J Immigrant Minority Health DOI 10.1007/s10903-014-9986-x
ORIGINAL PAPER
Increasing HIV Testing Among African Immigrants in Ireland: Challenges and Opportunities Adebola A. Adedimeji • Aba Asibon • Gerard O’Connor • Richard Carson Ethan Cowan • Philip McKinley • Jason Leider • Patrick Mallon • Yvette Calderon
•
Springer Science+Business Media New York 2014
Abstract In 2012, immigrants constitute 63 % of new cases of heterosexually transmitted HIV among individuals born outside Ireland. Current strategies to encourage testing can be ineffective if immigrants perceive them as culturally insensitive. We obtained qualitative data to explore challenges to voluntary HIV-testing for immigrants in Ireland. Content analysis was undertaken to identify and describe pertinent themes. Widespread beliefs that HIV is primarily a disease of African immigrants were identified as challenges that constrain access to testing and care. The organization and location of testing services, attitude of health workers, and beliefs regarding mandatory HIV-testing for
A. A. Adedimeji (&) E. Cowan Y. Calderon Department of Epidemiology and Population Health, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Harold and Muriel Block Building #515, Bronx, New York, NY 10461, USA e-mail: [email protected]; [email protected] A. Asibon J. Leider Y. Calderon Departments of Emergency Medicine and Internal Medicine, Jacobi Medical Center, Bronx, New York, NY, USA G. O’Connor Department of Emergency Medicine, Mater Misericordiae University Hospital, Dublin, Ireland G. O’Connor P. Mallon HIV Molecular Research Group, School of Medicine and Medical Science, University College, Dublin, Ireland R. Carson P. McKinley AIDS Care Education and Training, Dublin, Ireland P. Mallon Department of Infectious Diseases, Mater Misericordiae University Hospital, Dublin, Ireland
immigrants seeking access to welfare benefits were also identified. Immigrants in Ireland encounter a variety of structural, cultural and personal constraints to HIV testing. Opportunities exist in the Irish Health system to increase testing among immigrants through greater acknowledgement of cultural sensitivities of immigrant groups. Keywords
HIV Testing Immigrants Ireland
Background Until 2009, Ireland experienced increased migration of individuals from sub-Sahara Africa [1]. The majority of immigrants come from countries with generalized HIV epidemics with the health service executives (HSE) reporting that migrants from these countries represented 63 % of new infections due to heterosexual contact diagnosed in 2012 [2]. Ireland, like many countries has put in place interventions aimed at increasing detection of HIV through testing programs in pregnant women, injecting drug users (IDU) and men who have sex with men (MSM). However success of any intervention to increase HIV detection of HIV rests on individuals’ knowledge of the importance of testing and willingness to adopt protective measures against HIV acquisition. Through increased detection of HIV and appropriate care linkage, availability and access to HIV testing is effective in reducing incidence especially among at risk populations [3–6]. Studies show that knowing one’s HIV status will likely modify/reduce risk behaviors [7–9], reduce the risk of late diagnosis, facilitate timely access to care and treatment and improve quality of life [10, 11]. Thus, routine voluntary HIV screening is therefore
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recommended for all adults in a variety of healthcare settings [12, 13]. Among immigrants, uptake of HIV testing through existing testing programs is still low due to individual and structural constraints [2, 14–24]. In Ireland, the HSE reported a testing rate of 38.2 per 1,000 population in 2012 [2], necessitating the need to explore challenges specific to this population. In this study, we describe barriers to accessing voluntary HIV testing for African immigrants and explore the potential opportunities that may help to increase testing rates in this population group.
Methods Research Design and Study Setting The research setting was African immigrant communities in County Dublin and County Meath, Republic of Ireland. The study population is culturally diverse but close-knit and congregated in and around northwest Dublin (Clonee, Clonsilla, Blanchardstown and Tyrrelstown) and Navan. We utilized descriptive qualitative design to obtain data through focus group discussions and individual interviews to describe behaviors toward HIV, perceptions of HIV related stigma, challenges to accessing voluntary counseling and testing services.
linkage to care. Issues related to stigma and disclosure to significant others were also explored. Two of the six focus groups (one male group and one female group) and one female opinion leader interview were held in Navan and the others in Dublin. A team of 3-moderator, note taker and observer facilitated each focus group. Each focus group and interview, which was digitally recorded, averaged 60 and 45 min respectively. All participants gave informed oral consent for study participation. Data Analysis Standard qualitative data analysis procedures described by Pope and Mays [25] were used. All interviews conducted in English were transcribed and scrutinized for consistency with the digital recordings. Authors reviewed the transcripts several times to become familiar with the content before editing, coding and identifying themes. Data analysis followed a thematic framework in which themes were identified through an inductive and deductive process [26]. Thereafter, codes from the transcripts were assigned to relevant themes to facilitate interpretation and reporting based on the study’s aims. Where appropriate, verbatim quotes from the data were used to support the results and discussion.
