Know your epidemic, know your response. The case of the HIV epidemic among sub-Saharan African migrants in Flanders, Belgium


Sub-Saharan African migrants are an important priority group for HIV-prevention in Europe. Like in the other Western European countries, are they the second largest group affected by HIV in Flanders. Tailoring HIV-prevention responses to the epidemiological situation, requires in-depth understanding of HIV-transmission dynamics within this small but heterogeneous target group. However, hardly any research has been conducted to acquire this understanding for the regional context, apart from epidemiological routine surveillance. “Know your epidemic, know your response”, UNAIDS’ approach to HIV-prevention, could therefore for decades not effectively guide the Flemish response to HIV-prevention. This thesis wished to contribute to filling this research gap.

In 2006, patients of sub-Saharan African origin continued to be diagnosed late, regardless of wide availability of antiretroviral medication. Yet, insight in the underlying factors were lacking. Qualitative research showed that sub-Saharan Africans migrants’ experiences from their home countries combined with the realities of migrant life, were keeping them from testing. However, if proactively proposed by a physician sub-Saharan Africans were willing to test. Physicians, on their side,  are unaware of this implicit expectation. They see no epidemiological relevance of provider initiated HIV-testing and have multiple concerns (i.e. apprehension of discriminate, legal aspects, financial issues,  extensive counseling demands and lack of time). Based on these findings, a number of interventions at community and healthcare level were developed, implemented and evaluated.

In 2011, increasing evidence on post-migration HIV-transmission within Europe’s communities of sub-Saharan African migrants urged for a preventive focus on primary prevention. Yet in-depth understanding of the driving factors was lacking. The TOGETHER Project, a community based participatory study generated the first HIV-prevalence estimates for a representative sample of sub-Saharan Africans in a European city, 5.9% among women in Antwerp city and 4.2% among men. This prevalence is comparable to the situation in Africa. High levels of undiagnosed HIV-infections,  social vulnerability and sexual concurrency increases the risk for further onward HIV-transmissions. Findings from a multiple case study, complementary showed that tight migration laws, legal- and financial hardship and mental distress directly facilitated HIV-acquisition in transactional- and concurrent sexual relationships and through sexual exploitation. Migration aspirations, preventive- and sexual norms, strained social networks and discrimination leads to reduced sexual agency. These results call for an aligned European approach towards HIV-prevention with migrants, prioritizing the sub-groups at increased risk in the settings where they gather. Supporting, access to all HIV-prevention interventions and tools should be assure regardless of legal status.