Sexual and HIV risk behaviour in Central and Eastern European migrants in London
- Fiona M Burns1,
- Alison R Evans1,
- Catherine H Mercer1,
- Violetta Parutis2,
- Christopher J Gerry2,
- Richard C M Mole2,
- Rebecca S French3,
- John Imrie1,4,
- Graham J Hart1
- 1Centre for Sexual Health and HIV Research, Research Department of Infection and Population Health, University College London, London, UK
- 2The School of Slavonic and East European Studies, University College London, London, UK
- 3Department of Social and Environmental Health Research, London School of Hygiene and Tropical Medicine, London, UK
- 4The Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Mtubatuba, South Africa
- Correspondence to Dr Fiona M Burns, UCL Centre for Sexual Health and HIV Research, Mortimer Market Centre, Off Capper Street, London WC1E 6JB, UK;
Contributors FB, CM, CG, RM, RF, JI, GH participated in the design of this study. AE, VP and FB were responsible for study coordination and data collection. FB, AE and CM conducted the statistical analysis. FB was the lead writer of this paper. All authors have seen and approved the final version of this manuscript.
- Accepted 3 April 2011
Background Accession of 10 Central and Eastern European (CEE) countries to the EU resulted in the largest migratory influx in peacetime British history. No information exists on the sexual behaviour of CEE migrants within the UK. The aim of this study was to assess the sexual lifestyles and health service needs of these communities.
Methods A survey, delivered electronically and available in 12 languages, of migrants from the 10 CEE accession countries recruited from community venues in London following extensive social mapping and via the Internet. Reported behaviours were compared with those from national probability survey data.
Results 2648 CEE migrants completed the survey. Male CEE migrants reported higher rates of partner acquisition (adjusted OR (aOR) 2.1, 95% CI: 1.3 to 2.1) and paying for sex (aOR 3.2, 95% CI: 2.5 to 4.0), and both male and female CEE migrants reported more injecting drug use (men: aOR 2.2, 95% CI: 1.3 to 3.9; women: aOR 3.0, 95% CI 1.1 to 8.1), than the general population; however, CEE migrants were more likely to report more consistent condom use and lower reported diagnoses of sexually transmitted infections (STI). Just over 1% of respondents reported being HIV positive. Most men and a third of women were not registered for primary care in the UK.
Discussion CEE migrants to London report high rates of behaviours associated with increased risk of HIV/STI acquisition and transmission. These results should inform service planning, identify where STI and HIV interventions should be targeted, and provide baseline data to help evaluate the effectiveness of such interventions.
- Sexual behaviour
- knowledge and attitudes
- health services research
Over the past decade, the UK has experienced large migratory fluxes from Central and Eastern Europe (CEE). In particular the accession on 1 May 2004 of Czech Republic, Estonia, Hungary, Latvia, Lithuania, Poland, Slovakia and Slovenia (the ‘A8’) into the European Union (EU), and of Bulgaria and Romania (the ‘A2’) on 1 January 2007, was followed by large-scale, though often, circular migration from these countries.1 Circular migration is a form of migration that allows some degree of legal mobility back and forth between two countries.
The uptake of safer sex measures and patterns of health service use in these migrant populations is unknown. Also the demographic profile of CEE migrants (young and frequently single),1 the often high background prevalence of sexually transmitted infections (STIs) and HIV in their countries of origin,2–4 and their lack of experience of the British health system may place these new migrant communities at higher risk of sexual ill health and reproductive morbidity compared with the general population.
As research on the sexual behaviour of the general populations of CEEs is sparse and no information exists on the sexual behaviour of CEE migrants within the UK, our aim was to establish an understanding of the sexual lifestyles and health service needs of these communities. This study is part of the SALLEE (sexual attitudes and lifestyles of London's Eastern Europeans) project. Papers examining the sexual risk of CEE migrant men who have sex with men5 and CEE migrant attendance at genitourinary medicine clinics and STI diagnoses,6 which arise from this project as well, are also published in this issue of STI.
A detailed description of the methodology has been previously published.7 A brief summary is provided below.
