Who falls between the cracks? Identifying eligible PrEP users among people with Sub-Saharan African migration background living in Antwerp, Belgium

Access to medicines among asylum seekers, refugees and undocumented migrants across the migratory cycle in Europe: a scoping review

INTRODUCTION

Access to essential medicines is a critical element of health systems and an important measure of their performance. Migrants may face barriers in accessing healthcare, including essential medicines, throughout the migration cycle, which includes the stages of departure from home or residence countries, transit through non-European or European countries, reception and settlement in a country in Europe and deportation. We aim to provide an overview of research and grey literature concerning access to essential medicines for asylum seekers, refugees and undocumented migrants in or heading to Europe (European Union, European Economic Area, Switzerland and the UK).

METHODS

To delineate and conceptualise access to medicines, we considered the definition of the Lancet Commission on Essential Medicines and the Pharmaceutical Management framework. These frameworks were combined to guide several critical steps in our review, including defining the search terms, data extraction, data analyses and reporting. Relevant studies and reports were identified through searches in bibliographic and grey literature databases.

RESULTS

Out of 5760 studies and 66 grey literature reports, 108 met the inclusion criteria, with 72 focusing on medicine access. Overall, medicine use and medicine expenditure were found to be lower in migrant populations compared with the host population in many European countries. Although many studies focused on the use of infectious disease and psychotropic medicines, the most frequently used medicines by migrants were analgesics, hypertension and diabetes medicines. Determinants of medicine access were legal restrictions, language and transit times, which all contributed to interruption of and inequities in access to medicines among this population. This scoping review also indicated significant gaps in the literature regarding the evidence on access to medicine at different stages of the migration cycle, specifically in departure, transit and deportation stages.

CONCLUSION

Overall, our findings highlighted significant unmet medicine needs among migrants in or on the way to Europe and access disparities attributable to various interconnected barriers. Urgent access is needed to address such inequities, particularly legal barriers, including registration of certain medicines required for treatment. Future research should prioritise investigating medicine access during departure, transit and deportation stages. Policy discussions around migrants' access to medicines should be centred on framing healthcare as a fundamental right.

Improving access to oral pre-exposure prophylaxis for HIV among international migrant populations

Pre-exposure prophylaxis (PrEP) is recommended for people susceptible to HIV acquisition, and the scale-up of PrEP programmes has contributed to new HIV case reductions at a population level. However, international migrants continue to be disproportionately affected by HIV. Understanding barriers and facilitators to PrEP implementation among international migrants can optimise PrEP use among this population and ultimately reduce HIV incidence worldwide. We reviewed the evidence regarding factors influencing PrEP implementation among international migrants; 19 studies were included. The barriers and facilitators at the individual level were related to knowledge and risk perception of HIV. Cost, provider discriminations, and health system navigation influenced PrEP use at the service level. Positive or negative perception towards LGBT+ identities, HIV, and PrEP users affected PrEP use at the societal level. Most existing PrEP campaigns do not target international migrants; therefore, culturally tailored approaches for people from different backgrounds are warranted. Potentially migration-related and HIV-related discriminatory policies must be reviewed to increase access to HIV prevention services to end HIV transmission at a population level.

The Construction of Pre-exposure Prophylaxis (PrEP) by Prevention Professionals as a Tool for Black African Migrant Women … or Not?

While sub-Saharan African migrants are recognized as a key population in the HIV epidemics, they are absent from the PrEP delivery system and in particular women. The central argument of this article is that PrEP for Black African migrant women is an ambivalent offer that makes it necessary to understand how migration, gender, sexuality, and origin interact. Bringing together a sociologist and a prevention project manager, this article looks at how Belgian prevention professionals navigate with this ambivalent offer. From semi-directive interviews we explore how PrEP is constructed as a prevention tool for this population. The results show that different causalities are attributed to their absence from PrEP delivery system. This pluralism leads us to argue that there is a real blurring in the definition of this public as a "priority" in terms not only of representations and practices but also of political agenda.

How Do Family Physicians Perceive Their Role in Providing Pre-exposure Prophylaxis for HIV Prevention?-An Online Qualitative Study in Flanders, Belgium

Introduction:

In Belgium, the provision of pre-exposure prophylaxis (PrEP) for HIV prevention is centralized in specialized HIV clinics. Engaging family physicians in PrEP care could help scale-up its delivery and reach underserved populations. The objective of this study was to gain insight into family physicians' self-perceived roles in providing PrEP.

Methods

We conducted 16 online group discussions with a total of 105 Flemish family physicians, between November 2020 and February 2021. A brief online questionnaire assessed their socio-demographics and experience with sexual health. We analyzed verbatim transcribed data using a grounded theory approach.

Results

Despite limited awareness and experience, participants reported a high willingness to be more actively involved in PrEP care. Four potential roles for the family physician in PrEP care were identified: acting as low-threshold entry point for advice; opportunistic case finding of PrEP candidates; initiating appropriate care for PrEP-eligible clients; and ensuring high-quality follow-up care for PrEP users. Participants framed each of these roles within their current activities and responsibilities as primary care providers. Yet, participants differed in their views on the concrete operationalization of these roles, and in the extent of their involvement in PrEP. Particular challenges were a lack of experience with antiretrovirals, perceived limited exposure to clients at high HIV risk, and a lack of expertise and resources to conduct time-intensive risk assessments and counseling related to PrEP.

Conclusion

Belgian family physicians demonstrated a keen willingness to be involved in PrEP care, but had differing views on the practical implementation into their practices. Providing tailored training on sexual health and PrEP, and investing in collaboration between primary and secondary care, could optimize the integration of PrEP in the primary care practice.