Results Participant Selection We utilized snowball and convenience sampling to select participants for a total of 6 focus groups consisting of two male groups, two female groups and two mixed-gender groups. There were 8 participants in single gender groups and 12 participants in mixed gender groups. In addition, individual interviews were held with two male and two female opinion leaders selected by snowball techniques. Black African immigrants C18 years, lived in Ireland for at least 2 years, communicate in English and not previously diagnosed with HIV were eligible. Data Collection The ethics review committees of Albert Einstein College of Medicine, Bronx, New York, and the Mater Misericordiae University Hospital/Mater Private Hospital, Dublin Ireland granted ethical approval for the study. Data was obtained using a semi-structured interview guide that allowed facilitators flexibility to consider other issues that emerged during the interview. The goal was to gain insights into participants’ behaviors and perceptions about HIV/AIDS as well as access to services for prevention, treatment and
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A total of 60 respondents participated. All were first generation immigrants aged 18–64 years with a mean of 4.7 years since migrating to Ireland. One-third of participants have postgraduate diplomas and the rest are currently studying in Irish colleges and universities. Two-thirds were employed or self-employed while the rest receive social welfare/unemployment assistance from the government through the asylum system. Ten participants in the refugees/asylum system were previously offered HIV testing. None tested positive. The two major themes identified-barriers to accessing and utilizing services and negative perceptions and attitudes toward testing are described below. Barriers to Accessing and Utilizing Health Services Cost, Location and Organization of Services The cost of healthcare was one of the most frequently reported barriers by participants. In Ireland, residents with incomes below a certain threshold are entitled to free primary and hospital care, and medication cost through the medical card system. Asylum seekers are also entitled to
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medical card healthcare and those who have passed through the system may continue to avail of the benefits of the medical card. Unfortunately, the eligible income level threshold for medical card is set quite low and many individuals with incomes above this threshold are required to pay a fee of about 40–50 Euros for primary [consultation with general practitioner (GP)] and/or secondary care. The recent economic downturn has considerably affected the ability and/or willingness to pay this fee particularly among immigrants most of whom have low paying jobs and may not consider healthcare a worthwhile investment unless the illness is life threatening. In addition to this fee, individuals may incur additional costs associated with purchasing medication and transportation. Cost is a major reason for the unwillingness to patronize local GPs for routine health concerns or request an HIV test. As reported by one FGD participant: It is difficult to come up with 40 or 50 euros just to see the doctor…most people are unwilling to pay the money because of other commitments. To get an HIV test from the doctor means you will have to pay this money and this is the reason many immigrants are not accessing health care (Female FGD participantNavan). The location and organization of HIV testing and treatment services was also reported as another constraint for immigrants seeking access to testing services. A few public and private testing centers are located in Dublin, but participants are familiar with those in the main hospitals including St. James’s GUIDE Clinic, Mater Misericordiae and Beaumont hospitals. None of the participants was aware of private testing centers such as the Gay Men’s Health Clinic. Location of testing facilities in these hospitals and lack of awareness of private facilities hinder access to HIV testing. Many immigrants believe hospitals do not offer privacy for those seeking confidential testing. One participant reported: ‘‘There’s only one or two clinics where you can go to get tested and there’s no privacy at all because it is the place where everyone in need of HIV testing goes no matter how sick they are. Once you are there, everyone automatically knows what you are there for’’ (Male FGD participant, Navan). Delay in Accessing Services Waiting times in government funded health facilities result in delayed/late diagnosis, missed opportunities for prevention/early detection and linkage to care, and is a major factor in poor health-seeking behavior among immigrants. Some participants described their experiences:
Many immigrants prefer to self-medicate, you know, instead of going through the trouble of accessing the Irish health system. When it comes to seeing a consultant or specialist, the process is so long that sometimes you are better off doing something on your own than being put on a wait list for 9 months or being asked to provide all kinds of documentation you don’t have (Male Community Leader, Dublin)