Participants and procedure
Eligible respondents were literate men and women aged over 17 who self-identified as migrants from one of the 10 CEE countries. The community sample was recruited in London and the web survey was advertised on websites for CEE nationals in the UK as described in reference 7. Web survey respondents who gave their home post-code outside London were excluded from the study.
Fieldwork took place over a 9-month period (July 2008–March 2009). The nine fieldworkers involved in the recruitment of respondents for the community sample were native speakers of six of the languages of the CEE countries.
The survey instrument was a self-completed questionnaire designed using SNAP 9 survey software (Snap Survey Ltd., Bristol, UK) that was fielded using hand-held computers for the community sample and a web survey for the Internet sample. The community and internet survey questions were identical. The questionnaire was anonymous. The questionnaire was piloted to examine: its feasibility and acceptability and to explore the understanding of the question items and underlying constructs; the use of the hand-held computers, question routing and technical usability were also tested during piloting.
The questionnaire was translated into 11 languages (the 10 official languages of the CEE countries plus Russian) and bilingual native speakers of the 11 languages checked the translation accuracy.
There is no adequate sampling frame of this new migrant population from which to draw a probability sample of CEE nationals in London. The study therefore relied on convenience sampling in order to generate a cost-effective sample that would be sufficiently robust for detailed analysis. This study adopted two sampling strategies (community and Internet) in order to ensure representation of key elements of the population and minimise bias. A detailed social mapping exercise was conducted prior to recruitment of the community sample.7 This provides some confidence that the selected boroughs and locations capture a broad cross-section of CEE migrants in London.
Standard statistical tests, for example, χ2 and Student's t, were used to examine associations between variables. Multivariate analysis of factors associated with one or more new heterosexual partner in previous 12 months used a backwards-stepwise model; all variables with a p value <0.1 for the crude association were retained for incorporation in the multivariate model. To evaluate reported behaviours with those of the British population we conducted a comparison with individual-level data from the National Survey of Sexual Attitudes and Lifestyles (Natsal) 2000, the most recent national probability sample survey at the time of writing, conducted between May 1999 and February 2001. Logistic regression modelling was used to obtain adjusted ORs (aORs) to control for any variation in age, gender, marital status and education between the two data sources.
Due to the sample size, it was not possible to analyse by individual countries. Rather, because of the differing dates of accession (2004 vs 2007), we grouped respondents into two regions (the A8 and A2). Accession into Europe was dependent on countries fulfilling certain political and economic conditions, both have potentially influenced the sexual attitudes and behaviours of populations; in addition, there were tighter controls on A2 (compared with A8) migration to the UK. Also within the sociopolitical sciences, ‘Eastern Europe’ is often subdivided into Central Europe (the A8 states) and South-Eastern Europe (the A2). Historically, Central European political culture has been characterised as more rational, contractual and individualistic, while South-Eastern Europe is more essentialist, collectivistic and arbitrary. Over the centuries, this has resulted in different ways of thinking about individual freedoms, the boundaries between public and private and the role of the state—all of which influence attitudes and behaviours in society.8–10
The sample size of 2000 people provides 80% power to detect as significant the association with an explanatory factor where the difference in prevalence is around 6%. A sample of this size also allows for adequately powered subgroup analysis. Analysis was performed using Intercooled STATA 8.0 (STATA Corp., College Station, Texas, USA) and SPSS 12.0 (SPSS Inc., Chicago, USA).
This CEE population sample (n=2648) was derived by merging the community sample (n=2276) with the Internet sample (n=372). The mean age of respondents was 29.0, 51.4% were married or cohabiting, and almost half (48.3%) of respondents were men (Supplementary table 1). The majority of respondents were Polish (n=1082, 40.9%), Romanian (n=492, 18.6%), or Lithuanian (n=449, 17.0%). The Internet sample was more likely to be born in an A8 country (97.8% vs 74.2%, p<0.001), to be educated to degree level (43.9% vs 29.4%, p<0.001) and in paid employment (84.1% vs 72.8%, p<0.001), than the community sample. Most respondents had migrated post-accession, 79.3% arriving after May 2004. Those who arrived in the UK post-accession had been in the UK for a mean of around 1.5 years (median 17–9 months). Three-quarters (74.6%) of respondents had returned to their home country at least once in the past year and 15.0% had returned four or more times.
