign-born persons are mapped onto countries of birth. Sources: Surveillance data reported to the NYC Department of Health and Mental Hygiene as of June 30, 2013, for HIV diagnoses in 2006–2012; and American Community Survey 2006–2010 for 2006–2010 NYC population by country of birth (the denominators for the calculation of diagnosis rates). c HIV incidence per 100,000 persons, 2011 (UNAIDS). Source: UNAIDS Report on the Global AIDS Epidemic—2012

Results Number and Rate of New HIV Diagnoses by Foreign Country and Region of Birth, 2006–2012 Of 26,946 persons newly diagnosed with HIV in NYC, foreign-born persons comprised 7,829 (29 %) and had a lower HIV diagnosis rate overall than non-foreign-born (38 [95 % CI 35–40] vs. 53 [95 % CI 51–55] per 100,000 per year; Table 1). Four of the five top foreign countries of birth by absolute numbers were Caribbean: the Dominican Republic, Jamaica, Haiti, and Trinidad and Tobago (Fig. 1a; Supplemental Digital Content 1). The fifth country was Mexico. Foreign-born New Yorkers newly diagnosed with HIV were more likely than foreign-born New Yorkers overall to be from the Caribbean, Central America, or Africa; less likely to be from Asia and the Middle East or Europe; and about equally likely to be from South America. By region of birth, African-born New Yorkers had the highest rate of new HIV diagnosis, followed by Central Americans, Caribbeans and South Americans (Table 1). Four of the five countries with the top diagnosis rates were African: Cameroon (1,035 [95 % CI 698–1,478]), Cape Verde (366 [95 % CI 44–1,323]), Kenya (208 [95 % CI 121 –332]), and South Africa (199 [95 % CI 146–265]) (Fig. 1b). The fifth country was Brazil (140 [95 % CI 76–204]). New Yorkers born in The Gambia, Guinea, Togo, Ivory Coast, Senegal, Burkina Faso, and Mali, all in West Africa, each had more than 20 diagnoses between 2006 and 2012, but ACS provided no population denominator with which to calculate the diagnosis rate for these countries. Place of Acquisition of HIV Among Foreign-Born Newly Diagnosed and Interviewed by the FSU, 2006–2012 The FSU interviewed 29 % of all persons newly diagnosed with HIV in NYC in 2006–2012 and 24 % of the foreignborn (n = 1,849 foreign-born). Among these foreign-born, foreign acquisition appeared probable for 23 % (highly

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likely for 16 %), US acquisition appeared probable for 61 % (highly likely for 28 %), and place of acquisition could not be estimated for the remaining 16 % (Table 2). By region of birth, foreign acquisition was probable for 43 % of Africans, 33 % of Asians, 20 % of Caribbeans, 21 % of Europeans, 14 % of South Americans, 14 % of Central Americans, and 9 % of Middle Easterners. US acquisition was probable for 75 % of South Americans, 68 % of Central Americans, 65 % of Caribbeans, 64 % of Middle Easterners, 60 % of Europeans, 53 % of Asians, and 34 % of Africans. Foreign acquisition was probable for a higher percentage of females than males (33 vs. 17 %) and US acquisition probable for a higher percentage of males than females (68 vs. 50 %). By major categories of transmission risk, foreign acquisition was least probable and US acquisition most probable for men who have sex with men (12 % foreign acquisition, 76 % US acquisition) and male and female injection drug users (8, 74 %).

Discussion HIV diagnosis rates in NYC among foreign-born persons varied between and within foreign regions of birth. A composite measure suggested that 23 % of foreign-born persons newly diagnosed with HIV in NYC were infected abroad and 61 % were infected in the US. Relative to their share in the NYC population overall, foreign-born New Yorkers from the Caribbean, Central America, and Africa were overrepresented among persons newly diagnosed with HIV. Countries of birth with the greatest numbers of new diagnoses were either Caribbean or Central or South American. As we previously reported, the overall diagnosis rate was lower among foreign-born than non-foreign-born [3]. However, this finding masks important variability at the region and country level. New Yorkers born in Africa had the highest diagnosis rate and persons from Asia and the Middle East the lowest, which is consistent with other US findings [2]. For persons from countries such as South Africa, Kenya, and Cameroon, their high diagnosis rates in the US may be explained partly by foreign-born persons having contact with populations from or in countries of birth (including before migration or during visits between countries). Indeed, newly diagnosed New Yorkers from Africa, where HIV is hyper-endemic, were more likely than other foreign-born to have probable foreign acquisition, although this amounted to less than half of newly diagnosed Africans. London studies of newly diagnosed Africans found that one-quarter to half may have acquired HIV domestically since migration [13, 14]. A study of African patients at a Minnesota HIV clinic found that more than half were infected before arriving in the US, [15] but, unlike NYC foreign-born, of whom 73 % had been in the

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895

Table 2 Probable place of acquisition of HIV infection among foreign-born persons newly diagnosed with HIV in New York City in 2006–2012 and interviewed by the Field Services Unit Probable place of acquisition of HIV infection Total