Provider–Patient Relationship Participants described how poor provider–patient relationships discourage them from seeking healthcare from hospitals. They mentioned arrogant providers who are insensitive to the needs of immigrants and difficulty in communication due to language limitations of the patient and the unavailability of interpreter services when accessing primary care. ‘‘Sometimes when you go to the Irish doctor, he’s already judged you because you are black and gives you little opportunity to explain how you see things. Because of ignorance or arrogance, some doctors will tell you they know better than you. If I encounter a black doctor who is talking about HIV, I would be more inclined to listen because he’s less likely to be biased since we are from the same continent’’’’ (Male FGD participant, Dublin) ‘‘In some cases, it is your inability to speak English as well as they do. ‘‘Many women from my country cannot go to see a doctor unless there is someone to accompany them and interpret for them. Doctors forget English is not your first language, so even when they have to explain something to you, they use big words that make no sense to you. Generally, Irish doctors need training on how to empathize with immigrants’’ (Female Community Leader, Dublin)
Negative Perceptions and Attitudes that Discourage HIV Testing Perceived and Experienced Stigma Ignorance, stigma and negative attitudes continue to prevent African immigrants in Ireland from seeking or accepting routine HIV testing services or accessing care/ treatment. There is a strong perception among participants that HIV is still regarded by many as a disease of ‘‘people from Africa’’, thus creating an atmosphere of mistrust and suspicion in the immigrant community. As one participant said:
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‘‘… It is unfortunate that HIV and AIDS is associated with black people maybe because of our low socioeconomic status, you know that we are poor…’’ (Female FGD participant, Navan). Stigmatizing attitudes from health workers was also reported. Participants described experiences of stigma from ‘‘very ignorant doctors who think everyone from Africa is living with HIV’’. There is strong suspicion that health workers are required to report those with positive status to immigration authorities who may then initiate a deportation process. Perceived Discriminatory Policies Participants described their angst about discriminatory policies that reinforce stereotypes of Africans as HIV carriers. Reports that routine HIV tests are offered only to black African refugees and asylum seekers, or those seeking to access state funded welfare benefits and certain services from financial institutions were examples of discriminatory practices, which they believed are due to government-backed policies that reinforce perceptions of HIV/AIDS as ‘‘primarily a disease of black Africans’’. Perceived Lack of Support from Religious Leaders and Social Networks Apathy towards voluntary HIV testing is intensified by the perceived lack of support from social networks. The close-knit nature of immigrant communities often mean that social activities are concentrated in and around cultural and/or religious groups. The intense social interaction that exists also means that news and gossips circulate very rapidly within the social network. Thus, a perceived lack of social support and rapid spread of gossip about a potentially stigmatizing condition makes it unattractive to seek voluntary HIV testing or disclose seropositive status. Negative reactions from the wider social network and lack of trust for religious leaders were also reported as key concerns among those who may be contemplating an HIV test as reflected in the following quotes: ‘‘It is understandable when an ignorant person believes you are the embodiment of HIV simply because of the color of your skin. When your own people [other immigrants] and especially those you look up to for social support are the ones who do not want to associate with you or spread rumors about your positive status, it is the worst thing ever. You feel its better to keep your secrets to yourself.’’ (Female FGD participant, Dublin)
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‘‘Pastors are not to be trusted with such details. To be fair, they will not mention the name of the person, but by the time they include anecdotes about your situation in their sermon notes, it is clear to everyone who they are talking about’’ (Male FGD participant, Dublin) Similarly, participants feel that the inability of leaders to meaningfully engage with HIV issues constitute another barrier. Religious leaders were accused of neglecting an important issue facing immigrants as reflected below: ‘‘…Simply because they do not want to be heard encouraging their congregation to get tested for HIV as that would mean acknowledging that premarital or extramarital sexual relations exist in groups’’ (Male Community Leader, Navan). The consensus that emerge from the group however is that in dealing with the problem of HIV among immigrants, religious leaders and community leaders should be doing a lot more than they are currently. Moreover, as one participant reported: ‘‘…until we deal with the issue of stigma, you can preach all you can that people should get tested, it will all fall on deaf ears’’ (Female FGD participant, Dublin)
Discussion Our findings reveal a number of issues that warrant attention in order to increase uptake in voluntary HIV testing in this population. The cost of accessing health services in general was highlighted as a challenge for immigrants desiring to get tested for HIV. Many immigrants, like other groups in the population, are discouraged from seeking testing because of the fee associated with routine healthcare from GPs. Financial challenges are exacerbated by the economic downturn that has seen healthcare spending decreased from 15.3 billion Euros in 2008 to 13.6 billion Euros in 2013. Immigrants in low paying jobs find it ludicrous to incur this out of pocket expense when weighed against other necessities for daily survival, including food and paying bills. Some studies have suggested that testing rates have been generally low in contexts where user fees are charged for health services [21, 27–34] and in Ireland, recent media reports [35] confirm that many individuals are missing out on critical care due to GP consultation fees. While cost alone may not solely determine willingness to test, other studies have shown increases in overall number of people tested in contexts were HIV testing is free [29, 30, 34, 36]. The lack of enthusiasm toward voluntary HIV
