Introduction
PrEP is a biomedical HIV prevention method with particularly high efficacy demonstrated for men who have sex with men [6‐8]. In Belgium, PrEP service delivery is centralized through specialized HIV clinics since 2017. PrEP is partly reimbursed under the national health insurance for individuals who meet the eligibility criteria [9] contingent on screening by a specialist physician. The user can then buy PrEP with an out-of-pocket cost of around €15 for 90 tablets [9, 10]. Belgium has a system of compulsory national health insurance for all registered residents, however, only legal residents have access to the health insurance scheme [11]. All asylum seekers are entitled to health care coverage while awaiting their asylum decision [12, 13]. Undocumented migrants are entitled to limited services through the system of urgent medical assistance (UMA). Because of an unclear definition of UMA, and a detailed and intrusive social enquiry conducted by the social welfare services at municipalities, the care people with undocumented status receive may differ [11]. |
Methods
Design
Study participants and recruitment
Data collection
Data analysis
Research team and reflexivity
Results
Participants
In-depth interviews ( n = 23) | |
Gender | |
Cisgender man | 22 |
Transgender woman | 1 |
PrEP use | |
Current PrEP user | 14 |
Never used PrEP | 6 |
Former PrEP user | 3 |
Region of origin | |
North Africa | 6 |
Middle East | 6 |
Eastern Europe | 1 |
Asia | 3 |
Central- and South America | 7 |
Years in Belgium | |
0 to 4 years | 8 |
5 to 9 years | 7 |
Over 10 years | 8 |
Interview language | |
English | 7 |
Spanish | 6 |
French | 6 |
Arabic | 2 |
Dutch | 2 |
Residence statusa | |
Documented | 16 |
Undocumented | 6 |
Currently in asylum procedure | 1 |
Ever involved in transactional sex or sex worka | |
Yes | 12 |
No | 11 |
Key informant interviews ( n = 8) | |
Gender | |
Cisgender woman | 5 |
Cisgender man | 3 |
Position/affiliation | |
Social worker | 2 |
Nurse | 4 |
Volunteer at community organization | 2 |
Language | |
Dutch | 7 |
English | 1 |
Codes and categories
Underlying determinants of PrEP uptake
Intersecting identities: migrant and men and transwomen who have sex with men
“How was my life in [country of birth]? (…) I’m gay, should I tell you about this life? Or my other personality? Which one do you prefer to hear about?”Participant 4 (PrEP-user).
“That's the reason that, one of the reasons why I came here yeah, right. One of the biggest reasons there is, the freedom, the way to, the way to live fully, a little bit more openly homosexual”Participant 7 (former PrEP user).
“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”Participant 4 (PrEP user).
Migration related stressors and restrictive policies
“For example, when I was looking for apartment, they choose Belgian people. Or some girls in street, or something in the night, they see black hair, they move apart. They scared. I can understand it, but sometimes it’s a feeling of racism.”Participant 12 (never used PrEP).
“As a rejected person, this is difficult for me. I had kidney stones and the ambulance did not take me to the hospital. You would have seen me lying on the road from the pain. (…) It was necessary to carry out the operation right away but they [reception centre] refused because it was an expensive operation. (…) I don’t give them [the Belgian healthcare system] 1 out of 10 [in terms of trust].”Participant 10 (never used PrEP).
“Then the transsexuals started to travel, they started to travel to Europe, it was like a boom because in the past [region of origin] people wanted to immigrate to [country X]. Migration to [country X] was so difficult that without a visa, without documents or money you could do it. Then it was like another way to Europe opened up”Participant 2 (PrEP user).
Socio-economic vulnerability
“Look, I'll be honest, thank God I have food, I have a house, and I don't worry much, what worries me is having the money to pay for the house. That, and from there, nothing else.”Participant 11 (never used PrEP).
“Because that's what I came to Europe to do, without papers, without anything, without speaking the language, without anything, what are you going to work on?”Participant 15 (PrEP user).
“Sometimes they say: ‘if you can have sex without condom, I give you extra’. Sometimes I say yes.”Participant 12 (non-PrEP user).
Mental health
“Mental health is also important for sexual health (…) just because of the difficult situation I had, it conditions your mental state, it makes you commit more risks perhaps. Since in a normal state, you wouldn’t do certain things”Participant 7 (former PrEP user).
