Intended for healthcare professionals

Opinion

Where is the PrEP for migrants?

BMJ 2024; 384 doi: https://doi.org/10.1136/bmj.q315 (Published 07 February 2024) Cite this as: BMJ 2024;384:q315
  1. Rebecca Irons, senior research fellow
  1. University College London

Displaced Venezuelans and other refugee populations are at risk of HIV infection. Providing PrEP and tackling stigma are critical to preventing this, writes Rebecca Irons

With more than seven million people displaced, the Venezuelan refugee crisis—fuelled by political, economic, and social instability—is on a similar scale to that of Ukraine and Syria, yet it remains out of international headlines.1 Despite Venezuela’s health system reaching near collapse,2 medical and humanitarian aid have steadily declined in recent years, with an acceleration in 2021 as international agencies redirected funds towards Ukraine.3

To prevent the spread of HIV, access to sexual and reproductive health services for displaced people is essential. An estimated 8000 Venezuelan migrants are living with HIV,4 mostly in neighbouring Latin American countries. To stem the virus’s spread and to attend to migrant health, PrEP (pre-exposure prophylaxis) must urgently be made available to Venezuelans in Latin America and to other migrant populations around the world, as they may be facing a similar stigma that acts as a barrier to healthcare. They continue to rely on the support of non-governmental organisations and aid agencies providing antiretroviral treatment until they can get access to state funded healthcare. But PrEP continues to be unavailable to these migrants.

The lack of PrEP’s availability to migrants may be closely related to stigmatised perceptions of who transmits HIV. Myriad factors mean that Venezuelans are often labelled as vectors for sexually transmitted diseases and as a risk to local populations in Latin America.5 The country’s shortage of antiretroviral treatment in 2017-18 has led to perceptions that the virus has run rampant in Venezuela,6 which in turn could cause the misconception that host populations are at risk from Venezuelans, not the other way around. This view and the associated stigma may result in cases of vulnerable migrants struggling or being unable to negotiate the use of contraception in serodiscordant relationships (where one partner is infected with HIV and the other is not)—and, in the absence of PrEP, being infected with HIV themselves.

Evidence and lived experience

In Latin America the demand for PrEP has increased in recent years,7 although only 11 of 17 countries in the region offered it as of 2022.8 Colombia—Venezuela’s neighbour and the nation with the highest intake of Venezuelan migrants—is one of them.9 Since PrEP was approved there in 2019, studies suggest that some reticence remains among Colombian doctors in prescribing PrEP,10 where a perceived risk of HIV exposure is a key factor in the willingness to prescribe.

From a policy perspective Venezuelan migrants aren’t considered to be at high risk of HIV infection, and no international aid agency or local healthcare provider currently offers PrEP to this population. This is an error, and migrants must be considered a key population at risk of HIV infection and in need of access to PrEP. Health related data from Venezuela, and about Venezuelan migrants, are difficult to obtain. But evidence of lived experience and social contributory factors highlight this need.

In my work I came across the case of a woman who migrated from Venezuela and had been in Colombia for a few years when she met her Colombian boyfriend, who was HIV positive. Although efforts were made to seek PrEP for her, it was unavailable because of her “refugee” status. The couple relied on condom use, and she ended up contracting HIV. In cases such as this, where the status of the partner is known and antiretroviral treatment is unavailable or not adhered to so as to reach undetectability, PrEP should be offered to the partner to avoid infection. Clearly, Venezuelans need PrEP as much as Colombians, so why is it not available to them?

The same issue is relevant to other migrant populations. For example, Poland currently hosts the largest number of Ukrainian refugees,11 but it doesn’t reimburse PrEP and lacks formal implementation for this population.12 This suggests that Ukrainians who engage in unprotected sex are at risk of HIV infection with limited access to PrEP. HIV is reportedly spreading in Ukraine because of the war’s impact on healthcare services,13 and migrant women are being sexually propositioned by men in host countries.14

To tackle these intersecting issues, I recommend that healthcare providers in migrant host countries urgently seek to secure adequate provision of PrEP for all people who may be at risk of HIV exposure. For this to be effective it will be necessary to confront deep seated stigmatisation of migrants as “HIV vectors” and instead adopt a nuanced understanding of host-migrant relations and risk factors in sexual health.

Footnotes

  • Conflict of interest: I declare no conflict of interest.

  • Provenance and peer review: Not commissioned, not externally peer reviewed.

References