A tale of two (or more) cities: Becoming disconnected from sexual-health careBrett
By Dr Dean Murphy, Research Fellow, Kirby Institute, UNSW, Sydney, and Alfred Health, Melbourne.
The concepts of linkage to, and retention in, HIV care, have quite rightly been a focus of public health policy and health promotion in recent years.
However, given that new biomedical strategies – in particular pre-exposure prophylaxis (PrEP) – have become a greater focus of HIV prevention, it is becoming increasingly important to also consider linkage to, and retention in, HIV prevention care. Becoming disconnected from clinical care may create vulnerability to HIV by reducing access to HIV/STI testing and PrEP. One way in which people can become disconnected from clinical care is through relocating between cities and/or jurisdictions.
Studies of the mobility of men within high-income countries have tended to focus on risks for HIV acquisition, especially changes in sexual practices and initiation of drug use after moving to urban areas (1, 2). Some studies have also looked at the impact of the social and physical environment (and movement between neighbourhoods) on sexual risk (3) and overall health and well-being (4). However, these studies have generally not explored mobility on patterns of sexual-health care, and specifically HIV testing and patterns of PrEP use.
In a paper just submitted for publication, drawing on data from the RISE Study¹, we explored connections to – and disconnections from – sexual-health care among gay, bisexual and queer men (GBQ) in the period prior to their HIV diagnosis. We found that almost one-third of the GBQ men in a current interview-based study of people recently diagnosed with HIV provided accounts of discontinuity in their sexual-health care related to mobility within Australia in the period prior to acquiring HIV.
For several men, this discontinuity in care also meant that they lost access to PrEP. Also, reconnection with services for these men usually only came about at the time of seeking the HIV test associated with their diagnosis, which for one man at least was several years later (despite having been a very frequent tester in the city where he lived previously).
This focus on domestic mobility (or intra-national migration) complements other existing strands of research on mobility and HIV risk among GBQ men. The first strand has investigated travel, and in particular changed sexual behaviour while travelling (often in the context of higher HIV prevalence and/or different expectations around disclosure of HIV status (5, 6). The other strand has explored the association between migration and increased HIV risk (1, 3, 7-9). This research has documented the high rate of post-migration HIV acquisition among MSM in North America and Europe (1, 3).
Our recent work suggests that even among men who are well connected to sexual-health care and HIV-prevention services, it is easy to become disconnected from these services after moving to a new jurisdiction. This finding suggests a need for a more formalised process for referrals across jurisdictions. Given that moving cities and states is not an uncommon occurrence, HIV and LGBTQ health organizations could also encourage community members to advise providers when they intend to relocate.
 RISE-Recently Diagnosed and the Impact of Support on the Experience of HIV, is study conducted by researchers at the Kirby Institute, UNSW, Sydney. https://kirby.unsw.edu.au/project/rise
- Lewis NM, Wilson K. HIV risk behaviours among immigrant and ethnic minority gay and bisexual men in North America and Europe: A systematic review. Soc Sci Med. 2017;179:115-28.
- Buttram ME, Kurtz SP. Risk and Protective Factors Associated With Gay Neighborhood Residence. American Journal of Men’s Health. 2013;7(2):110-8.
- Alvarez-Del Arco D, Fakoya I, Thomadakis C, Pantazis N, Touloumi G, Gennotte AF, et al. High levels of postmigration HIV acquisition within nine European countries. Aids. 2017;31(14):1979-88.
- Koblin BA, Egan JE, Rundle A, Quinn J, Tieu H-V, Cerdá M, et al. Methods to Measure the Impact of Home, Social, and Sexual Neighborhoods of Urban Gay, Bisexual, and Other Men Who Have Sex with Men. PLOS ONE. 2013;8(10):e75878.
- Elsesser SA, Oldenburg CE, Biello KB, Mimiaga MJ, Safren SA, Egan JE, et al. Seasons of Risk: Anticipated Behavior on Vacation and Interest in Episodic Antiretroviral Pre-exposure Prophylaxis (PrEP) Among a Large National Sample of U.S. Men Who have Sex with Men (MSM). AIDS Behav. 2016;20(7):1400-7.
- Brown G, Prestage G, Down I, Ellard J, Triffitt K. Not so different? Comparison of risk profile of gay men who acquired HIV while travelling with those who acquired HIV in Australia. Health Promot J Austr. 2018;29(1):58-64.
- Taylor TN, DeHovitz J, Hirshfield S. Intersectional Stigma and Multi-Level Barriers to HIV Testing Among Foreign-Born Black Men From the Caribbean. Front Public Health. 2019;7:373.
- Wiewel EW, Torian LV, Hanna DB, Bocour A, Shepard CW. Foreign-Born Persons Diagnosed with HIV: Where are They From and Where Were They Infected? AIDS and Behavior. 2015;19(5):890-8.
- Pachankis JE, Hatzenbuehler ML, Berg RC, Fernandez-Davila P, Mirandola M, Marcus U, et al. Anti-LGBT and Anti-immigrant Structural Stigma: An Intersectional Analysis of Sexual Minority Men’s HIV Risk When Migrating to or Within Europe. J Acquir Immune Defic Syndr. 2017;76(4):356-66.