Partners or sexual partners were defined as people who have had sex together—whether just once, or a few times, or as regular partners, or as married partners. This definition was made explicit in the questionnaire. Table 1 shows the distribution of reported numbers of partners (in the past year and past 5 years) by age and gender. There was substantial heterogeneity in numbers of heterosexual partners reported in the past 5 years; 70.3% of men and 48.8% of women reported more than one partner, whereas 29.1% of men and 6.9% of women reported more than five. Men consistently reported higher numbers of heterosexual partners than women over all time periods. Same-sex partnerships were reported by 3.4% of men and 4.0% of women.
Nearly half (44.9%) of men and 29.1% of women had formed a new heterosexual partnership over the past year. The mean number of new partnerships in the past year varied from 5.3 among previously married men aged 25–34 to 0.1 among married women aged over 34. The mean number of new partners declined with increasing age for men but not for women. Younger respondents were less likely to be in a married or cohabiting relationship. Across all age groups and both genders, new partner acquisition was highest among the single or previously married. Over half (55.6%) of all male respondents were single or previously married; these men formed 74.0% of all new heterosexual partnerships by men in the past year.
Among those respondents reporting sex in the past year, a quarter of men and 7.6% of women reported relationships that were concurrent (overlapped or were simultaneous). Just over half (51.5%) of men and most (80.2%) women reported only one partner. The majority of new heterosexual partnerships in the past year were consummated in the UK. Approximately three-quarters of most recent sexual partnerships were with nationals from the home country of the respondent (75.6% for men and 71.1% for women). A UK national was the most recent sexual partner for 10.4% of men and 14.5% of women.
STIs and HIV
An ever previously diagnosed STI (excluding HIV) was reported by 11.1% of respondents. Most infections had not been diagnosed in the UK (table 2). A third of respondents had ever had an HIV test, and a third of these had their last HIV test in the UK. Just over 1% of respondents reported that they were HIV positive (18 men and 11 women), with 31.0% being diagnosed in the UK. The majority of respondents who reported being HIV positive were Polish (n=23, 79%). Risk factors for HIV in those respondents who reported being HIV positive were: previous injecting drug use (n=2), sex between men (n=1), six (21%) had ever paid for sex but none reported having been paid for sex, and eight (28%) reported a previous STI diagnosis.
Among the 546 (21%) respondents who reported a recreational drug use in the past year, marijuana was most widely used (87.8%), followed by ecstasy (31.0%), cocaine (23.4%), speed (18.6%) and crystal-meth (5.4%).
Risk behaviours by region and sex
Table 3 presents the prevalence of sexual behaviours, attitudes and drug use by sex and region of origin. Many risk behaviours varied by region and sex. Compared with their A2 counterparts, A8 respondents were more likely to report heterosexual oral or anal sex and recreational drug use in the past year. A8 men were more likely to have ever injected drugs (6.6% vs 1.2%, p<0.001), while A8 women were more likely to report concurrent relationships in the past year, a same sex partner ever, and more heterosexual partners in the past year than those from the A2. Having paid for sex was widely reported across both regions but was more likely among men from the A2 countries (44.1% vs 28.5%, p<0.001), as was concurrency in the past year (32.2% vs 23.4%, p=0.019). A2 men were also more likely to have had an HIV test than A8 men (37.5% vs 31.0%, p=0.032), and to have used condoms consistently in the past 4 weeks, especially among those reporting two or more partners in the past year (55.3% vs 34.8%, p=0.002). A2 men and women were significantly less likely to be registered with a general practitioner (GP) although this association was lost when adjusted for time in the UK.
To examine high-risk sexual behaviour we calculated the OR, 95% CI and aOR of factors associated with one or more new heterosexual partners in the past year (Supplementary table 2). Male respondents reporting other risk behaviours in the same time period such as recreational drug use (aOR 1.37, 95% CI 1.01 to 1.87), drinking alcohol on average three or more days a week (aOR 1.62, 95% CI 1.14 to 2.28) and anal sex (aOR 1.89, 95% CI 1.35 to 2.64) had increased odds of new heterosexual partners, as were those reporting a previous STI diagnosis (aOR 1.69, 95% CI 0.99 to 2.86) or oral sex (aOR 3.61 95% CI 1.64 to 3.31), while married or cohabiting men and men registered with a GP were less likely (aOR 0.35, 95% CI 0.25 to 0.47, and aOR 0.69, 95% CI 0.51 to 0.93 respectively).
