Concurrent partnerships and sexual risk taking among African and Caribbean migrant populations in the Netherlands

Patterns of Sexual Risk Behavior, HIV Infection, and Use of Health Services Among Sub-Saharan African Migrants in Portugal

This study identified patterns of sexual risk behavior among a sub-Saharan African migrant (SAM) population in Portugal and examined its associations with human immunodeficiency virus (HIV) prevalence, sociodemographics, use of sexual health services, and HIV testing. A cross-sectional biobehavioral survey was conducted with a venue-based sample of 790 SAMs. Data were collected using questionnaires and rapid HIV tests. Cluster analysis identified five subgroups with differing levels of HIV infection (2.5% to 11.3%). In Cluster 1, most participants reported sexual abstinence over the past year and the remaining used condoms consistently; this cluster had the highest HIV prevalence (11.3%). In Cluster 2, most reported one sexual partner and all reported unprotected sex; all HIV-positive participants in this cluster were unaware of their HIV-positive status. In Clusters 3 and 4, most had four or more partners, yet all used condoms. In Cluster 3, 56.5% reported both regular and occasional partners. In Cluster 4, 74% had only occasional partners; all engaged in commercial sex. In Cluster 5, all reported four or more partners and condomless sex. In all subgroups we found low rates of HIV testing and high unawareness of HIV serostatus. Targeted prevention interventions are needed to reduce unprotected sexual relations and undiagnosed infection, as well as improve linkage to sexual health services.

Exploring barriers to consistent condom use among sub-Saharan African young immigrants in Switzerland

No study to date has focused on barriers to condom use specifically among young immigrants to Europe from sub-Saharan Africa. Based on a qualitative study in sociology, this paper explores generational differences in barriers to condom use between first-generation immigrants (born in Africa and arrived in Switzerland after age 10) and second-generation immigrants (born in Switzerland to two native parents or arrived in Switzerland before age 10). Results are based on in-depth, semistructured individual interviews conducted with 47 young women and men aged 18 to 25 to understand how individual, relational, and cultural dimensions influence sexual socialization and practices. Six main barriers to consistent condom use were identified: reduced pleasure perception, commitment and trust, family-transmitted sexual norms and parental control, lack of accurate knowledge on HIV transmission, lack of awareness about HIV in Switzerland, and gender inequalities. The three first barriers concerned both generations of immigrants, whereas the three last revealed generational differences. These findings can help sexual health providers identify social causes for young sub-Saharan immigrants not using condoms. The findings also highlight the necessity of offering accurate, accessible, and adapted information to all young immigrants, as well as the particular importance of addressing families' lack of discussions about sex, understanding the sexual norms transmitted by parents, and taking into consideration cultural differences among young people born in immigration countries.

First HIV prevalence estimates of a representative sample of adult sub-Saharan African migrants in a European city. Results of a community-based, cross-sectional study in Antwerp, Belgium

Introduction

While sub-Saharan African migrants are the second largest group affected by HIV in Europe, sound HIV prevalence estimates based on representative samples of these heterogeneous communities are lacking. Such data are needed to inform prevention and public health policy.

Methods

This community-based, cross-sectional study combined oral fluid HIV testing with an electronic behavioral survey. Adopting a two-stage time location sampling HIV prevalence estimates for a representative sample of adult sub-Saharan African migrants in Antwerp, Belgium were obtained. Sample proportions and estimated adjusted population proportions were calculated for all variables. Univariable and multivariable logistic regression analysis explored factors independently associated with HIV infection.

Results

Between December 2013 and October 2014, 744 sub-Saharan African migrants were included (37% women). A substantial proportion was socially, legally and economically vulnerable: 21% were probably of undocumented status, 63% had financial problems in the last year and 9% lacked stable housing. Sexual networks were mostly African and crossed national borders, i.e. sexual encounters during travels within Europa and Africa. Concurrency is common, 34% of those in a stable relationship had a partner on the side in the last year. HIV prevalence was 5.9%(95%CI:3.4%-10.1%) among women and 4.2% (95%CI:1.6%-10.6%) among men. Although high lifetime HIV testing was reported at community level (73%), 65.2% (CI95%:32.4%-88.0%) of sub-Saharan African migrants were possibly undiagnosed. Being 45 years or older, unprotected sex when travelling within Europe in the last year, high intentions to use condoms, being unaware of their last sexual partners’ HIV status, recent HIV testing and not having encountered partner violence in the last year were independently associated with HIV infection in multivariable logical regression. In univariable analysis, HIV infection was additionally associated to unemployment.

