Treatment as prevention for migrants in Europe: an examination of HIV testing and access to treatment and care

Improving access to human immunodeficiency virus (HIV) testing and treatment is at the core of a global strategy known as “Treatment as Prevention” which aims to bring about the end of the acquired immune deficiency syndrome epidemic. Within Europe, migrants bear a disproportionate burden of HIV infection, yet evidence about the HIV testing and care needs of this population is sparse. This thesis identifies the barriers and facilitators to Treatment as Prevention for migrants living in Europe and explores how these factors differ between women, heterosexual men, and gay and bisexual men. Two cross-sectional surveys were conducted. One study was the first multinational survey to sample multiple migrant groups living with HIV in Europe, and recruited 2,221 migrant adults living with HIV from 57 HIV clinics in nine European countries. Questionnaires were completed electronically and linked to clinical records. The second study recruited 1,628 respondents to a web-based survey. The primary outcomes were access to primary care and a HIV testing history. Data were analysed using logistic regression (with random effects for clinics). Twenty-two in-depth interviews provided historical and ecological context for the survey data. An ecosocial framework was used to guide analysis and interpret the findings. The results show that the primary outcomes were associated with structural factors such as immigration status and country of residence, as well as sexual behaviour, risk perception and HIV-related stigma. Migration plans and histories influence health-seeking behaviour and migrant networks are important facilitators for accessing healthcare. Despite ready access to HIV treatment which allowed individuals to survive, some migrants were unable to thrive because of immigration-related stress, stigma and social deprivation. For Treatment as Prevention to work for migrants, interventions should focus on reducing seroconversion among gay and bisexual men and increasing provider-initiated HIV testing opportunities for women and heterosexual men