CEE women were more likely to have had new sexual partner(s) in the past year if they reported a same sex partner ever (aOR 2.31, 95% CI 1.26 to 4.26), anal or oral sex in the past year (aOR 1.48, 95% CI 1.01 to 2.15 and aOR 1.76, 95% CI 1.23 to 2.52 respectively), drinking alcohol more frequently (aOR 1.68, 95% CI 1.02 to 2.80) and a previous STI diagnosis (aOR 1.75, 95% CI 1.13 to 2.73); they were less likely if they were married or cohabiting (aOR 0.28, 95% CI 0.20 to 0.38), from the A8 compared with the A2 (aOR 0.60, 95% CI 0.37 to 0.97), and over the age of 24 years (aOR 0.71, 95% CI 0.51 to 0.98).
No association between time in the UK and most of the risk behaviours was found (data not shown). The notable exception was reporting of ever having had sex with someone of the same sex, which was more likely with increasing time in the UK (p=0.034).
Comparison with British national data
Among respondents who reported heterosexual sex ever, the CEE sample was younger (27.7 vs 31.8 yrs, p<0.001) than the Natsal sample, more likely to be single (40.2% vs 35.0%, p<0.001), and less likely to have a degree (31.8% vs 35.8%, p<0.001).
Significant behavioural differences between samples remained after adjusting for socio-demographic variables in multivariate analyses (table 4). Male CEE respondents were more likely to report two or more partners in the past year (aOR 2.1, 95% CI 1.3 to 2.1) and in the past 5 years (aOR 1.7, 95% CI 1.6 to 2.6), but were less likely to report having had an STI (aOR 0.7; 95% CI 0.5 to 1.0) than Natsal respondents. CEE men were more than three times as likely to have paid for sex with a woman (aOR 3.2; 95% CI 2.5 to 4.0) and twice as likely to have injected non-prescribed drugs (aOR 2.2; 95% CI 1.3 to 3.9).
CEE women were three times more likely to have injected non-prescribed drugs than Natsal women (aOR 3.0, 95% CI 1.1 to 8.1) and were less likely to report having had an STI (aOR 0.7, 95% CI 0.6 to 1.0). The proportion of female respondents reporting two or more partners in the past 5 years and in the past year were similar across surveys. Consistent condom use in the past 4 weeks was higher in the CEE sample (aOR 1.3, 95% CI 1.0 to 1.8).
The accession of 10 CEE countries to the EU has resulted in one of the largest migratory influxes in peacetime British history. This project provides estimates of sexual behaviour patterns in these new communities. As would be expected we found wide variability in sexual lifestyles by gender, age, relationship status and region of origin. While reports of prior STIs are lower than in the general British population, CEE migrants, especially male migrants, report high rates of behaviours associated with increased risk of HIV and STI transmission. The benefits of more consistent condom use may be offset by higher rates of partner acquisition, paying for sex and injecting drug use.