Conclusions

This is the first HIV prevalence study among adult sub-Saharan African migrants resettling in a European city based on a representative sample. HIV prevalence was high and could potentially increase further due to the high number of people with an undiagnosed HIV infection, social vulnerability, high levels of concurrency and mainly African sexual networks. Given this population’s mobility, an aligned European combination prevention approach addressing these determinants is urgently needed.

'The full has never been told': building a theory of sexual health for heterosexual Black men of Caribbean descent

Research on Black sexual health often fails to represent the heterogeneity of Black ethnic groups. For people of Caribbean descent in the USA, ethnicity is a salient cultural factor that influences definitions and experiences of sexual health. Most research on people of Caribbean descent focuses on the relatively high rate of STIs, but sexual health is defined more broadly than STI prevalence. Psychological and emotional indicators and the voice of participants are important to consider when exploring the sexual health of a minority culture. The purpose of this study was to qualitatively explore how heterosexual Black men of Caribbean descent define and understand sexual health for themselves. Eleven men who self-identified as Black, Caribbean and heterosexual participated in three focus groups and were asked to define sexual health, critique behaviours expertly identified as healthy and address what encourages and discourages sexual health in their lives. Findings point to six dimensions of sexual health for heterosexual Black men of Caribbean descent. These include: heterosexually privileged, protective, contextual, interpersonal, cultural and pleasurable dimensions. There were some notable departures from current expert definitions of sexual health. Recommendations for further theory development are provided.

Ethnic and regional differences in STI clinic use: a Dutch epidemiological study using aggregated STI clinic data combined with population numbers

OBJECTIVES

Ethnic minorities (EM) from STI-endemic countries are at increased risk to acquire an STI. The objectives of this study were to investigate the difference in STI clinic consultation and positivity rates between ethnic groups, and compare findings between Dutch cities.

METHODS

Aggregated population numbers from 2011 to 2013 of 15-44 year-old citizens of Amsterdam, Rotterdam, The Hague and Utrecht extracted from the population register (N=3 129 941 person-years) were combined with aggregated STI clinic consultation data in these cities from the national STI surveillance database (N=113 536). Using negative binomial regression analyses (adjusted for age and gender), we compared STI consultation and positivity rates between ethnic groups and cities.

RESULTS

Compared with ethnic Dutch (consultation rate: 40.3/1000 person-years), EM from Eastern Europe, Sub-Sahara Africa, Suriname, the Netherlands Antilles/Aruba and Latin America had higher consultation rates (range relative risk (RR): 1.27-2.26), whereas EM from Turkey, North Africa, Asia and Western countries had lower consultation rates (range RR: 0.29-0.82). Of the consultations among ethnic Dutch, 12.2% was STI positive. Positivity rates were higher among all EM groups (range RR: 1.14-1.81). Consultation rates were highest in Amsterdam and lowest in Utrecht independent of ethnic background (range RR Amsterdam vs Utrecht: 4.30-10.30). Positivity rates differed less between cities.

CONCLUSIONS

There were substantial differences in STI clinic use between ethnic groups and cities in the Netherlands. Although higher positivity rates among EM suggest that these high-risk individuals reach STI clinics, it remains unknown whether their reach is optimal. Special attention should be given to EM with comparatively low consultation rates.

TOGETHER Project to Increase Understanding of the HIV Epidemic Among Sub-Saharan African Migrants: Protocol of Community-Based Participatory Mixed-Method Studies

Background

Sub-Saharan African Migrants (SAM) are the second largest group affected by HIV/AIDS in Belgium and the rest of Western Europe. Increasing evidence shows that, more than previously thought, SAM are acquiring HIV in their host countries. This calls for a renewed focus on primary prevention. Yet, knowledge on the magnitude of the HIV epidemic among SAM (HIV prevalence estimates and proportions of undiagnosed HIV infections) and underlying drivers are scarce and limit the development of such interventions.

