Italy

The HIV prevalence among female sex workers in Italy is 2.5%. This data was gleaned from a European Centre for Disease Prevention and Control Report where input was provided from country representatives.  The HIV prevalence data that Italy provided on female sex workers to this 2012 report was from 2001. Data on condom use by female sex workers was also provided, however it was from 1998. There is a serious knowledge gap when it comes to HIV and sex workers in Italy.

Information on migrant sex workers is sparse. No information was found on HIV incidence or prevalence among migrant sex workers.

There are an estimated 138,000 injection drug users in Italy. The HIV prevalence among this population is 1.7%. Only 34% of HIV positive injection drug users know about their HIV status. Twenty-two percent of injection drug users report using condoms during sexual intercourse.

Gaps in the detection of HIV-positive injection drug users and migrant injection drug users have been reported in Italy, due to low access to HIV testing and a high percentage of late diagnosis.

Information on migrant injection drug users is sparse. Only one study was found that measured HIV incidence among Italians and migrants. The study found that Italian injection drug users were found to have a HIV incidence rate of 7.5% versus 3.3% in migrant injection drug users.

In Europe, more than one third of all newly diagnosed cases of HIV are in migrants. Although it is unknown whether migrants acquire HIV before or after their journey there is growing evidence that migrants from high-prevalence countries (most are African countries) are at risk of acquiring HIV after their arrival in the European Union.

Migrants from countries with generalized HIV epidemics (where the epidemic affects certain populations more significantly) are at risk of acquiring the disease in their country of origin, however the risk remains as they migrate also. As migrants become sexually active within migrant communities where HIV prevalence is higher the risk of acquiring HIV also increases. Social inequalities associated with migration, including low income, unemployment, poor housing, HIV‐related stigma and discrimination, and changes in sexual behaviour may increase the risk of HIV infection.

In the early 20^th century, Italy was a country of emigration with some 12 million Italians leaving to escape poverty and organized crime. Between 1946 to 1970, 3 million Italians returned. In the early 1970’s migrants from the Philippines began arriving to work in the home sector. During the 1980’s migrants from the Middle East and sub-Saharan Africa began to arrive. In the early 1990’s and 2000’s the immigrant population in Italy increased quickly. At the end of 2010, 7.5% of Italy’s population were foreign born and in 2017 this increased to 10%.  Italy has seen a large influx of migrants in the past few years. In 2018, migrants from Tunisia, Eritrea and Sudan made up the largest number of Africans arriving in Italy.  Most are migrating due to unstable political situations in their home countries.

Since 2006, the number of foreign migrants with a new diagnosis of HIV infection increased compared to Italians, Higher migratory flows can in part explain this phenomenon. Even though migrants are generally younger and healthier, they are at increased risk of HIV infection.  The largest group of newly diagnosed migrants with HIV in Italy is from sub Saharan Africa.

Migrants in Italy are generally diagnosed at a later stage in the HIV disease progression than Italians. This suggests that migrants face barriers to accessing health care services even though Italy offers free health care services to everyone in Italy.  In addition, migrant women in Italy face a significant risk of HIV and STI infection since women face tougher social and labour challenges and may resort to commercial sex.  Language barriers, marginalisation and social exclusion, and legal obstacles have been reported as the most common factors contributing to HIV vulnerability of migrants.

The Italian National Health Service (SSN) aims to grant universal access to health care  for nationals, residents and migrants throughout Italy. The SSN operates at a central, regional and local level. The central government (central level) and 20 regions (regional level) share the responsibility of providing health care. Local Health Administrations (ASLs) provide health care services at the local level.

On paper, the Italian health care system provides equitable health coverage to migrants irrespective of their status. However, in practice access to health care is not evenly implemented and differences exist among the 20 regions and the ASLs. There is a lack of knowledge about current legislation among health care workers. There is also evidence that migrants with irregular status are not aware of their rights when it comes to accessing health are services.

Differences between citizens and migrants with irregular status have been observed when trying to access HIV testing and treatment services. These differences in access are the result of lack of information, ignorance, cultural and language barriers, and migrants’ fear of being arrested. Frequent moves and short stays in cities or towns by migrants also pose as barriers to accessing health care services and being retained in care.

Irregular migrants are entitled to free urgent or otherwise essential care in public outpatient health facilities and in hospitals. They are also entitled to free continuous care, care for illness and injury and prevention programs. The following services are ensured for irregular migrants:

• social protection of pregnancy and maternity;
• protection of the child’s health;
• vaccinations;
• international prophylactic interventions;
• prophylaxis, diagnosis and treatment of infectious diseases.