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test in the immigrant community could be decreased if user fees were waived. Health system factors, including the availability, location, organization and access to HIV testing facilities have been documented as factors that affect acceptability of HIV testing [14, 37–39]. We found that the location and organization of testing facilities constituted barriers to acceptability of HIV testing among immigrants. Among those willing to be tested, only a few is willing to access testing in hospital settings because of concerns about privacy and anonymity, anxieties about disclosure of sero-status to immigration authorities and social stigma. Although, other non-hospital settings are available in Ireland, most participants are unaware of these options. Furthermore, restricted access to interpreter services at the primary care level may alienate non-English or Irish speakers who need interpreters to utilize health facilities. Addressing these concerns and gap in information may facilitate increased testing rates as demonstrated in studies, which reported increases in testing rates in contexts where health system-related barriers were eliminated [21, 27, 39–42]. Negative attitudes from healthcare providers and poor awareness and perception of health services interfere with individuals’ desire to voluntarily test for HIV. Previous studies have highlighted how stigmatizing attitudes from healthcare workers discourage utilization of testing services [37, 39, 43, 44] whereas other studies reported increase in testing rates when providers demonstrate positive attitudes [45]. While much of the existing literature regarding negative attitudes from health providers come from contexts with generalized epidemics, few studies have examined providers’ attitudes in low prevalence contexts such as Ireland where limited opportunities for health professionals to work with immigrants may hinder provision of culturally appropriate care and treatment. Some studies have examined the cultural challenges inherent in HIV testing programs [46–48], however further research is warranted to explore what this means within immigrant communities and the relational process involved in developing and implementing culturally sensitive interventions. Furthermore, health workers need to be mindful of the mistrust existing within immigrant communities with regard to how positive HIV test results are used and disseminated. Of note is the perception of government supported discriminatory policies and lack of support from community and religious leaders—a manifestation of stigma—that resonated throughout the interviews. The perception that financial policies in particular support discrimination against those with health issues may be due to increased regulation following the banking collapse and recession in which financial institutions were empowered to obtain a
variety of information including on health before they offer products/services to customers [49]. The impact of HIV related stigma- interpersonal, internalized and institutional has been extensively documented with studies highlighting important lessons from one context that can be applied in others [18, 50–54]. Nonetheless, the peculiarities in each context must be taken into account to inform interventions to address the problem of stigma. The close-knit nature of immigrant communities in Ireland means that individuals’ lives and social networks revolve around faith-based institutions with leaders and significant others playing a pivotal role in the life of their members. Thus, while social networks are incredibly strong, perceived lack of support result from fears about the consequences of a breach of confidentiality regarding HIV status. The lack of an ethical framework that equips faith-based leaders with dealing with these challenges can potentially disempower individuals from testing or sharing results of a seropositive status. The foregoing suggests that changes in individual perceptions and attitudes and the structure of HIV testing services are urgently needed if testing is to be encouraged among African immigrants living in Ireland. Some of these changes may involve working with relevant stakeholders including health providers, faith-based communities and policy makers to identify and develop effective interventions using community-based participatory approaches that are culturally sensitive and acceptable to the immigrant community.
Conclusion This study highlights issues that are synergistically connected in terms of their ramifications for increasing uptake in HIV testing. Anxieties about access to and affordability of HIV testing fees may be intensified if there are fears of the negative consequences of a positive test to an individual’s residency status or social relationships. Addressing these challenges require involving relevant stakeholders- leadership of immigrant groups, religious leaders, health providers and policy makers in planning culturally sensitive and relevant interventions, which might include educating community members on the benefits of HIV testing, training faithbased leaders on ethical issues around HIV testing, cultural sensitivity training for healthcare workers and formulating policies that ease access to HIV testing for migrants. Acknowledgments The authors gratefully acknowledge the support from the leadership of African immigrant communities in Dublin and Navan and the individuals who participated in the study. Funding for this study was made possible by the Albert Einstein College of Medicine Center for Global Health Micro and Pilot Grants in 2011 and 2013.
