Among migrants in Europe, the risk of contracting HIV or developing AIDS is exacerbated by the many social vulnerabilities they face in their daily lives. Furthermore, these vulnerabilities intersect and are embedded in sexism, cisgenderism and racism. This is illustrated by three case-studies from a Swiss sociological and qualitative study recently published in Culture, Health and Sexuality.
A significant proportion of HIV-positive migrants to Europe acquire HIV after arriving on the continent. This implies that there is an urgent need for HIV prevention that is specific to migrants and addresses the risk factors identified in the study.
The study
Back in 2016, the Swiss Federal Office for Public Health established a framework for the prevention of HIV and other sexually transmitted infections (HIV/STIs) specific to migrants, based on six main factors contributing to vulnerability:
- High HIV prevalence in a person’s country of origin.
- Engagement in sex work.
- Being a man who has sex with men.
- Injecting drugs.
- Being a transgender person.
- Being an undocumented immigrant or having a temporary resident status in Switzerland.
The public health authorities also commissioned a study whose purpose was to strengthen the evidence base for HIV/STI prevention for migrants. This sociological, participatory and qualitative study was conducted by a team of social researchers from the University of Fribourg.
Participants all had a refugee permit or temporary residence permit or were undocumented and were over 18, with purposive sampling of people belonging to the six categories mentioned above. Recruitment was facilitated by people working in HIV, sexual health and migration, who were also involved in the design of the study.
Data were collected through in-depth interviews (in a foreign language when necessary) with migrants living in French and German-speaking Switzerland and with prevention specialists working in the field of migration and HIV.
Last year, the researchers published results showing that migrants may face particular legal and socioeconomic vulnerabilities, but also even more specific ones, for example people who are not cisgender, are not heterosexual or who engage in sex work.
They also looked at how the intersection of social vulnerabilities increase migrants’ risks of HIV and AIDS. To achieve this, they considered three dimensions:
- biographical (legal status, socioeconomic conditions, gender, sexual identity)
- intersectional (interactions between sexual partners and with health professionals)
- contextual (power relations and sociocultural structures in Switzerland, including sexism, cisgenderism and racism).
Explaining how significant this intersectionality of dimensions can be in an individual’s life, Dr Laura Mellini and her colleagues say that “power relations and sociocultural structures place, for example, undocumented transgender women in a disadvantaged situation, which shapes their interactions with other people”, adding that “all these aspects, and any intersection of them exacerbate migrants’ vulnerability to HIV and AIDS.”
Out of the twenty-eight interviews with migrants, the researchers propose a nuanced understanding of this complexity by focusing on three case-studies – Adira, Rose, Obi – which illustrate the intersectional vulnerability to HIV and AIDS faced by migrants living in Switzerland.
Adira, in constant fear of being deported
Adira is in her fifties and comes from an Asian country. She was assigned male sex at birth but she self-identifies as a transgender woman. After university, she moved to another Asian country where she was hired as a domestic worker and could afford hormonal treatment for transition. She then met a man who promised her a domestic worker job in Switzerland and helped her get a tourist visa. Two years later she was laid off, and then she had years of job searching which were unsuccessful due to her undocumented status or being transgender – notably because sexual services were often expected from her.
Eventually, Adira lost her housing and started to drink alcohol “to forget my situation.” Then, one day, after feeling very weak and going to the hospital, she was shocked to hear that she had AIDS. During her interview, Adira reported feeling dirty since her HIV diagnosis and fearing rejection:
“I feel so dirty to myself. I really feel dirty, because I’m not healthy anymore. I’m afraid because if somebody knows I have this sickness, he doesn’t like me anymore.”
Besides the HIV organisation and the healthcare professionals providing support to her, she has not disclosed her HIV status to anyone. She lives in constant fear of being deported from Switzerland and of being unable to access treatment in another country.
At the time of her interview in 2020, Adira was receiving housing in exchange for sex with a man with whom she would not dare discuss condom use, but because her viral load was undetectable, she thought the man “did not have this sickness.”
Rose, afraid to talk about sex work and to ask for PEP at the hospital
Born in the late 1980s, Rose comes from a sub-Saharan country. After leaving high school, she arrived in Italy for a job of hairdresser she had been promised. She was received by a “mama” who confiscated her passport until she paid her €45,000 for travel expenses, accommodation and food. She ended up being forced into sex work until her debt was repaid, and this meant working on the street day and night, seven days a week. Her living conditions were dire (control, deprivation, exploitation, submission to threatening rituals).
