For African migrants in Europe, destitution shapes sexual behaviour and HIV risk

For African migrants recently arrived in France, periods without a residence permit, secure housing or enough money are very common and are associated with transactional and casual sexual relationships, especially in women, Annabel Desgrées du Loû and colleagues report in AIDS. Moreover one third of those living with HIV seroconverted after arriving in the country and the destitution experienced appears to have contributed to those infections.

Another analysis from this cohort (reported in July at the 8th International AIDS Society conference in Vancouver and also in a recent issue of Eurosurveillance) is one of several recent studies to demonstrate that not all African migrants who are now living with HIV in European countries became HIV positive while they were in Africa. Analysis of CD4 cell counts and life history data showed that between a third and a half probably acquired HIV after migration and while living in France.

The implication is that European health services need to do more than provide HIV testing to African migrants, but also create and provide effective HIV prevention interventions. The study published in AIDS highlights some of the social factors that this prevention needs to take account of. Harsh immigration and economic policies which put migrants into situations of economic insecurity and destitution appear to encourage sexual behaviours that increase their risk of acquiring HIV.

Glossary

odds ratio

Comparing one group with another, expresses differences in the odds of something happening. An odds ratio above 1 means something is more likely to happen in the group of interest; an odds ratio below 1 means it is less likely to happen. Similar to ‘relative risk’. 

sample

Studies aim to give information that will be applicable to a large group of people (e.g. adults with diagnosed HIV in the UK). Because it is impractical to conduct a study with such a large group, only a sub-group (a sample) takes part in a study. This isn’t a problem as long as the characteristics of the sample are similar to those of the wider group (e.g. in terms of age, gender, CD4 count and years since diagnosis).

multivariate analysis

An extension of multivariable analysis that is used to model two or more outcomes at the same time.

qualitative

Qualitative research is used to explore and understand people’s beliefs, experiences, attitudes or behaviours. It asks questions about how and why. Qualitative research might ask questions about why people find it hard to use HIV prevention methods. It wouldn’t ask how many people use them or collect data in the form of numbers. Qualitative research methods include interviews, focus groups and participant observation.

However the behavioural patterns of men and women are, in many cases, distinct.

The study

The data come from interviews with 2464 migrants who were attending healthcare facilities in the Paris region in 2012 and 2013. Recruitment took place at HIV, hepatitis and primary care clinics.

All participants were born in an African country and were now living in France. The sample was divided into four groups:

  • 296 people who probably acquired HIV in France.
  • 599 people who were probably HIV-positive before they came to France.
  • 776 people who had hepatitis B.
  • 762 people without either infection (reference group).

The interviews focused on their life histories, exploring key events both before and after migration, so as to understand the interviewee’s family history, education and employment, sexual relationships, and use of health services.

Most participants were born in countries of western and central Africa, especially Ivory Coast, Cameroon, Mali, the Democratic Republic of the Congo and Senegal. Three-quarters had a secondary or university education.

On average, they had come to France at the age of 26 and had stayed for 13 years. While many of the men had migrated to seek work or to study, around half the women had migrated to join a partner or family members. Some people had fled their country because they were under threat there.

Key findings

Problems with immigration status and destitution were very commonly reported, especially in the first few years after arriving in France. Across the sample, around half of respondents reported that they had spent at least a year without a residence permit (i.e. they were an undocumented migrant). One in ten had spent a year with no financial resources at all and one third had spent a full year without stable housing (including sleeping on friends’ sofas or in the street).

Most of the migrants were sexually active while in France. Four-fifths had had at least one stable relationship, with no differences between genders or groups. The situation for other types of sexual partnerships was different for men and women.

Among women in the reference group of people without a viral infection, 30% had had casual partnerships, 19% overlapping partnerships, and 2% had had transactional sex (i.e. sex in order to obtain housing, money, clothes, food or documents). None had paid for sex.

Among men, 54% had casual partnerships, 46% overlapping partnerships, 1% transactional sex and 12% had paid for sex.

However those who acquired HIV after arriving in France were more likely to report some of these behaviours. For example 52% of women had casual partnerships, 8% of women had transactional sex and 21% of men had paid for sex. Women who had HIV before arrival were also a little more likely to report these behaviours.

Moreover multivariate analyses – which take into account other factors which could influence the results – suggest a strong link between people’s social situations and their sexual partnerships.

Women were eight times more likely to have transactional sex (in order to secure money, a placed to sleep or other resources) if they didn’t have stable housing (odds ratio 8.17). During periods in which they didn’t have a residence permit, they were three times more likely to do so (odds ratio 3.56). The authors note that qualitative studies with migrants have previously shown that difficult living conditions lead to sexual harassment and exchanging sex for basic goods, accommodation and official documents.

Both women and men were more likely to have casual partnerships in periods when they had no residence permit, had no housing, or were dependent on others for somewhere to live. Women were also more likely to have overlapping partnerships in these circumstances.

On the other hand, women who had migrated to join a partner, had financial resources or had their own housing were more likely to have a stable partnership.

Men were far less likely to have a stable partnership when they didn’t have a residence permit (odds ratio 0.23), had no financial resources (odds ratio 0.60), were housed by family members (odds ratio 0.32), were living in a hostel (odds ratio 0.30) or had no stable housing (odds ratio 0.36).

Men were more likely to pay for sex when they didn’t have a residence permit or their own place to live. However greater financial resources also appeared to facilitate men paying for sex as well as having casual and overlapping partnerships.

Conclusion

“These results underline the gendered organization of sexuality,” the authors say. Whereas men need resources for all kinds of sexual relationships – whether stable, casual or paid – women are more likely to engage in casual or transactional sex when faced with material hardship.

“The associations observed between casual, transactional and concurrent partnerships and the acquisition of HIV while in France may reveal behavioural determinants of HIV acquisition after migration,” they write. “Social hardships appear to favour risky sexual behaviour, especially among women, and might be thus viewed as an indirect risk factor for female HIV acquisition.”

References

Desgrées du Loû A et al. Is hardship during migration a determinant of HIV infection? Results from the ANRS PARCOURS study of sub-Saharan African migrants in France. AIDS, online ahead of print, 2015.