Health care providers cannot report irregular migrants to the authorities, except in cases where the report is mandatory. Although health care services are provided to all people in Italy regardless of their legal status, it has been found that definitions of “urgency” vary considerably throughout Italy.

Italy has reported that there are major gaps in HIV prevention services for migrants from high-prevalence countries. Italy has also reported there are major gaps in HIV prevention services for undocumented migrants although health care services are legislated to be provided to everyone in Italy irrespective of their immigration status. Stigma and discrimination in Italy limits uptake of HIV prevention services. This includes stigma and discrimination within migrant populations and among health professionals.

HIV testing rates among migrants are low. Italy has no data on HIV testing among migrants from high-prevalence countries. Migrants are also more likely to be diagnosed late with HIV than non-migrants in Italy. Among foreign migrants with a new diagnosis of HIV infection in Italy, 39.7% were late presenters.  The proportion of foreign migrants who are late presenters increased from 29.8% in 2006 to 40.1% in 2013. Factors that contribute to late HIV diagnosis include gaps in service for migrants due to stigma and discrimination by health care professionals, low risk perception, fear of knowing HIV status and lack of HIV knowledge.

Given that the majority of late HIV diagnosis occur in migrants in Italy, promoting earlier and increased uptake of HIV testing is required. However, because migrants in Italy face stigma and discrimination by health care workers, education of health care workers around their legislative responsibilities should be prioritized as an intervention to reduce inequities in health care access for migrants.

HIV prevalence is higher among key populations in Italy. Policies that prioritize key populations including asylum seekers and refugees, undocumented migrants, sex workers and men who have sex with men will help to alleviate the burden of HIV among these groups and may in the long-term lead to reduced HIV incidence.  The HIV incidence among foreign born migrants from Africa (primarily from Nigeria, Ghana and Ivory Coast) has been reported to be as high as 46.6% in Italy; health policies that increase uptake of health care services for this group are required. Language barriers have been cited to be an obstacle to HIV vulnerability in migrants. Providing culturally relevant HIV health care services with language interpretation services could increase health seeking behaviour among migrants.

In Italy, national data on the number of HIV-diagnosed individuals and their characteristics (clinical, immunological, behavioral, and treatment) are lacking, and so are the other figures needed to describe the HIV care continuum. Despite the vast amount of research conducted on HIV in Europe, there are gaps in information about migration and HIV, especially among migrant key populations. The risk of HIV transmission among migrants is higher than in Italian nationals. Developing a solid evidence base of the clinical, social and demographic characteristics of migrants living with HIV and those acquiring HIV in Italy will provide the necessary information to develop health and social policies that positively impact this population.

Controlling the transmission of HIV in Italy depends on ensuring that migrants have prompt access to HIV testing, antiretroviral therapy and ongoing health care.

It is evident that “a one size fits all” approach is not a feasible solution in Italy given that migrants and key populations (men who have sex with men, sex workers and injection drug users) are disproportionately affected by HIV. For example, in Italy the HIV prevalence is 1.2% among the general population, however HIV prevalence among men who have sex with men is 9.6%.

Inconsistencies between health and immigration policies are generally seen to be counterproductive to public health. Although Italy provides universal access to health care irrespective of immigration status, there is evidence that migrants face stigma and discrimination when seeking health care services. Another major challenge facing migrants is the Italian government’s current anti-immigration agenda. In September 2018, Italy’s Council of Ministers approved a decree to sharply curtail access to asylum, downgrade the care asylum seekers receive and increase immigration detention to give the state more time to complete deportation procedures. The decree also widens the range of criminal offences that lead to the revocation of asylum privileges applied for or already granted to a migrant. These immigration guidelines were packaged together with new security rules which include heightened controls on those who rent trucks, and stripping naturalized foreigners who are convicted on terrorism charges of their Italian citizenship.

Even though Italian law makes a generic reference to the right to access employment without indicating any limitations, asylum seekers report difficulties in obtaining a residence permit which provides the right to work. It has been reported that many Provincial Officers for Labour in Italy do not allow for asylum seekers to enroll in unemployment programs. In addition, the recent immigration decree, stipulates that refugees could carry out unpaid “public utility works.” It is unclear whether free labour is a condition to obtaining legal status in Italy.

The criminalization of migrants by the Italian government only serves to widen health disparities between migrant populations and Italian citizens. Comprehensive action to tackle negative social attitudes towards migrants, exacerbated by racist government policies and biased media reporting is required in Italy. initiatives that meet the wider health, social, economic and legal needs of migrants needs to be undertaken through joint efforts between policymakers, health and social care professionals and civil society.