Very few migrant women of African origin in Belgium use PrEP, a situation which is attributed to low levels of knowledge about the HIV prevention tool. According to a recent study, this low awareness is partly explained by gatekeeping by HIV prevention professionals, who withhold information about PrEP because of (often stigmatising) beliefs about migrant women’s ability to access and use PrEP.
The authors argue that the exclusion of migrant women of African origin from European PrEP trials and marginalisation of Black African and women’s organisations within the HIV and sexual health sector has shaped the views of Belgian HIV prevention professionals. Consequently, the reasons provided by these professionals for the absence of migrant women among PrEP users – including perceived cultural differences, and biomedical and systemic barriers to access – can be seen as justification for the status quo, undermining the assertion that these women are a ‘priority’ population for the HIV response. As a result, migrant women of African origin in Belgium are prevented from accessing a prevention option from which they could substantially benefit.
Despite only making up 2% of Belgium’s population, over a third of new HIV diagnoses in 2020 were in women from sub-Saharan Africa. Research indicates that social conditions experienced during and after migration (such as poverty and unequal access to healthcare) increase the risk of HIV acquisition, with between a quarter and a third of sub-Saharan migrants acquiring HIV after they arrive in Europe. In Belgium’s National HIV Plan, migrant and undocumented populations are identified as a key population in need of PrEP. Nevertheless, PrEP users in Belgium are overwhelmingly white gay and bisexual men, and neither migration experience nor undocumented status are mentioned in Belgium’s PrEP eligibility criteria.
In order to explore the structural reasons why migrant women of African heritage in Belgium do not use PrEP and what would make PrEP use possible for them, Dr Sarah Demart (a sociologist at the Université Libre de Bruxelles) and Emilie Gérard (an HIV prevention professional working for Plateforme Prévention Sida) interviewed HIV prevention professionals from 21 organisations working within the three regions of Belgium in 2021 and 2022.
While all of the interviewees stated that the main reason why migrant women of African heritage do not use PrEP is a lack of knowledge, the reasons provided by the professionals for this lack of knowledge varied. What became clear throughout the interviews is that many professionals do not promote PrEP to migrant women, as they regarded PrEP as ‘too complicated’ an intervention to discuss with this group.
Perceived cultural differences as a reason to withhold information about PrEP
When discussing supposed cultural differences, professionals displayed racist, essentialising, and paternalistic attitudes. They argued that due to low levels of sexual health knowledge, it was better to not mention PrEP to women they believed were not ‘ready’ to learn about it. They expressed concerns that doing so could lead to them not using condoms when having sex, putting them at risk of STIs and pregnancy:
“There are more basic things than PrEP that we have trouble making people aware of: taking contraception, using a condom, understanding sexually transmitted diseases, getting tested. There are other factors that we don’t talk about in counselling because we think that using PrEP could put them at more risk than anything else. They will make shortcuts: they don’t want to have HIV so they don’t protect themselves anymore, except that there are all the other sexually transmitted diseases. If they don’t use a condom, there will be risks of pregnancy, as contraception is not often used.”
One professional argued that discussing PrEP with migrant women of African origin is difficult since they do not understand HIV prevention in the same way as Europeans:
"They don’t think about prevention in the same way as we do, or they believe very strongly that putting ginger inside their vagina will change something, I mean, and that’s important for them, so I think we don’t have the same understanding of things, we’re more rooted in something medical and they’re more into something magical . . . spiritual, nature.”
Required daily adherence to PrEP was deemed by professionals as something migrant women would struggle to achieve:
“And for me, I also have another fear regarding women, whether they are newcomers or not, is that they really have to take medication every day, and we can see that in the figures, they are overrepresented in terminations of pregnancy compared to a pattern of taking the classic pill, which they really have difficulty taking, so I really don’t know....”
Others made assumptions about the taboo nature of sexuality among migrant women, arguing that this made it too difficult to talk about PrEP to them.
“Homosexuals talk easily about sexuality. They accept talking about it. Women don’t talk about it, its taboo, it seems like it doesn’t exist, and yet! Among women it is directly linked to prostitution, it becomes negative.”
Biomedical barriers as a reason to withhold information about PrEP
While some professionals saw problems with adherence as specific to migrant women, others understood it as a universal issue among PrEP users. Nevertheless, the exclusion of women from on-demand dosing (due to biological differences between women and men in the levels of drug required to prevent HIV transmission) was then identified as a further barrier for migrant women.
“The first response is ‘Yes, but I don’t want to take a treatment all my life, every day.’ So for [gay and bisexual men] too, there is the obstacle of daily treatment, and then when we say to them, ‘Ah but no, you can take it on demand because they’re men,’ then they say, ‘Yes, but I’m afraid of the side effects,’ so I say to myself, the women haven’t even reached the second obstacle, they’re already on the first obstacle, which is very important.”
Some professionals believed that PrEP does not meet all the sexual and reproductive health needs of women. They argued that since women may also need protection from STIs and unwanted pregnancy, condoms would be more appropriate. Of course, this disregards that many women choose not to use condoms or are unable to negotiate condom use with sexual partners, and other forms of contraception do not prevent HIV.