Objective

By applying a community-based participatory and mixed-methods approach, the TOGETHER project aims to deepen our understanding of HIV transmission dynamics, as well as inform future primary prevention interventions for this target group.

Methods

The TOGETHER project consists of a cross-sectional study to assess HIV prevalence and risk factors among SAM visiting community settings in Antwerp city, Belgium, and links an anonymous electronic self-reported questionnaire to oral fluid samples. Three formative studies informed this method: (1) a social mapping of community settings using an adaptation of the PLACE method; (2) a multiple case study aiming to identify factors that increase risk and vulnerability for HIV infection by triangulating data from life history interviews, lifelines, and patient files; and (3) an acceptability and feasibility study of oral fluid sampling in community settings using participant observations.

Results

Results have been obtained from 4 interlinked studies and will be described in future research.

Conclusions

Combining empirically tested and innovative epidemiological and social science methods, this project provides the first HIV prevalence estimates for a representative sample of SAM residing in a West European city. By triangulating qualitative and quantitative insights, the project will generate an in-depth understanding of the factors that increase risk and vulnerability for HIV infection among SAM. Based on this knowledge, the project will identify priority subgroups within SAM communities and places for HIV prevention. Adopting a community-based participatory approach throughout the full research process should increase community ownership, investment, and mobilization for HIV prevention.

Urogenital Chlamydia trachomatis infections among ethnic groups in Paramaribo, Suriname; determinants and ethnic sexual mixing patterns

BACKGROUND

Little is known about the epidemiology of urogenital Chlamydia trachomatis infection (chlamydia) in Suriname. Suriname is a society composed of many ethnic groups, such as Creoles, Maroons, Hindustani, Javanese, Chinese, Caucasians, and indigenous Amerindians. We estimated determinants for chlamydia, including the role of ethnicity, and identified transmission patterns and ethnic sexual networks among clients of two clinics in Paramaribo, Suriname.

METHODS

Participants were recruited at two sites a sexually transmitted infections (STI) clinic and a family planning (FP) clinic in Paramaribo. Urine samples from men and nurse-collected vaginal swabs were obtained for nucleic acid amplification testing. Logistic regression analysis was used to identify determinants of chlamydia. Multilocus sequence typing (MLST) was performed to genotype C. trachomatis. To identify transmission patterns and sexual networks, a minimum spanning tree was created, using full MLST profiles. Clusters in the minimum spanning tree were compared for ethnic composition.

RESULTS

Between March 2008 and July 2010, 415 men and 274 women were included at the STI clinic and 819 women at the FP clinic. Overall chlamydia prevalence was 15% (224/1508). Age, ethnicity, and recruitment site were significantly associated with chlamydia in multivariable analysis. Participants of Creole and Javanese ethnicity were more frequently infected with urogenital chlamydia. Although sexual mixing with other ethnic groups did differ significantly per ethnicity, this mixing was not independently significantly associated with chlamydia. We typed 170 C. trachomatis-positive samples (76%) and identified three large C. trachomatis clusters. Although the proportion from various ethnic groups differed significantly between the clusters (P = 0.003), all five major ethnic groups were represented in all three clusters.

CONCLUSION

Chlamydia prevalence in Suriname is high and targeted prevention measures are required. Although ethnic sexual mixing differed between ethnic groups, differences in prevalence between ethnic groups could not be explained by sexual mixing.

Higher Chlamydia trachomatis prevalence in ethnic minorities does not always reflect higher sexual risk behaviour

Background

In affluent countries, the prevalence of Chlamydia trachomatis (CT) is often higher in certain ethnic minorities than in the majority population. In the Netherlands, we examined why CT prevalence is higher in Surinamese/Antilleans, the largest minority in the country.