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ORIGINAL PAPER
Increasing HIV Testing Among African Immigrants in Ireland: Challenges and Opportunities Adebola A. Adedimeji • Aba Asibon • Gerard O’Connor • Richard Carson Ethan Cowan • Philip McKinley • Jason Leider • Patrick Mallon • Yvette Calderon
•
Springer Science+Business Media New York 2014
Abstract In 2012, immigrants constitute 63 % of new cases of heterosexually transmitted HIV among individuals born outside Ireland. Current strategies to encourage testing can be ineffective if immigrants perceive them as culturally insensitive. We obtained qualitative data to explore challenges to voluntary HIV-testing for immigrants in Ireland. Content analysis was undertaken to identify and describe pertinent themes. Widespread beliefs that HIV is primarily a disease of African immigrants were identified as challenges that constrain access to testing and care. The organization and location of testing services, attitude of health workers, and beliefs regarding mandatory HIV-testing for
A. A. Adedimeji (&) E. Cowan Y. Calderon Department of Epidemiology and Population Health, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Harold and Muriel Block Building #515, Bronx, New York, NY 10461, USA e-mail: [email protected]; [email protected] A. Asibon J. Leider Y. Calderon Departments of Emergency Medicine and Internal Medicine, Jacobi Medical Center, Bronx, New York, NY, USA G. O’Connor Department of Emergency Medicine, Mater Misericordiae University Hospital, Dublin, Ireland G. O’Connor P. Mallon HIV Molecular Research Group, School of Medicine and Medical Science, University College, Dublin, Ireland R. Carson P. McKinley AIDS Care Education and Training, Dublin, Ireland P. Mallon Department of Infectious Diseases, Mater Misericordiae University Hospital, Dublin, Ireland
immigrants seeking access to welfare benefits were also identified. Immigrants in Ireland encounter a variety of structural, cultural and personal constraints to HIV testing. Opportunities exist in the Irish Health system to increase testing among immigrants through greater acknowledgement of cultural sensitivities of immigrant groups. Keywords
HIV Testing Immigrants Ireland
Background Until 2009, Ireland experienced increased migration of individuals from sub-Sahara Africa [1]. The majority of immigrants come from countries with generalized HIV epidemics with the health service executives (HSE) reporting that migrants from these countries represented 63 % of new infections due to heterosexual contact diagnosed in 2012 [2]. Ireland, like many countries has put in place interventions aimed at increasing detection of HIV through testing programs in pregnant women, injecting drug users (IDU) and men who have sex with men (MSM). However success of any intervention to increase HIV detection of HIV rests on individuals’ knowledge of the importance of testing and willingness to adopt protective measures against HIV acquisition. Through increased detection of HIV and appropriate care linkage, availability and access to HIV testing is effective in reducing incidence especially among at risk populations [3–6]. Studies show that knowing one’s HIV status will likely modify/reduce risk behaviors [7–9], reduce the risk of late diagnosis, facilitate timely access to care and treatment and improve quality of life [10, 11]. Thus, routine voluntary HIV screening is therefore
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recommended for all adults in a variety of healthcare settings [12, 13]. Among immigrants, uptake of HIV testing through existing testing programs is still low due to individual and structural constraints [2, 14–24]. In Ireland, the HSE reported a testing rate of 38.2 per 1,000 population in 2012 [2], necessitating the need to explore challenges specific to this population. In this study, we describe barriers to accessing voluntary HIV testing for African immigrants and explore the potential opportunities that may help to increase testing rates in this population group.
Methods Research Design and Study Setting The research setting was African immigrant communities in County Dublin and County Meath, Republic of Ireland. The study population is culturally diverse but close-knit and congregated in and around northwest Dublin (Clonee, Clonsilla, Blanchardstown and Tyrrelstown) and Navan. We utilized descriptive qualitative design to obtain data through focus group discussions and individual interviews to describe behaviors toward HIV, perceptions of HIV related stigma, challenges to accessing voluntary counseling and testing services.
linkage to care. Issues related to stigma and disclosure to significant others were also explored. Two of the six focus groups (one male group and one female group) and one female opinion leader interview were held in Navan and the others in Dublin. A team of 3-moderator, note taker and observer facilitated each focus group. Each focus group and interview, which was digitally recorded, averaged 60 and 45 min respectively. All participants gave informed oral consent for study participation. Data Analysis Standard qualitative data analysis procedures described by Pope and Mays [25] were used. All interviews conducted in English were transcribed and scrutinized for consistency with the digital recordings. Authors reviewed the transcripts several times to become familiar with the content before editing, coding and identifying themes. Data analysis followed a thematic framework in which themes were identified through an inductive and deductive process [26]. Thereafter, codes from the transcripts were assigned to relevant themes to facilitate interpretation and reporting based on the study’s aims. Where appropriate, verbatim quotes from the data were used to support the results and discussion.
