Sweden

Sweden saw a large influx of migrants from Latin America and the Islamic Republic of Iran in the 1970s and 80s. In the 1990’s and 2000’s migrants to Sweden came mostly from Somalia, Iraq and the former communist countries of Yugoslavia and the Soviet Union. Somalis continue to represent the largest population of Sub-Saharan Africans in Sweden.

Migration impacts health in a number of ways. Migrants are confronted with multiple risk factors that affect HIV susceptibility and transmission. Undocumented migrants face additional risks for contracting HIV because of the additional hurdles in accessing health and social services, legal protections and secure housing and employment. In 2013, migrants in Sweden accounted for 35 % of new HIV diagnoses with Sub-Saharan African migrants accounting for 15 % of cases and migrants from other regions accounting for 20 % of new diagnoses.

In a study conducted by Statistics Sweden, people born outside of Sweden reported having poorer health, and living in worse social conditions (housing and employment) than those with Swedish backgrounds. On average, it takes at least ten years for migrants to have the same living conditions as the rest of Sweden’s population.

Sweden has a publicly-funded healthcare system with universal access for Swedish citizens. Asylum seekers and undocumented children have the right to the same health care services that are provided for permanent residents.  Adult asylum seekers are entitled to health and dental care “that cannot be deferred” as well as contraceptive advice, pregnancy termination and maternity care.  Undocumented migrants have the right to receive non-subsidized immediate care.

Since 2013, health care providers have been under obligation by Swedish law to provide undocumented migrants healthcare that cannot be deferred and free healthcare pursuant to the Communicable Diseases Act. The Swedish health care system provides all HIV-positive patients care and treatment by physicians specializing in infectious diseases in hospital-based outpatient clinics.

Although undocumented migrants have the right to non-subsidized health care, many experience barriers to access because health care staff are either unaware of the law or unwilling to provide healthcare to this group.

Sweden is the first country reported to meet all UNAIDS 90-90-90 goals. The goal is that by 2020, 90% of people living with HIV will know their status, be on antiretroviral therapy and have viral suppression. Factors that contribute to this success include that Sweden is a low-endemic country and that all HIV-positive people should be linked to specialized HIV care centres. Anti-retroviral therapy is provided free of charge to all patients.  Although Sweden has had success in reaching the UNAIDS goals, the country still has one of the highest proportions of late diagnoses, mostly among migrants.

Fear of social exclusion, social isolation and language barriers among African migrants may be contributing factors to late diagnoses among this group.

Sweden does not impose immigration restrictions on HIV-positive people entering the country. HIV testing is free of charge to everyone in Sweden. The rate of HIV testing in the general population is low. Increasing testing in key populations and improving rates of earlier diagnoses are a challenge in Sweden. 60% of all HIV patients diagnosed in Sweden in 2011, were late presenters. A majority of these late presenters were migrants.

There are no population based or key-population based screening programs for HIV testing in Sweden (except for injection drug users who take part in needle-exchange programs).  Early HIV and care treatment is associated with viral suppression, improved health outcomes and reduction in HIV transmission risks. More investment in targeted screening and testing among migrants should be undertaken in Sweden given that this group is over-represented in the late presenters cohort.

Unemployment levels, dependence on social welfare and segregation remains high among migrants in Sweden. Approximately half of the 7,000 HIV positive people living in Sweden are migrants of which the majority are heterosexuals and originate mainly from sub-Saharan Africa, Southeast Asia and South America.

Sweden has adopted a policy of HIV criminalization where a failure to comply with HIV disclosure obligations and unprotected sex can result in charges of attempted aggravated assault and a prison sentence, even if HIV transmission does not occur. Although 90% of people with HIV in Sweden are on anti-retroviral therapy, an HIV positive person cannot have unprotected sex under any circumstance even if they reveal their status to their partner. This law is being challenged since experts agree that people on effective anti-retroviral therapy have an extremely low risk of transmitting HIV.

Migrant workers in Sweden have more temporary employment, fewer possibilities to find work that matches their level of education and have lower salaries compared to native Swedes. Additionally, migrants have higher rates of unemployment. Migrants from Africa and Asia are over-represented among those at are unemployed and typically hold low status occupations.

Policy-making in the migration, health and labour sphere are often developed in sector-siloes. Sweden’s failure to develop policies that protect the health and well-being of migrants is obvious given that sub-Saharan African migrants are over-represented in the population of people with HIV in Sweden, as well as those that are unemployed. Decriminalizing HIV, as well as creating labour policies that deter employers from capitalizing on the vulnerable status of migrants should be developed to protect and increase the health and labour status of migrants.