Targeted approaches to HIV prevention

among immigrants living in high-

income countries

Tadgh McMahon

Outline of research

Review of HIV prevention interventions at group-

and community-levels with immigrants

Key assumption of cultural appropriateness

What are the ‘best’ mechanisms that contribute to

cultural appropriateness in HIV prevention?

Systematic searches of public health databases -

74 studies included in the review

Key Findings

‘understanding’ and ‘consonance’ – optimise the

use of language and cultural values in

interventions

‘authenticity’ and ‘specificity’ and ‘embeddedness’

– staffing, targeting through ethnicity, and settings

in interventions

‘endorsement’ and ‘framing’ – harness community

endorsement and partner with immigrant

communities

Global migration, mobility and HIV

Migration – a force in the spread of infectious disease (Apostopoulos et al , 2007)

Mobility - unprecedented in volume, speed and reach (Wilson, 2007)

95% of people living with HIV reside in low and middle-income countries (UNAIDS, 2009)

Upward HIV trend among immigrants in high-income countries, alongside evidence of disparities in HIV-related health (NCHECR, 2009)

Immigrants have vulnerabilities to HIV (UNAIDS, 2001)

HIV prevention in Australia

Strengths of targeted approaches with priority

populations

Shift in HIV policy towards immigrants, people

from CALD backgrounds

Limited evidence from Australia of how to improve

HIV prevention with immigrants

What can be learned about ‘what works?’ from

other high-income countries

Theoretical frameworks: intervention ‘chains’ (Weiss, 1997)

Activity -HIV

information resources

in community language

Mechanism -theorised as

’understanding’

Response- immigrants comprehend and act on

HIV messages

Resistance – inaccurate translation

creates confusion and

inaction

Research methods

A realist review of evidence (Pawson, 2006)

Seven theorised mechanisms: –‘authenticity’,

‘understanding’, ‘consonance’, ‘specificity’,

‘embeddedness’, ‘endorsement’ and ‘framing’

Mechanisms tested and refined:

– studies of HIV prevention interventions

– qualitative studies of immigrants views of HIV

prevention

Systematic searches: PubMed; CINAHL; Sociological

Abstracts, ERIC, PAIS, Social Services Abstracts; and

Google Scholar

Searches, culling and appraisal

Intervention studies: 3,300 records 160 full

reports

Qualitative studies of immigrants’ views: 2,700

records 110 full reports

Included if; 65% immigrants from low and middle-

income countries; living in high-income countries;

focus was on HIV/AIDS

74 studies: 34 interventions and 40 qualitative

studies

‘understanding’ mechanism

Activity -HIV

information resources

in community language

Mechanism - theorised as ’understanding’

Response- immigrants comprehend and act on

HIV messages –

‘shared language’

Resistance – inaccurate translation

creates confusion and

inaction

‘consonance ’ mechanism

Activity –

integrating cultural

values and elements into the

intervention content

Mechanism - theorised as ’consonance’

Response-

immigrants understand intervention

in a symbolic sense –‘shared values’

Resistance – dissonance if acculturated or if values are a

source of oppression and

stigma

‘authenticity’ mechanism

Activity – bicultural

staffing (culture=

ethnicity) or use of

imagery

Mechanism - theorised as ’authenticity’

Response– immigrants

trust and credibility

enhanced by peer

interaction–‘shared culture’

Resistance – heterogeneity of ‘culture’ and ‘which culture?’

as well as reluctance

among HIV-positive people

‘embeddedness’ mechanism

Activity – delivery through

immigrant community structures ad settings

Mechanism -theorised as

’embeddedness’

Response- immigrants

encounter intervention

in familiar/local settings –

‘shared place’

Resistance –

marginalising when

immigrants have

withdrawn from ‘ethnic

worlds’

‘specificity’ mechanism

Activity – targeting in terms of ethnicity

Mechanism - theorised as

’specificity ’

Response– sufficiently targeted to respond to

ethnic diversity –

‘shared ethnicity’

and ‘shared difference’

Resistance – stereotyping of ethnicity as primary source of identity and

loss of ‘difference’ implied by

categories such as ‘Africa’, ‘Asian’ and

‘Latino’

‘endorsement’ and ‘framing’ mechanisms

Activities: community consultation processes and framed

within wider social contexts (e.g. racism or homophobia) of

immigrants

Responses:

– intervention is supported, and intended outcomes

match, immigrant community expectations

– ‘shared permission’ and ‘shared decision-making’

Resistances:

– denial of HIV as a priority; migration-related stressors

The mechanisms - a ‘real-life’ example(Carballo-Diequez et al, 2006)

Staffed by Latino gay men- ‘authenticity’

Intervention materials and assessments in Spanish/English – ‘understanding’

Incorporated cultural values and elements (e.g. dichos) – ‘consonance’

Diversity of Latino gay men – ‘specificity’

Community outreach – ‘embeddedness’

Community consultation and focus testing -‘endorsement’

Assumption of dis-empowerment – (lack of) ‘framing’

Key Findings

Pivotal: ‘understanding’ and ‘consonance’ –

optimise the use of language and cultural values in

interventions

Moderate: ‘authenticity’ and ‘specificity’ and

‘embeddedness’ – staffing, targeting through

ethnicity, and settings in interventions

Least critical: ‘endorsement’ and ‘framing’ –

harness community endorsement and partner with

immigrant communities

Implications for HIV prevention with

immigrants

Multiple inter-related mechanisms for

culturally appropriate HIV prevention

Mechanisms complementary to health

promotion practice

Utility of mechanisms dependent on context

Analyse and synthesise evidence from

practice to build the evidence base

Acknowledgements

Prof Paul Ward, Discipline of Public Health, Flinders University; Assoc

Prof John Imrie, NCHSR, UNSW

Expert Reference Group:

– Assoc. Prof. John Chin, Columbia University, USA; Prof. Varda Soskolne, Bar-Ilan

University, Israel ; Prof. Michele G. Shedlin, University of Texas, USA; Georg

Bröring, formerly of the European AIDS & Mobility Project, NIGZ, The Netherlands;

Dr Henrike Körner, NCHSR, Australia

Key Informant Group:

– Phillip Keen, AFAO; Assoc. Prof. Carla Treloar, NCHSR, UNSW; Assoc. Prof. Lisa

Maher, NCHECR; Lisa Ryan, AIDB, NSW Health; Claire Ferguson, HARP,

SESIAHS; Barbara Luisi, MHAHS.

Internship from the Consortium for Social Policy on HIV, Hepatitis C

and Related Disease, NCHSR

Past and present colleagues at Multicultural HIV/AIDS and Hepatitis C

Service