Foreign country

N

N

%

N

%

N

%

1,849

420

23

1,130

61

299

16

Caribbean

908

184

20

592

65

132

15

Central America

281

39

14

192

68

50

18

South America

211

29

14

159

75

23

11

Africa

320

138

43

110

34

72

23

Asia

45

15

33

24

53

6

13

Middle East

11

1

9

7

64

3

27

Europe

63

13

21

38

60

12

19

Other or unknown region

6

0

0

5

83

1

17

Not specified

4

1

25

3

75

0

0

Total

United States

Unknown

Foreign region of birth

Sex at birth and transmission risk Male

1,172

197

17

793

68

182

16

Men who have sex with men Injection drug use history

553 35

64 3

12 9

419 25

76 71

70 7

13 20

Heterosexual

179

34

19

113

63

32

18

Other

0

0

0

0

0

0

0

Unknown

405

96

24

236

58

73

18

Female

677

223

33

337

50

117

17

Injection drug use history

3

0

0

3

100

0

0

Heterosexual

656

219

33

325

50

112

17

Other

1

0

0

1

100

0

0

Unknown

17

4

24

8

47

5

29

13–19

71

23

32

39

55

9

13

20–29

458

78

17

291

64

89

19

30–39

495

119

24

314

63

62

13

40–49

447

115

26

260

58

72

16

50–59 60?

263 115

57 28

22 24

160 66

61 57

46 21

18 18

Black

945

260

28

533

56

152

16

Hispanic

776

130

17

521

67

125

16

White

61

10

16

38

62

13

21

Asian/Pacific Islander

59

17

29

35

59

7

12

Native American

7

3

43

3

43

1

14

Multiracial

1

0

0

0

0

1

100

Manhattan

307

57

19

190

62

60

20

Brooklyn

608

126

21

400

66

82

14

Bronx

555

137

25

313

56

105

19

Queens

276

57

21

183

66

36

13

Age at HIV diagnosis

Race/ethnicity

Borough of residence at diagnosis

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Table 2 continued Probable place of acquisition of HIV infection Total

Foreign country

United States

Unknown

N

N

%

N

%

N

%

Staten Island

1

0

0

1

100

0

0

Outside NYC

98

43

44

39

40

16

16

Unknown

4

0

0

4

100

0

0

Surveillance data reported to the NYC Department of Health and Mental Hygiene as of June 30, 2013. Probable place of acquisition of HIV was calculated using a composite measure and categorized as ‘‘probable foreign acquisition,’’ ‘‘probable US acquisition,’’ and ‘‘unknown place of acquisition.’’ Probable foreign acquisition was defined as HIV believed to be acquired outside or diagnosed outside and believed to be not acquired in US (i.e., it may have been acquired during residency in, or travel to, home country); highly likely foreign acquisition was the subset of these in the US 0–9 years. Probable foreign acquisition also included persons who did not state a belief about where they acquired HIV, whose place of diagnosis was the US or unknown, and who were in the US 0–9 years and diagnosed concurrently with AIDS. Probable US acquisition was defined as HIV believed to be acquired and diagnosed in US; highly likely US acquisition was the subset of these in the US C 10 years. Probable US acquisition also included persons not believed to have acquired HIV in a foreign country who resided in the US C 10 years and not diagnosed concurrently with AIDS. Unknown place of acquisition was assigned for any person that did not meet the above definitions

US for at least a decade [5], most persons in the Minnesota study had been in the US for fewer than 5 years and were entering a relatively low-incidence US city [16]. For many foreign-born persons, however, the US and NYC in particular have a higher HIV diagnosis rate (16 and 48 per 100,000 total population, respectively) than that of their country of birth, and life in the US may present new or elevated risks for exposure [1, 16–20]. For example, Hondurans and Brazilians have high diagnosis rates in NYC (88 and 140 per 100,000, respectively), while estimated HIV incidence in their birth countries is relatively low (40 and 20 per 100,000 persons aged 15–49, respectively; Fig. 1c) [7]. Additionally, newly diagnosed foreignborn New Yorkers from the relatively low-incidence regions of Central and South America [7] were most likely to have probable US acquisition and among the least likely to have probable foreign acquisition. Place of acquisition differed not only by home country and region but also by demographics and HIV transmission risk categories, with males, men who have sex with men, and injection drug users the foreign-born persons most likely to have acquired HIV in the US. In NYC and the US overall, HIV diagnosis rates are higher for males, and men who have sex with men in particular, than females [16, 21], and gay male migrants may face unique HIV-related risks [22] that, among other factors, could increase their probability of acquisition in the US and particularly in NYC relative to their places of origin. Injection drug users comprise 7 % of New Yorkers diagnosed with HIV overall and only 3 % among the foreign-born [21, 23]. That most foreign-born injection drug users appeared to have acquired HIV in the US suggests that they may have begun injecting in the US. This has been seen among some Mexican migrant populations