"So I lost myself self-confidence. All of us. The most important fact that they have to challenge with it, it’s the self-confidence. That they [migrants] lost it and they have to rebuild it. That’s the most important fact about migrants life”Participant 4 (PrEP user).
“Belgium made me use more drugs. I felt myself alone and depressed. And I used drugs”Participant 12 (never used PrEP).
Barriers and facilitators to PrEP uptake and use
Accessibility of services
“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.”Participant 14 (PrEP user).
“lf you don't have health insurance, you can't have PrEP. Because PrEP , I've heard from the pharmacy or something, is expensive. Is almost 100 euros or so. But if you have health insurance, you get that from 8 euros or 12 euros”Participant 9 (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”Participant 6 (never used PrEP).
“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, the doctor asks questions, you have to go to a nurse, there is a lot of information coming at you. 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, so you have to get the explanation again because you've already forgotten what they said at the beginning, (...) So I think the procedure should be much faster if possible. I think that's definitely a threshold for them, and that for just the average middle-class gay man it's not a problem”Key informant D.
“I do not know much about other diseases, even when the doctor asked me to do several tests, I agreed without knowing them except for AIDS because there was some difficulty in communicating because of the language (...) I mean, the last thing was she did not understand me and I did not understand her. She even got to the point of translating via computer and show me what she meant”Participant 10 (never used PrEP).
“It [location] is very much known as an HIV clinic. Um. [They think] that everyone who comes here is HIV-positive. Really, the gossip… 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, or 'say, I saw that one in the [location] and that one might have [HIV]”Key informant G.
“When I moved to [city], the [HIV clinic], it is so well located. It seems so clean. I made an appointment very easily. I could have an appointment I think 5 days after I searched online”Participant 13 (PrEP user).
Availability of information
“For example in some countries, homosexuality is never discussed. Let alone sexual health or STIs, they don't know what that is. So often with those clients it's just starting from 0. (…) then PrEP is already quite complicated”Key informant B.
“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. That they're not mentally ready for that yet and they don't want to think about that. Yes, denial and then ignoring out of fear”Key informant D.
“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, they always go with insecurity because they always go with insecurity that the police or things like that, so sometimes that can happen”Participant 16 (PrEP user).
Social resources
“I’m alone, I feel alone. I just have separated with my boyfriend and I don’t have any family here and I cannot find a friend or find someone for a relationship, so. It’s a little bit difficult for me”Participant 1 (PrEP user).
"My boss from my volunteer work helped me. Because she knows my situation and I explained everything. She has a friend who lives here in the city, has a big house and has a studio in the roof. She asked me, if you want, I have a friend and you can live there”Participant 9 (PrEP user).
Providers’ attitudes
“The first time I was here, I was paranoia, I am afraid of HIV, I am afraid of the PrEP and so on. I was with an old doctor who does not laugh and explained everything very dryly. That was a bit difficult for me”Participant 9 (PrEP user).
PrEP acceptance
“I felt, when I started the PrEP I felt more relaxed (…) because for chlamydia, for gonorrhea or syphilis there will always be an injection or pills, but for HIV there is no injection or pills”.Participant 16 (PrEP user).
“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. I would need real proof to know if it works”Participant 5 (never used PrEP).
“Exactly, it has given me the freedom to enjoy my sexual life, which I never did before. Because I was always scared, you know”Participant 3 (PrEP-user).
Individual agency in prevention behavior
“Well the truth is, I think they [PrEP users] are smart on their part because if there is a pill that helps you do that function of protecting your body, why not take it?”Participant 15 (PrEP user).
“Yes it worries me, but at the end of the day in this job [sex work] it’s like Russian roulette. (...) and you have to take care of yourself as far as you can. If it happens to you, well, it's destiny and you have to take your treatment (...) because if you are working as an escort, as a prostitute, you know that it can happen, that is, at any moment it may not be HIV but it can be syphilis, or other sexually transmitted diseases, you know what I mean, so you have to have a clear mind that if you don’t take care of yourself it could happen”Participant 14 (PrEP user).
“There is nothing wrong with me, why would I take pills? I am sexual, I protect myself. But why would I take pills?”Participant 8 (never used PrEP).
"I tell others if you do a lot of sex with a lot of people, 100% you have to take it, but in my case right now, I don't do clients"Participant 6 (never used PrEP).