Culturally Tailored Approaches Needed to Improve Access to PrEP for HIV

In a review of 19 prior studies, investigators said that international migrants are disproportionately affected by HIV. In their study, published in Lancet Public Health, the investigators noted that culturally tailored approaches and access to pre-exposure prophylaxis (PrEP) for individuals who are from different backgrounds should be considered.

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The study authors noted that possible risk factors for HIV among migrant populations could be social, economic, political, and legal barriers. They added that despite an increase in HIV and poorer clinical outcomes among this population, the uptake of PrEP has been understudied.

The aim of the review was to identify barriers and facilitators of PrEP implementation among international migrants. Investigators found that 14 studies contained factors at the individual level, 12 at the service level, and 10 at the societal level.

Eighteen of the 19 studies were in high-income countries and 9 of the 19 studies included at least 2 populations, including men who have sex with men and heterosexual men and women. Additionally, 6 studies included African migrants, 4 included South American migrants, and 3 included Asian migrants.

At the individual level, investigators identified 2 themes as a barrier: lack of knowledge of PrEP and low-risk perception of HIV. Out of the 19 studies, 13 reported a lack of knowledge of PrEP, with individuals reporting they had not received any information about PrEP in their country and first learned about it at the country they traveled to.

In 3 studies, the low-risk perception of HIV was also a barrier to PrEP use. Investigators said that some migrants were unaware of the risk of acquiring HIV, some felt that they did not need it due to their relationship status, and some thought they were at low risk because they avoided sex with those living with HIV.

Investigators said increasing awareness can be a facilitator for PrEP use in these individuals. One study suggested that promoting PrEP information on social media, including the cost, was beneficial. Additionally, at the service level, investigators found that cost and provider discrimination could be barriers to PrEP use.

Cost was a major barrier in 9 studies, with 1 study noting financial hardships and a lack of health insurance as a challenge. Three studies identified discrimination from health care professionals. South American migrants in the United States showed a lack of trust in their health care providers and feared discrimination against their sexual behaviors or identifies. As a result, they said they feared deportation and avoided HIV prevention services, according to the research.

Investigators identified navigating tools and public funding as facilitators of PrEP at the service level. In 3 studies, mobile HIV prevention services and counseling at publicly funded sexual health clinics or sexual health workshops drove more migrants to use PrEP and other HIV prevention methods.

Two studies showed that public funding would increase access to PrEP for migrants, with 1 showing that Medicare-ineligible migrants in Australia would consider PrEP if it were free or at an affordable price.

Furthermore, at the societal level, investigators identified negative perception toward PrEP users as a barrier to PrEP use. Six studies reported this barrier, with the belief that PrEP was only for sexually active men who have sex with men, those in sex work, those who engaged in infidelity, and those who preferred condomless sex. Investigators said that the perception was that these were deemed unacceptable by some in the community.

Investigators identified that engaging a positive perception toward PrEP users, HIV, and those in the LGBTQ+ community were facilitators at the societal level. Six studies reported that a positive perception increased PrEP usage, with 1 study determining that users could be perceived as being responsible for taking care of sexual health and protecting themselves from HIV.

Two studies also determined that a positive perception toward the LGBTQ+ communities could be beneficial due to the stigma around PrEP usage. One study reported that acceptance made migrants more open to learning about PrEP and sexual health.

Investigators determined that although there is existing support for PrEP usage and the benefits, most do not involve migrants. They called for a review of policies that may be discriminating against these individuals, which is among the reasons migrants may not use PrEP. Including culturally appropriate approaches to education and ending HIV stigma would also be beneficial, according to the investigators.

Reference

Tieosapjaroen W, Zhang Y, Fairley CK, Zhang L, et al. Improving access to oral pre-exposure prophylaxis for HIV among international migrant populations. Lancet Public Health. 2023. doi:https://doi.org/10.1016/S2468-2667(23)00105-6