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[24, 25]. HIV transmission among injection drug users is now lower in the US than in numerous other foreign countries (particularly in Eastern Europe and Central Asia) [7], migrants from which may have been more likely to acquire HIV in those countries had they been injecting there. HIV among injection drug users may be particularly important to track given the resurgence of heroin use in the US [26], which is likely to change the dynamics of drug injection and HIV among US- and foreign-born persons here. The distribution of foreign vs. non-foreign place of acquisition among foreign-born persons overall in any given area may be influenced by the distribution of places of birth among the foreign-born population (vis-a`-vis home country prevalence or incidence), extent to which migrants are representative of the general population in the home country, local prevalence and incidence at the destination, length of time at the destination (also in relation to immigration policy), and risk behaviors and partner selection in the home country vs. the destination [1, 2, 13, 18, 20]. US immigration policy changed in 2010, no longer requiring an HIV test for entry nor considering persons with HIV to be inadmissible; [27] an analysis such as ours does not assess the influence of this change in NYC. In NYC and perhaps many other places, a substantial portion of HIV cases among foreign-born persons—even among African-born persons— are not imported. Foreign-born persons from any region, and of any demographic characteristic or risk category, may benefit from efforts to prevent local HIV transmission and identify HIV infections. Limitations This analysis was subject to a number of limitations. Place of birth was unknown for 11 % of the analysis population

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(2,918/26,946 diagnosed in 2006–2012), and these persons were classified as non-foreign-born. Surveillance abstracts the majority of its country of birth data from medical records, which may not document place of birth. Underascertainment of foreign birth in surveillance is considered to be modest, in part because some characteristics of persons missing country of birth were similar to those of US-born persons. However, the true extent of underascertainment is unknown. Approximately nine percent of foreign-born persons newly diagnosed and reported in NYC were not NYC residents, potentially modestly artificially inflating NYCspecific diagnosis rates. Diagnosis rates could not be calculated for countries of birth with too few persons in NYC for ACS to produce a country-specific population estimate. New Yorkers born in some such countries, such as the aforementioned West African countries, had considerable numbers of HIV diagnoses here and presumably had high HIV diagnosis rates. FSU interviewees may differ from non-FSU foreignborn persons such that interview data may not be generalizable to all foreign-born New Yorkers newly diagnosed with HIV, e.g., foreign-born FSU interviewees were predominantly diagnosed at hospitals or hospital-based outpatient clinics (67 % of foreign-born FSU interviewees, vs. 38 % of non-FSU foreign-born persons, p \ 0.01) and were more likely than non-FSU foreign-born persons to be diagnosed with AIDS at the time of HIV diagnosis (33 vs. 24 %, p \ 0.01). The substantial number of interviewed cases with missing data on time in US and believed place of acquisition reduced the precision, reliability and generalizability of our estimate of likely place of acquisition, an issue for other such analyses [13, 28]. Our measure of probable place of acquisition was based on four parameters and may be inaccurate. It did not include age of migration relative to age of diagnosis because we could rule out neither perinatal transmission nor transmission during visits to the home country. Someone who migrated to the US during childhood, was diagnosed more than 10 years later, and did not leave the US during the interim could be presumed to have acquired HIV in the US. However, surveillance does not collect information about travel. We attempted to acknowledge varying levels of certainty by identifying the subset of persons for whom foreign or US acquisition was ‘‘highly likely,’’ based on criteria stated in the methods section. Some persons with prevalent infection may be misclassified as new diagnoses, likely falsely increasing the association between home country/region incidence and diagnosis rate in the US. Determination of earliest diagnosis date, while imperfect, is among the highest priorities of HIV surveillance; the reliability of diagnosis date has not yet been characterized by area of birth [29–31].

897

Conclusions This analysis illuminates several aspects of the complex epidemiology of HIV among immigrants by focusing on a high-incidence US city that is an immigration hub. To our knowledge, it is the first analysis to calculate HIV diagnosis rates for a US city by foreign region or country of birth, and the first population-based assessment of probable place of acquisition of HIV infection, overall and by region, among newly diagnosed foreign-born persons. It includes persons regardless of citizenship or residency status and considers findings within the context of the general NYC population and the global HIV epidemic. Expanded prevention and testing efforts that are underway [32] or planned may need to address challenges that different immigrant populations face after arrival [22], both in preventing HIV infection and in being tested and diagnosed. The high proportion of foreign-born persons (particularly men who have sex with men) in NYC who apparently acquired HIV in the US underscores the importance of HIV prevention programs targeting both foreign- and US-born persons at risk. Acknowledgments The authors thank Hani N. Nasrallah for his contribution to preliminary data analyses and Rafael Ponce and Eleonora Jimenez-Levi for their help translating the abstract into Spanish. This analysis was supported through a cooperative agreement between the New York City Department of Health and Mental Hygiene, HIV Epidemiology and Field Services Program, and the Centers for Disease Control and Prevention (PS08-80202, #U62/CCU223595).

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Foreign-Born Persons Diagnosed with HIV: Where are They From and Where Were They Infected?

We sought to calculate rates of HIV diagnoses by area of birth among foreign-born persons in a high-incidence US city with many immigrants, and determ...
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