"You Have Been Left with No Option of Saying 'no to without Protection:'" HIV Risk Among Sexual and Gender Minority Migrants in Cape Town, South Africa

Background and Purpose

HIV remains one of the world’s greatest public health challenges, especially in low- and middle-income countries. In South Africa, for instance, prevalence among sexual and gender minority (SGM) individuals is among the highest in the world (UNAIDS, 2019). Although there has been a robust response to address the epidemic in South Africa, one group whose needs remain overlooked is SGM migrants. There are 4 million migrants in South Africa (IOM, 2019), and while official figures do not exist, reports indicate that a significant number are SGM. Studies demonstrate that SGM migrants are at high risk for HIV acquisition and treatment in host countries, though research on this population in South Africa is lacking. The purpose of this qualitative study was to explore the processes by which SGM migrants are exposed to HIV risk, as well as those that may reduce this risk, in South Africa.

Methods

In 2019, we conducted six focus groups with a total of 30 participants, who were between the ages of 21-42 (M=29.57; SD=6.44). We categorized participants according to the terminology used South by the African AIDS Council (2017) to address HIV-related disparities among SGM minorities. These categories were: men who have sex with men (n=24), women who have sex with women, (n=3), and transgender people (n=3). Participants resided in South Africa between 6 months and 17 years (Mdn=6 years). The majority of participants (77%) were undocumented, while 3 had a work permit, 3 had been granted asylum, and 1 had permanent residence. Participants originated from the following African countries: Zimbabwe (n=13), Malawi (n=8), Democratic Republic of Congo (n=3), Burundi (n=2), Uganda (n=2), Lesotho (n=1), and Tanzania (n=1). Participants reported that their HIV serostatus was negative (n=20), unknown (n=2), and positive (n=8).

Results

Grounded theory analysis was used to identify four themes: seeking food and shelter: desperate, dependent, endangered; immigration, employment: encountering roadblocks at every turn; engaging in sex work: ‘you have no right to say no, because you need money’; and treating/preventing HIV. We found that SGM migrants in Cape Town experienced a number of factors (insecure citizenship status, financial and housing instability, food insecurity, and lack of social support) that shaped sexual risk-taking behaviors and use of prevention treatment interventions. Because SGM found themselves in a day-to-day struggle to survive, they also engaged in behaviors (e.g., sex work) that, while helpful in the short-term also placed them at high risk for HIV acquisition and transmission. However, some participants were aware of ways to protect themselves and others (e.g., using PrEP and taking HIV medication consistently.

Conclusion and Implications

Findings suggest that participants often dire circumstances that placed them at risk for HIV acquisition and transmission. Thus, it will be important to establish and expand programs for SGM migrants in South Africa that provide medical care, social services, counseling, as well as legal services to help with asylum claims. Such services, especially when combined, may help to buffer against the effects of the psychosocial and structural factors that may increase HIV risk.