A qualitative study on mixed experiences of discrimination and healthcare access among HIV-positive immigrants in Spain.

BACKGROUND: Immigrants are disproportionally impacted by HIV infection in Europe and in Spain. Immigrants are also identified as a vulnerable population during economic crises. Various socioeconomic barriers hinder HIV-positive immigrants from accessing healthcare services in the host country. As a result of the 2008 financial crisis, Spain has implemented multiple austerity measures, one of which was the enactments of Royal Decree Law (RDL) 16/2012 and Royal Decree (RD) 1192/2012 which abolished universal healthcare coverage. In this context, this study examined: 1) Participants' mixed experiences in accessing health care after the enactment of 2012 RDL and RD, and 2) Distress felt by the participants and their experiences as HIV-positive immigrants living in Spain. METHODS: Participants were recruited through a nongovernmental organization (NGO) during routine visits at the center. A total of 12 participants were interviewed to reach data saturation. Participants were HIV-positive immigrants living in Spain for 1 or more years, allowing for substantial experience with navigating the healthcare system. Thematic analysis was performed to identify common themes in participants' experiences living as HIV-positive individuals in Spain and in accessing healthcare. RESULTS: Four primary themes were identified. The primary systemic barrier to accessing health care encountered by participants was the inability to fulfill the requirement of having proof of registration in an Autonomous Community for the required time period, thus not being able to apply for a public health insurance card and utilize free care services. Participants identified a positive impact of third party (NGO, social worker, friend/family member) guidance on their experience of applying for a public health insurance card. Participants expressed experiencing emotional or physical (eg, side effects of medication) distress in adapting to life as HIV-positive individuals. Participants also identified experiencing discrimination while living as HIV-positive immigrants in Spain. CONCLUSIONS: HIV-positive immigrants are underserved in Spain. They encounter systemic barriers while accessing healthcare services, and experience fear and/or discrimination. The study underscores the role of NGOs in helping HIV-positive immigrants navigate the healthcare system. More research is needed on comprehensive approaches to address healthcare needs of HIV-positive immigrants in Spain.

Late HIV diagnosis among immigrants in Spain vs. native-born Spaniards, 2010-15.

BACKGROUND: In 2012, the central government of Spain enacted Royal Decree-Law (RDL) 16/2012 and Royal Decree (RD) 1192/2012, which abolished universal healthcare coverage, thus limiting access to care for undocumented immigrants. Free health care was also no longer granted to anyone who has never been employed. In this context, this study investigated the prevalence of late HIV diagnoses (LHDs) among immigrants living in Spain vs. native-born Spaniards. METHODS: Data (n = 5943) from the 2010 to 2015 Cohort of the Spanish AIDs Research Network were used, including HIV-positive and antiretroviral therapy (ART)-naïve patients throughout Spain. Multivariate logistic models were fitted to compare the prevalence of LHD among the groups, adjusting for covariates. RESULTS: The prevalence of LHD in the total sample was 39.5%. Compared with native-born Spaniards (n = 4445), immigrants (n = 1488) were more likely to have LHD (37.4% vs. 45.7%, respectively; P < 0.001). Multivariate analysis showed that the prevalence ratio of LHD among immigrants vs. native-born Spaniards was 1.15 [95% confidence interval (CI), 1.02-1.28], after adjusting for covariates. This disparity widened from 2010 to 2011 (APR = 1.14, 95% CI, 1.02-1.29) to 2012-15 (APR = 1.28, 95% CI, 1.17-1.39), although the change was not statistically significant. CONCLUSIONS: Immigrants in Spain had a higher risk of LHD compared with native-born counterparts. LHD is an important healthcare marker due to the positive benefits of early HIV diagnosis, including prevention, improvements in health outcomes and decreases in overall cost of treatment. More research is needed on the causes of the disparity and potential social and policy interventions to reduce the prevalence of LHD among immigrants.

Policy implementation analysis on access to healthcare among undocumented immigrants in seven autonomous communities of Spain, 2012-2018.

BACKGROUND: In 2012, the Government of Spain enacted Royal Decree-Law (RDL) 16/2012 and Royal Decree (RD) 1192/2012 excluding undocumented immigrants from publicly funded healthcare services. We conducted a policy implementation analysis to describe and evaluate the legal and regulatory actions taken at the autonomous community (AC) level after enactment of 2012 RDL and RD and their impact on access to general healthcare and HIV services among undocumented immigrants. METHODS: We reviewed documents published by the governments of seven ACs (Andalucía, Aragón, Euskadi (Basque Country), Castilla-La Mancha, Galicia, Madrid, Valencia) from April 2012 to July 2018, describing circumstances under which undocumented immigrants would be able to access free healthcare services. We developed indicators according to the main systemic barriers presented in official documents to analyse access to free healthcare across the participating ACs. ACs were grouped under five access categories: high, medium-high, medium, medium-low and low. RESULTS: Andalucía provided the highest access to free healthcare for undocumented immigrants in both general care and HIV treatment. Medium-high access was provided by Euskadi and medium access by Aragón, Madrid and Valencia. Castilla-La Mancha provided medium-low access. Galicia had low access. Only Madrid and Galicia provided different and higher level of access to undocumented migrants in HIV care compared with general healthcare. CONCLUSIONS: Implementation of 2012 RDL and RD across the ACs varied significantly, in part due to the decentralisation of the Spanish healthcare system. The challenge of healthcare access among undocumented immigrants included persistent systemic restrictions, frequent and unclear rule changes, and the need to navigate differences across ACs of Spain.

The prevalence of toxic hotspots in former Soviet countries.

Using a global database of contaminated sites, toxic hotspots in eight former Soviet countries were analyzed to identify the prevalence, types and sources of toxic pollution, as well as their associated potential public health impacts. For this analysis, polluted sites in Armenia, Azerbaijan, Kazakhstan, Kyrgyzstan, Russia, Tajikistan, Ukraine, and Uzbekistan were compiled and analyzed. The levels of contamination of seven key pollutants were assessed in each country. 424 contaminated sites were identified using data from Blacksmith Institute. Pesticides, lead (Pb), radioactive metals, arsenic (As), mercury (Hg), chromium (Cr), and cadmium (Cd) were the most commonly identified key pollutants. Collectively, these sites pose health risks to an estimated 6.2 million residents. The existing data on toxic hotspots in former Soviet countries likely captures only a small percentage of actual contaminated sites, but suggests potentially severe public health consequences. Additional assessments are needed to understand the risks posed by toxic pollution in the region.