Immigration and prevention: the effect of migration on risk behaviour

A range of risk behaviours are more common for men after migration, reported researchers at the International AIDS Conference on August 5^th. Sex with a commercial sex worker, sex while under the influence of drugs or alcohol, sex in exchange for money and sex with a man were behaviours identified as being more likely after migration.

These data come from one of a series of studies of Mexican immigration to the United States, and while many of the findings will be specific to that setting, they also highlight a number of issues that may be relevant to prevention work with migrants in other countries, including gay migrants.

Over eleven million Mexican people live in the United States. More men than women migrate, most are of working age, their stay in the US may be temporary, and around half are undocumented migrants. HIV prevalence is lower in Mexico than in the United States, but in the US it is relatively high among the Hispanic/Latino population, and recent migrants report higher levels of risky behaviours. The International AIDS Conference in Mexico City was an appropriate setting for a session on Tuesday afternoon exploring vulnerability to HIV among Mexican migrants.

Melissa Sanchez of the University of California highlighted a range of social factors which are likely to contribute to vulnerability among migrants: poverty, underemployment, poor housing, constant mobility (particularly in order to seek employment), isolation, depression and limited access to healthcare.

Her study was of 364 men who had either been in the US for less than five years, or who went back to Mexico regularly. Participants were recruited at worksites (farms, job pick-up points, makeshift camps), bars and nightclubs (including those used by men who have sex with men) and community venues (family housing, grocery stores, churches etc).

Several previous studies have identified that Mexican migrants to the US have a high level of risk behaviours, but have not been able to measure the change in risky behaviour on an individual level. She therefore asked her respondents about a range of risk behaviour, both before and after migration.

She found that while 18% of respondents had had sex with a sex worker before migration, 29% had done so afterwards (p= <0.0001). Similarly, those having sex while under the influence of drugs or alcohol rose from 25% to 41% (p= <0.0001), and those reporting sex with another man rose from 4% to 7%. Concerning transactional sex (sex in exchange for money, food, shelter, drugs or protection), 1.4% reported this before migration, and 2.7% afterwards.

Sanchez found that risk behaviours were more common in men recruited at work sites and bars/clubs, venues where men were more likely to be isolated from their families.

However Sanchez’s more optimistic finding was that there was greater use of condoms after migration. Those reporting condom use only sometimes, rarely or never, dropped from 81% to 65% (p= <0.0001).

Similar findings on condoms were presented by Rene Leyva-Flores in the same session. The male Mexican migrants he interviewed most commonly perceived California to be a place where AIDS is present, and where condoms need to be used. However when they went back home to their wives in Mexico, AIDS was not seen to be relevant, and condoms were not used.

Pilar Torres’ study was a qualitative investigation into attitudes to migration among young Mexicans, aged 15 to 24. She spoke both to returned migrants and to those who had stayed in Mexico.

Those who moved to the US often sought to resolve financial difficulties, to follow family members, and to escape a variety of problems in Mexico. On the other hand, those who did not migrate often had fewer financial problems and wished to stay in Mexico to care for relatives or pursue their education.

Another difference in attitude emerged, which may be relevant to HIV. Those who migrated were characterised as adventurous and risk-tolerant, whereas those who did not were more fearful and risk-averse. Migration itself is full of dangers, ranging from finding oneself in an unfamiliar and hostile environment, to the risk of death during the border crossing. Torres suggested that these attitudes to risk and uncertainty influence sexual and drug-using behaviours.

Also launched at the conference was a report by Hector Carrillo (chair of the session discussed above) on issues for gay and bisexual Mexican migrants. He found that many men moved to the US to pursue a gay lifestyle, but that their lack of experience in such an environment sometimes led them to take risks with their health.

The study was based on in-depth interviews in California with 77 Mexican-born men, as well as interviews with men who dated Mexicans and interviews with US-born Latino men. All men identified as gay or bisexual, and most were interviewed again after one year. Observation in venues where the men socialise was also conducted.

Carrillo highlights that men moved to the US for a variety of reasons. Many men had been living an open or semi-open gay life in Mexico, but wished to live a fuller, more openly gay life in the US. They may have wished to ‘protect’ their family from gossip about their lifestyle, or wished to pursue a relationship with an American man they had met in Mexico. These reasons were frequently combined with economic motives. (The phenomenon of ‘sexual migration’ has also been explored in a UK context by Sigma Research’s report on Migrant Gay Men. and in Terrence Higgins Trust's Gay Britain project.)

The study finds that “in order to explain how HIV risk is produced among Mexican gay and bisexual immigrant men in the United States, we must pay attention to where these men started, how they experienced same-sex desires while living in Mexico, and how those experiences flavour their cultural understandings and expectations.”

Such experiences are heavily influenced by social class, education and geography. More specifically, some men had had sex with other men primarily in the context of strongly defined ‘top’ and ‘bottom’ roles with little notion of a gay identity. Other men were part of gay communities in large Mexican cities.

Recent migrants, particularly men who had not had a gay lifestyle in Mexico, often face new situations and contexts where the “rules of the game” are quite different to those they had previously experienced. The boldness and impersonal nature of saunas, sex parties and internet cruising can be surprising. Men with limited language skills and different expectations of how things are organised can find it difficult to maintain protection in these settings.

Some men have had limited experience of long-term relationships with men. As for many other people, the desire for trust and intimacy can lead to condoms being abandoned before the real risks have been examined. Moreover, there may be strong power imbalances between partners, for example between an undocumented migrant in an unfamiliar environment and his US-born partner.

Moreover, the researchers found that men born in Mexico tended to have less individualistic attitudes than those raised in the US. The men raised in Mexico (both HIV-positive and HIV-negative) commonly expressed the belief that sexual partners should protect each other, whereas US-born men often suggested that each man is responsible for his own health. In the absence of clear discussions between partners about HIV status and risk, men rely on assumptions, which may be particularly unreliable when each man is acting according to his own cultural expectations.

Concluding, Hector Carrillo notes that specific prevention programmes for Latino and migrant men have begun in the US, “but that more work can be done to address the contextual and situational aspects of HIV risk.”