Systemic barriers as a reason to withhold information about PrEP
Some professionals identified that the locations where PrEP is provided in Belgium – at HIV reference centres in the infectious disease department of hospitals – can be off-putting to migrant women due to fears of being perceived as HIV-positive.
“We are very aware of the obstacles, especially for the population of people living with HIV, that there are still a lot of stigmas linked to getting treatment, not only for being HIV positive but also for HIV prevention. You have to go through the same centers to get PrEP.”
They also reasoned that the bureaucracy involved in accessing PrEP can be especially difficult for migrant women to navigate.
“In this way, we also express the complicated pathway that you have to follow if you want to get PrEP; it’s already pointed out for gay men as being a bit of a barrier: the appointment you have to make, you have to take time off work, the very repetitive follow-up for a population that has, by default, difficult or more hindered access to care; it’s not going to work as a motivation.”
"These professionals act as gatekeepers to PrEP information, preventing migrant women from making their own choices."
Others pointed out that restrictive eligibility criteria and the clinical risk assessment that accompanies this can exclude migrant women. The only category in which migrant women who are not sex workers could be deemed eligible for PrEP is that of “persons generally exposed to unprotected sexual practices with a high risk of HIV infection.” One interviewee described the case of a migrant woman of African heritage who had secured a PrEP appointment and had health insurance to cover the cost, but during the clinical assessment she could not “prove” that she was sufficiently “at risk.” She did not have the words to articulate it and experienced the clinical assessment as intrusive and embarrassing.
Finally, a number of professionals cited legal restrictions on access to PrEP as a reason for being hesitant to share information about PrEP with migrant women. In each municipality, a government body known as the CPAS can provide urgent medical assistance for undocumented people. However, each CPAS has its own criteria for granting reimbursement of medical costs, and these criteria are often not publicly available or consistent across municipalities. It can also take weeks or even months for a decision to be made.
“I know that it is possible to get [PrEP] in some CPAS but not in all. It costs money for women who are already struggling to survive. It is already difficult for them to pay for contraception, for example.”
Among the professionals who cited systemic barriers as a reason to withhold information about PrEP, it was clear that they perceived PrEP as inaccessible to migrants and believed that most of the women who need it are undocumented migrants. However, this is not reflective of the overall Black African population in Belgium. The genuine uncertainties around access to PrEP for undocumented migrants discouraged the professionals from speaking to the wider group of women who might benefit from PrEP.
“We are not going to create a demand among the population in Red Cross centers if there is no possibility of offering the service.”
HIV prevention professionals’ attitudes and beliefs as a barrier to PrEP access for migrant women
Some of the participants interviewed recognised that attitudes amongst HIV prevention professionals were creating barriers. They recognised that other professionals viewed cultural differences and systemic barriers as a reason to withhold information about PrEP from migrant women, but they thought this was unacceptable:
“It’s already something that most of the population we’re addressing don’t have access to. From the moment they don’t have access, you have a group of people who say that if they don’t have access, there’s no point in providing information. I find this very problematic. A population does not have access, this should be subject to lobbying, and of a struggle to advocate the fact that it is a right. Can we not include this in Urgent Medical Aid? But this is in no way a justification for not giving this information to the population concerned.”
They noted that a perception of migrant women as “hard to reach” and being “unready” to receive PrEP information resulted in them being overlooked as a priority for advocacy and PrEP promotion.
“In congresses, in big meetings we will always talk about women, vulnerable migrants. All the qualifiers are correct otherwise. But it will be hard to reach. When it’s hard to reach them, it’s like there’s no one else who can reach them, and it stops there.”
This lack of prioritisation was also evidenced by the majority of participants beginning their interview by stating that they didn’t really have experience or expertise in PrEP for migrant women, either because these women are not their 'target population' or because migrant women of African origin are not involved in their activities.
This research reveals paternalistic and often disturbing attitudes towards and beliefs about migrant women of African origin among some Belgian HIV prevention professionals, which create a substantial barrier to these women accessing information about PrEP. These professionals act as gatekeepers to PrEP information, preventing migrant women from making their own choices on how to protect and promote their sexual health.
The researchers note that many of the participants held fixed views of women of African origin (as migrants and undocumented, with limited education) which are not representative of all Black African people living in Belgium. In part, they attribute this to the marginalisation of Black African and women’s organisations in the HIV and sexual health sector and call on professionals to confront this issue. They also blame the lack of inclusion of migrant women in European PrEP trials for the lack of understanding around the needs of this group, and their subsequent marginalisation in PrEP discourse within the sexual health sector.
The research also highlights that structural barriers such as restrictions on migrants’ access to healthcare can make healthcare providers hesitant to discuss PrEP to migrant women. Removing these barriers will require political action, and the authors encourage professionals to participate in activist movements for the reform of policies that discriminate against migrants and women.
Demart S & Gérard E. The Construction of Pre-exposure Prophylaxis (PrEP) by Prevention Professionals as a Tool for Black African Migrant Women … or Not? AIDS Education and Prevention 34: 496-511, 2022.