Results Participant Selection We utilized snowball and convenience sampling to select participants for a total of 6 focus groups consisting of two male groups, two female groups and two mixed-gender groups. There were 8 participants in single gender groups and 12 participants in mixed gender groups. In addition, individual interviews were held with two male and two female opinion leaders selected by snowball techniques. Black African immigrants C18 years, lived in Ireland for at least 2 years, communicate in English and not previously diagnosed with HIV were eligible. Data Collection The ethics review committees of Albert Einstein College of Medicine, Bronx, New York, and the Mater Misericordiae University Hospital/Mater Private Hospital, Dublin Ireland granted ethical approval for the study. Data was obtained using a semi-structured interview guide that allowed facilitators flexibility to consider other issues that emerged during the interview. The goal was to gain insights into participants’ behaviors and perceptions about HIV/AIDS as well as access to services for prevention, treatment and
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A total of 60 respondents participated. All were first generation immigrants aged 18–64 years with a mean of 4.7 years since migrating to Ireland. One-third of participants have postgraduate diplomas and the rest are currently studying in Irish colleges and universities. Two-thirds were employed or self-employed while the rest receive social welfare/unemployment assistance from the government through the asylum system. Ten participants in the refugees/asylum system were previously offered HIV testing. None tested positive. The two major themes identified-barriers to accessing and utilizing services and negative perceptions and attitudes toward testing are described below. Barriers to Accessing and Utilizing Health Services Cost, Location and Organization of Services The cost of healthcare was one of the most frequently reported barriers by participants. In Ireland, residents with incomes below a certain threshold are entitled to free primary and hospital care, and medication cost through the medical card system. Asylum seekers are also entitled to
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medical card healthcare and those who have passed through the system may continue to avail of the benefits of the medical card. Unfortunately, the eligible income level threshold for medical card is set quite low and many individuals with incomes above this threshold are required to pay a fee of about 40–50 Euros for primary [consultation with general practitioner (GP)] and/or secondary care. The recent economic downturn has considerably affected the ability and/or willingness to pay this fee particularly among immigrants most of whom have low paying jobs and may not consider healthcare a worthwhile investment unless the illness is life threatening. In addition to this fee, individuals may incur additional costs associated with purchasing medication and transportation. Cost is a major reason for the unwillingness to patronize local GPs for routine health concerns or request an HIV test. As reported by one FGD participant: It is difficult to come up with 40 or 50 euros just to see the doctor…most people are unwilling to pay the money because of other commitments. To get an HIV test from the doctor means you will have to pay this money and this is the reason many immigrants are not accessing health care (Female FGD participantNavan). The location and organization of HIV testing and treatment services was also reported as another constraint for immigrants seeking access to testing services. A few public and private testing centers are located in Dublin, but participants are familiar with those in the main hospitals including St. James’s GUIDE Clinic, Mater Misericordiae and Beaumont hospitals. None of the participants was aware of private testing centers such as the Gay Men’s Health Clinic. Location of testing facilities in these hospitals and lack of awareness of private facilities hinder access to HIV testing. Many immigrants believe hospitals do not offer privacy for those seeking confidential testing. One participant reported: ‘‘There’s only one or two clinics where you can go to get tested and there’s no privacy at all because it is the place where everyone in need of HIV testing goes no matter how sick they are. Once you are there, everyone automatically knows what you are there for’’ (Male FGD participant, Navan). Delay in Accessing Services Waiting times in government funded health facilities result in delayed/late diagnosis, missed opportunities for prevention/early detection and linkage to care, and is a major factor in poor health-seeking behavior among immigrants. Some participants described their experiences:
Many immigrants prefer to self-medicate, you know, instead of going through the trouble of accessing the Irish health system. When it comes to seeing a consultant or specialist, the process is so long that sometimes you are better off doing something on your own than being put on a wait list for 9 months or being asked to provide all kinds of documentation you don’t have (Male Community Leader, Dublin)
