Structural barriers impede Belgium-based migrants from accessing PrEP despite their willingness to take the HIV prevention drug. A study by Ella Van Landeghem of the Institute of Tropical Medicine in Antwerp and colleagues showed the country’s healthcare systems and PrEP reimbursement model are barriers for undocumented migrants and those who are experiencing financial hardship.
The majority of PrEP users in Belgium are male citizens who have sex with men; there are disparities in use compared to migrant men and transgender women who have sex with men. PrEP is available through HIV clinics for a fee which Belgian citizens and some documented migrants can have reimbursed. Undocumented migrants are entitled to restricted urgent medical assistance; each Belgian municipality defines its own eligibility criteria for this. The criteria are not publicly available and it can take weeks or even months before individuals know the outcome of their request for medical assistance.
The team wanted to understand how to improve PrEP uptake among migrant men and transgender women who have sex with men. They interviewed 23 migrants who had either used PrEP or had a known HIV risk but had not used PrEP. They were recruited via sexual health clinics or organisations working in HIV prevention and support for sex workers.
Interviews were held in Arabic, Dutch, English, French or Spanish. All participants were born outside of Belgium. They were from various regions, including Central and South America (n=7), North Africa (n=6) and Middle East (n=6). Around two-thirds had been in Belgium for less than ten years. Their residence status was either documented (n=16), undocumented (n=6) or seeking asylum (n=1).
Of the 23 migrants interviewed, one was a transgender woman and the rest (n=22) were cisgender men who have sex with men. Not all identified as gay, but most had left their country of birth because of their sexual orientation. Half of the group reported experience of sex work or transactional sex. Six of the 23 had never used PrEP.
The researchers also spoke with eight professionals. They worked in social work, nursing or volunteered at a community organisation.
PrEP information, expectations and acceptance
For this group of migrants, awareness of PrEP was generally high. The majority of the interviewees had used PrEP, so they knew of and accepted its effectiveness. Some participants described the reassurance they gained from taking the drug and having medical screenings.
One participant shared that societal expectations and specifically wanting to be part of Belgian gay culture led him to take PrEP:
“At the moment, you’re not part of this society. So we try to take any small step to improve ourselves to just be part of this society... Any step that helps me as a new part of this society, to be more acceptable, be more successful, I will do it. And as a gay, taking PrEP is really a small step that I can take.” - PrEP user
For those who had not accessed PrEP, language barriers and sceptism about the effectiveness PrEP were hindrances:
“I just don’t find it very credible that it really protects you. There is no physical barrier, you cannot see it. While with condoms you clearly can see it.” - Never used PrEP
The professionals focused on other barriers such as the ways self and perceived stigma prevented PrEP uptake:
“It [clinic] is very much known as an HIV clinic… Sometimes you even see people coming for [something else]. But they have their mouth mask on up to here and cap. Just because they don’t want to be seen. Because they are afraid that people might gossip about them.” - Professional
“There are those who don’t want to take PrEP or don’t want to take their HIV medication because that confirms to them every time that they are taking a risk, or that they are HIV-positive.” - Professional
Structural enablers and barriers
Participants shared the impact of structural barriers, such as not being Belgian citizens or not having the necessary migration documents to access the reimbursement scheme.
“I know that the health care system is very good because I have friends who have Belgian documents or [other European country] documents and they have had good care there. But with respect to us immigrants who do not have documents, ... it is difficult, even impossible to get to a doctor or a hospital or something like that.” - PrEP user
“I also heard from my friend that it’s expensive, but condoms are free so I don’t see it as something for me.” - Never used PrEP
More than half had been in precarious situations. Lack of legal documents prevented access to employment, housing and healthcare. One participant feared most official institutions and another participant anticipated being denied access to PrEP due to previous healthcare experiences.
“Maybe it’s because when you come here for free and without papers, people are afraid, people don’t trust anyone. So instead of asking for help, they are afraid to talk.” - PrEP user
“As a rejected person, this is difficult for me. I had kidney stones and the ambulance did not take me to the hospital… It was necessary to carry out the operation right away but they [the reception centre] refused because it was an expensive operation.” - Never used PrEP
Even when they did access PrEP, participants spoke of the continued barriers inside of the system, especially for those who are financially insecure:
“The procedure simply takes far too long for our population. There are already waiting lists, often too long for them. Then you have to go, blood is taken… Then you get a second appointment, a month later, but your PrEP still hasn’t started, but in the meantime you’re already about 3.5 months further on - and you’re not on PrEP yet… I think that’s definitely a threshold for them, and that for just the average middle-class gay man it’s not a problem.” - professional
“lf you don’t have health insurance, you can’t have PrEP. Because PrEP… is almost 100 euros or so. But if you have health insurance, you get that from 8 euros or 12 euros” - PrEP user
Only a small number of those interviewed were ineligible for reimbursed PrEP and the participants had high awareness of PrEP, so their experiences may not reflect other migrants with limited or no interactions with Belgian health services. Only one participant was a transgender woman, so the findings primarily give insight into the experiences of migrant men who have sex with men.
The study highlights that even those who are aware of PrEP and would be willing to take it are hindered by structural and socio-economic factors. This was particularly true for undocumented migrants who may worry about the ramifications for their residency status and those (although documented) who may be in financial hardship.
The authors stressed the importance of acknowledging the diversity among migrants. Structural factors may have a more significant bearing on PrEP access than assumed cultural influences, which has also been shown in a study on PrEP access among migrant women in Belgium. Free and equitable access to PrEP is key to reducing HIV disparities between Belgian citizens and non-citizens.
Van Landeghem et al. Insights into barriers and facilitators in PrEP uptake and use among migrant men and transwomen who have sex with men in Belgium. BMC Public Health, 23:712, 2023 (open access).
Full image credit: PrEP Emtricitabine/Tenofovir (Generic Truvada) PrEP Treatment Image 1. Image by Doctor 4U. www.doctor-4-u.co.uk Available at www.flickr.com/photos/144891950@N08/48663489683/ under a Creative Commons licence CC BY 2.0.
Update: This article was amended on 18 July 2023 to give the correct affiliation for Ella Van Landeghem.