Methods

Heterosexuals were recruited for a cross-sectional survey from May through August 2010 at the sexually transmitted infections (STI) clinic in Amsterdam. Participants completed a questionnaire and were tested for STI. A causal directed acyclic graph was assumed to investigate whether the association between ethnicity and CT could be explained by differences in sexual risk behaviour and socio-economic status.

Results

Subjects included 1044 with Dutch background and 335 with Surinamese/Antillean background. Median age for the combined population was 25 (IQR 22-30) years, and 55.4% was female. Sexual risk behaviour did not differ significantly between the two groups. CT was diagnosed in 17.9% of Surinamese/Antilleans and in 11.4% of Dutch. Surinamese/Antilleans were significantly more likely to have CT (OR 1.70; 95% CI 1.21-2.38). The association between ethnicity and CT remained statistically significant after adjusting for sexual risk behaviour, age, sex, and ethnic mixing (aOR 1.48; 95% CI 1.00-2.18), but not after adjusting for education and neighbourhood, markers of socio-economic status (aOR 1.08; 95% CI 0.71-1.64).

Conclusion

The difference in CT prevalence between the minority and majority groups was not explained by differences in sexual risk behaviour. The higher CT prevalence found among Surinamese/Antilleans appeared to reflect their lower educational level and neighbourhood, two markers of lower socio-economic status. We hypothesise that the effect results from lower health-seeking behaviour.

Do sexual risk behaviour, risk perception and testing behaviour differ across generations of migrants?

BACKGROUND

Behaviour and related health outcomes of migrants have been suggested to shift towards the practices of the indigenous population of the host country. To investigate this, we studied generational differences in sexual behaviour between first- and second-generation migrants (FGMs and SGMs) in The Netherlands.

METHODS

In 2003-05, persons aged 16-70 years with origins in Surinam, the Antilles and Aruba were interviewed on their sexual behaviour in The Netherlands and their country of origin. The relationship of generation, age at migration and sexual behaviour was studied by multinomial logistic regression analyses.

RESULTS

Generational differences were observed regarding concurrent partnerships, anal sex and history of sexually transmitted infection. Compared with FGMs who migrated at an age >25 years, those who migrated between 10 and 25 years of age were more likely to report concurrency [odds ratio (OR): 1.52, 95% confidence interval (CI): 1.14-2.04], whereas SGMs were less likely to report concurrency (OR: 0.65, 95% CI: 0.43-0.98). FGMs who migrated before the age of 10 were more likely to have had anal sex (OR: 1.90, 95% CI: 1.34-2.71) or a sexually transmitted infection diagnosis (OR: 1.80, 95% CI: 1.20-2.71) than those who had migrated at >25 years of age.

CONCLUSION

Our study shows that not only SGMs but also FGMs who migrated at an early age tend to differ from the sexual patterns of FGMs who migrated at an older age. Generational differences in sexual behaviour could be explained by acculturation and increased identity with the values of the host country.

'Migrants from over there' or 'racial minority here'? Sexual networks and prevention practices among sub-Saharan African migrants in France

Migrants from sub-Saharan Africa bear a disproportionate burden of HIV infection in Europe, with an increasing proportion of them acquiring HIV after migration. This transformation in the epidemic pattern has raised concerns about the sexual mixing and preventive behaviours of migrants. This paper aims at exploring how racial boundaries shape sexual networks and structure prevention practices among migrants from sub-Saharan Africa. Analyses are based on a French survey carried out among 1874 individuals born in sub-Saharan Africa, aged 18-49 and living in Paris and its surroundings. Our results provide evidence of the existence of African sexual networks, over and beyond those of national origin. The intra-African segregation of these sexual networks leads to sexual contacts between migrants from low- and high-HIV prevalence countries, which probably contribute to the development of the epidemic amongst these migrants. Moreover, racially-based perceptions of HIV-related risk seem to produce a specific attitude toward prevention practices as shown by higher rates of condom use among migrant women from sub-Saharan Africa with a partner born outside sub-Saharan Africa. As a consequence, community-based approaches to HIV prevention should take into account the identification of migrants from sub-Saharan Africa as a racial minority and not only focus on national borders.