Provider–Patient Relationship Participants described how poor provider–patient relationships discourage them from seeking healthcare from hospitals. They mentioned arrogant providers who are insensitive to the needs of immigrants and difficulty in communication due to language limitations of the patient and the unavailability of interpreter services when accessing primary care. ‘‘Sometimes when you go to the Irish doctor, he’s already judged you because you are black and gives you little opportunity to explain how you see things. Because of ignorance or arrogance, some doctors will tell you they know better than you. If I encounter a black doctor who is talking about HIV, I would be more inclined to listen because he’s less likely to be biased since we are from the same continent’’’’ (Male FGD participant, Dublin) ‘‘In some cases, it is your inability to speak English as well as they do. ‘‘Many women from my country cannot go to see a doctor unless there is someone to accompany them and interpret for them. Doctors forget English is not your first language, so even when they have to explain something to you, they use big words that make no sense to you. Generally, Irish doctors need training on how to empathize with immigrants’’ (Female Community Leader, Dublin)
Negative Perceptions and Attitudes that Discourage HIV Testing Perceived and Experienced Stigma Ignorance, stigma and negative attitudes continue to prevent African immigrants in Ireland from seeking or accepting routine HIV testing services or accessing care/ treatment. There is a strong perception among participants that HIV is still regarded by many as a disease of ‘‘people from Africa’’, thus creating an atmosphere of mistrust and suspicion in the immigrant community. As one participant said:
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‘‘… It is unfortunate that HIV and AIDS is associated with black people maybe because of our low socioeconomic status, you know that we are poor…’’ (Female FGD participant, Navan). Stigmatizing attitudes from health workers was also reported. Participants described experiences of stigma from ‘‘very ignorant doctors who think everyone from Africa is living with HIV’’. There is strong suspicion that health workers are required to report those with positive status to immigration authorities who may then initiate a deportation process. Perceived Discriminatory Policies Participants described their angst about discriminatory policies that reinforce stereotypes of Africans as HIV carriers. Reports that routine HIV tests are offered only to black African refugees and asylum seekers, or those seeking to access state funded welfare benefits and certain services from financial institutions were examples of discriminatory practices, which they believed are due to government-backed policies that reinforce perceptions of HIV/AIDS as ‘‘primarily a disease of black Africans’’. Perceived Lack of Support from Religious Leaders and Social Networks Apathy towards voluntary HIV testing is intensified by the perceived lack of support from social networks. The close-knit nature of immigrant communities often mean that social activities are concentrated in and around cultural and/or religious groups. The intense social interaction that exists also means that news and gossips circulate very rapidly within the social network. Thus, a perceived lack of social support and rapid spread of gossip about a potentially stigmatizing condition makes it unattractive to seek voluntary HIV testing or disclose seropositive status. Negative reactions from the wider social network and lack of trust for religious leaders were also reported as key concerns among those who may be contemplating an HIV test as reflected in the following quotes: ‘‘It is understandable when an ignorant person believes you are the embodiment of HIV simply because of the color of your skin. When your own people [other immigrants] and especially those you look up to for social support are the ones who do not want to associate with you or spread rumors about your positive status, it is the worst thing ever. You feel its better to keep your secrets to yourself.’’ (Female FGD participant, Dublin)
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‘‘Pastors are not to be trusted with such details. To be fair, they will not mention the name of the person, but by the time they include anecdotes about your situation in their sermon notes, it is clear to everyone who they are talking about’’ (Male FGD participant, Dublin) Similarly, participants feel that the inability of leaders to meaningfully engage with HIV issues constitute another barrier. Religious leaders were accused of neglecting an important issue facing immigrants as reflected below: ‘‘…Simply because they do not want to be heard encouraging their congregation to get tested for HIV as that would mean acknowledging that premarital or extramarital sexual relations exist in groups’’ (Male Community Leader, Navan). The consensus that emerge from the group however is that in dealing with the problem of HIV among immigrants, religious leaders and community leaders should be doing a lot more than they are currently. Moreover, as one participant reported: ‘‘…until we deal with the issue of stigma, you can preach all you can that people should get tested, it will all fall on deaf ears’’ (Female FGD participant, Dublin)
Discussion Our findings reveal a number of issues that warrant attention in order to increase uptake in voluntary HIV testing in this population. The cost of accessing health services in general was highlighted as a challenge for immigrants desiring to get tested for HIV. Many immigrants, like other groups in the population, are discouraged from seeking testing because of the fee associated with routine healthcare from GPs. Financial challenges are exacerbated by the economic downturn that has seen healthcare spending decreased from 15.3 billion Euros in 2008 to 13.6 billion Euros in 2013. Immigrants in low paying jobs find it ludicrous to incur this out of pocket expense when weighed against other necessities for daily survival, including food and paying bills. Some studies have suggested that testing rates have been generally low in contexts where user fees are charged for health services [21, 27–34] and in Ireland, recent media reports [35] confirm that many individuals are missing out on critical care due to GP consultation fees. While cost alone may not solely determine willingness to test, other studies have shown increases in overall number of people tested in contexts were HIV testing is free [29, 30, 34, 36]. The lack of enthusiasm toward voluntary HIV