When Rose eventually paid off her “debt” she continued with sex work until a client fell in love with her and married her. For a couple of years, her job was to care for an elderly woman, whose family was openly racist towards her. However, when Rose divorced her husband after a while, she returned to sex work, but as her Italian citizenship obtained through marriage offered her more opportunities, she started to split her time between Italy and Switzerland where she could earn more money. In her interview, Rose reported that she regularly received requests for condomless sex, which she always refused as “health comes before [other things].”
At the time of her interview, Rose was HIV-negative. Every three months, she got tested for HIV and other STIs in a Swiss organization specialising in sex work – her “family”. However, she felt judged at the hospital, so she did not feel confident talking about sex work or asking for post-exposure prophylaxis (PEP).
Obi, afraid of not receiving his HIV treatment in Switzerland
Obi is a heterosexual man who was born in the late 1970s in a sub-Saharan African country where he completed high school. After leaving his home and his family because of death threats, he travelled illegally to Greece where he developed a relationship with a Greek woman who helped him while he was living on the street. The couple always had condomless sex, although Obi knew there was a risk of contracting HIV.
“Because I had that trust in her, because she helped me before, giving me food, assisting me, bringing me to her house… I believed in her.”
In 2009, Obi was diagnosed with HIV, after which he started HIV treatment and obtained a humanitarian residence permit. His relationship with “the Greek lady” had ended and he had moved to a refugee centre. Obi did not talk about his HIV status to anyone but the professionals in charge of his care and the other people living with HIV he met at the hospital. Tired of the living conditions at the refugee centre, not being permitted to work and expressions of racism he was facing in Greece, he moved to Switzerland and settled in a homeless shelter.
Since then, Obi has gone back and forth between the two countries, trying not to stay in Switzerland longer than the three months allowed by his Greek humanitarian permit. During his interview in 2019, Obi said he wanted to stay in Switzerland, but he still did not have a residence permit there. In other words, he considered his future uncertain, especially because his biggest fear was that one day he might not be able to receive his antiretroviral therapy in Greece, the treatment being difficult to access without health insurance in Switzerland.
What do these stories tell us?
Following the description of the three cases, the researchers address how the biographical, interactional and contextual dimensions intertwine and create social vulnerabilities.
As Adira and Obi’s stories tell us, by not allowing undocumented migrants to work, Swiss laws lead them towards undeclared and underpaid jobs, which puts them at risk of exploitation and deprives them of housing, social protection and health insurance. Going without healthcare is highly prevalent among undocumented people who live in a constant fear of being denounced and / or deported.
The link between the three dimensions and social vulnerabilities is also seen in relation to work. Rose could only find work as a caregiver, where she experienced racism, pushing her back to sex work. Despite having a university degree, Adira also works in care, like a disproportionate number of other migrant women. However, Adira also faces discrimination based on her gender identity, in addition to that based on her undocumented status. “For migrants like Adira, these limitations can result in a precarious housing situation and may lead them to engage in transactional sex in exchange for financial, housing and other resources,” the researchers say.
The hardships migrants face in a receiving country – such as the lack of residence permit – shape their sexual behaviours and partnerships, and increase their vulnerability to HIV, notably with an increase in transactional partnerships. This is particularly well-illustrated by Adira’s story in conditions that limit marginalised migrants’ access to HIV treatment and, as a result, increase their risk of developing full-blown AIDS. This is also seen even among people with health insurance from other countries who stay temporarily in Switzerland: Rose and Obi forgo HIV prevention, care and treatment because these are either too restricted or too expensive.
The structural conditions in which interactions with sexual partners take place may enhance vulnerability to HIV. Inadequate refugee conditions led Obi to accept being provided material support from a person who also exposed him to HIV. In the case of Rose, because she is a sex worker who is female, African and undocumented, she navigates asymmetric sexual relations with clients who often insist on having condomless sex. When she needs PEP, she is disempowered by stigma towards sex work.
The researchers conclude that their findings have important implications for HIV prevention (testing, PrEP and PEP) and HIV treatment in the context of migration. For example, they highlight the need for structural change to achieve equity in healthcare and access to healthcare for all. Additionally, if migrants had greater economic and legal security through financial allowances and long-term residence permits, they would be less likely to get into intimate relationships with an unequal balance of power.
Perhaps the researchers’ most important comment is that their results “suggest that HIV and AIDS prevention among migrants cannot be effective without questioning social and cultural structures and systems of power, such as sexism, cisgenderism and racism.”
Mellini L et al. Migrants facing intersectional vulnerability to HIV and AIDS in Switzerland: an exploratory study. Culture, Health & Sexuality, published online 28 February 2024 (open access).