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test in the immigrant community could be decreased if user fees were waived. Health system factors, including the availability, location, organization and access to HIV testing facilities have been documented as factors that affect acceptability of HIV testing [14, 37–39]. We found that the location and organization of testing facilities constituted barriers to acceptability of HIV testing among immigrants. Among those willing to be tested, only a few is willing to access testing in hospital settings because of concerns about privacy and anonymity, anxieties about disclosure of sero-status to immigration authorities and social stigma. Although, other non-hospital settings are available in Ireland, most participants are unaware of these options. Furthermore, restricted access to interpreter services at the primary care level may alienate non-English or Irish speakers who need interpreters to utilize health facilities. Addressing these concerns and gap in information may facilitate increased testing rates as demonstrated in studies, which reported increases in testing rates in contexts where health system-related barriers were eliminated [21, 27, 39–42]. Negative attitudes from healthcare providers and poor awareness and perception of health services interfere with individuals’ desire to voluntarily test for HIV. Previous studies have highlighted how stigmatizing attitudes from healthcare workers discourage utilization of testing services [37, 39, 43, 44] whereas other studies reported increase in testing rates when providers demonstrate positive attitudes [45]. While much of the existing literature regarding negative attitudes from health providers come from contexts with generalized epidemics, few studies have examined providers’ attitudes in low prevalence contexts such as Ireland where limited opportunities for health professionals to work with immigrants may hinder provision of culturally appropriate care and treatment. Some studies have examined the cultural challenges inherent in HIV testing programs [46–48], however further research is warranted to explore what this means within immigrant communities and the relational process involved in developing and implementing culturally sensitive interventions. Furthermore, health workers need to be mindful of the mistrust existing within immigrant communities with regard to how positive HIV test results are used and disseminated. Of note is the perception of government supported discriminatory policies and lack of support from community and religious leaders—a manifestation of stigma—that resonated throughout the interviews. The perception that financial policies in particular support discrimination against those with health issues may be due to increased regulation following the banking collapse and recession in which financial institutions were empowered to obtain a
variety of information including on health before they offer products/services to customers [49]. The impact of HIV related stigma- interpersonal, internalized and institutional has been extensively documented with studies highlighting important lessons from one context that can be applied in others [18, 50–54]. Nonetheless, the peculiarities in each context must be taken into account to inform interventions to address the problem of stigma. The close-knit nature of immigrant communities in Ireland means that individuals’ lives and social networks revolve around faith-based institutions with leaders and significant others playing a pivotal role in the life of their members. Thus, while social networks are incredibly strong, perceived lack of support result from fears about the consequences of a breach of confidentiality regarding HIV status. The lack of an ethical framework that equips faith-based leaders with dealing with these challenges can potentially disempower individuals from testing or sharing results of a seropositive status. The foregoing suggests that changes in individual perceptions and attitudes and the structure of HIV testing services are urgently needed if testing is to be encouraged among African immigrants living in Ireland. Some of these changes may involve working with relevant stakeholders including health providers, faith-based communities and policy makers to identify and develop effective interventions using community-based participatory approaches that are culturally sensitive and acceptable to the immigrant community.
Conclusion This study highlights issues that are synergistically connected in terms of their ramifications for increasing uptake in HIV testing. Anxieties about access to and affordability of HIV testing fees may be intensified if there are fears of the negative consequences of a positive test to an individual’s residency status or social relationships. Addressing these challenges require involving relevant stakeholders- leadership of immigrant groups, religious leaders, health providers and policy makers in planning culturally sensitive and relevant interventions, which might include educating community members on the benefits of HIV testing, training faithbased leaders on ethical issues around HIV testing, cultural sensitivity training for healthcare workers and formulating policies that ease access to HIV testing for migrants. Acknowledgments The authors gratefully acknowledge the support from the leadership of African immigrant communities in Dublin and Navan and the individuals who participated in the study. Funding for this study was made possible by the Albert Einstein College of Medicine Center for Global Health Micro and Pilot Grants in 2011 and 2013.
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