Like other communities, heterosexual CEE migrants demonstrate assortative sexual mixing (whereby their most recent partner was from their home country).11 12 Nearly three-quarters of last sexual partnerships in the general CEE population sample were with a national from the home country of the CEE respondent. Risk of HIV and other STIs may increase as CEE communities become more integrated with the British population. Currently, the reported high-risk behaviours appear offset by low prevalence of infections within the CEE migrant community. With increasing time, it is possible that CEE migrants in the UK will have sexual partners from more diverse backgrounds, potentially increasing the likelihood of exposure to infections.5
STI screening opportunities differ in the UK compared with many CEE countries,13 which may impact on STI reports, especially on infections that are often asymptomatic. However, over 30% of respondents reported ever having an HIV test, higher than the 13% reporting an HIV test ever in the last Natsal survey.14
The reported HIV prevalence of 1.1% is substantially higher than the estimated prevalence of 0.09% in the general British population.15 This burden of infection is not, however, reflected in national HIV surveillance data. Although the numbers remain relatively small, there was a 10-fold increase between 2000 and 2007 in the total number (8–84), and proportion (0.3%–2.3%), of all new HIV diagnoses in people from the A8.16 Eastern Europe does have the highest rate of HIV across Europe but Poland has one of the lowest.17 In Eastern Europe although the mode of acquisition is often unreported,18 the epidemic is believed to be largely driven by injecting drug use (a behaviour reported by ∼4% of our respondents), although heterosexual transmission is also on the increase.17 18
Only 31% of the reported HIV diagnoses were made in the UK. Potentially migrants may be aware of their HIV infection but not accessing services in the UK, and hence not impacting on national surveillance data as yet. This seems unlikely but is not impossible, especially as our qualitative data suggest people continue to access healthcare in home countries and use the Internet to obtain medications (Burns, unpublished data). In Central and Eastern Europe there is a high degree of stigma and discrimination attached to being HIV positive19–21; given that these data rely on self-reports a bias towards under-reporting of HIV seropositivity would be expected. Conversely, HIV-positive people may be more interested in sexual health matters which may impact on participation.
The dilemma over how to interpret the HIV findings highlights one of the major limitations of our survey: the absence of biological samples. The high-risk behaviours reported suggest that blood-borne virus screening in this population would be informative and should be considered in future studies. A further limitation is that the data are based on self-reports. CEE populations are heterogeneous differing sociologically in ways that may impact on sexual attitudes and lifestyles, for example, religiosity and social liberalism. Numbers precluded analysis by specific country of origin, Polish, Lithuanian and Romanian respondents accounted for 76% of all data. A separate analysis was undertaken to ensure Polish responses did not substantially differ from responses from the other ‘A8’ nationalities combined; they did not (data not shown).
The limitations relating to convenience samples have previously been published.7 Natsal 2000 data were collected 9 years prior to these data. It is possible that the frequency of reported behaviours would have changed in the British population over this time. However, there is no more recent survey with which to compare our data until the Natsal 2010 data collection is completed. It is also possible that the sampling method may have created participation bias. Internet surveys of men who have sex with men show higher risk behaviours than the general population;22 however, these surveys use social networking sites used often to find sexual partners. None of the websites used to recruit for this study were social networking sites.
Public health implications
The economic recession has seen the rate of influx decline; however, large numbers of CEE nationals continue to migrate into the UK1 and many migrants have now made the UK their permanent home. The UK has a duty of care to ensure that appropriate risk reduction strategies are in place and these new communities are aware of and able to access these services. Paying for sex was reported by over a third of all CEE men. Further research is needed on the cultural factors associated with commercial sex, what type of sex is occurring and where, and the risks involved.
No association between time in the UK and many of the risk behaviours was found. The notable exception was participants reporting of ever having had sex with someone of the same sex, which was more likely with increasing time in the UK (p=0.034). High-risk behaviours, regardless of time in the UK, support the concept of the migrant as a ‘risk taker’. In Africa migration has been identified as a critical factor in high-risk sexual behaviour independent of marital and cohabitation status, social milieu or awareness of HIV23–25; it may be that this also holds true in other populations. Voluntary migrants are individuals who take a risk to travel to, and work in, environments that they hope will be beneficial to them. This risk-taking tendency may permeate into the choices they make in other areas of their lives.26
Migrants are often viewed as a health threat, yet evidence shows that the process of migration can present a health threat to migrants themselves. The ‘healthy migrant’ effect (whereby because of the health and human capital required for migration, immigrants are on average healthier than the population they originate from and often, also the population in their host country27) is likely to be evident in these new communities. Research, however, suggests that migrant health deteriorates more rapidly than the general population health with time.28 The mobile nature of migrant communities, language barriers and confusion over entitlement to services often means members are unlikely to benefit fully from public health programmes or access to health services. Men in particular were less likely to be registered with a GP yet reported significant risk behaviours for blood-borne viruses. While this study focused on sexual and reproductive health, there are, of course, many other aspects to health likely to be relevant to CEE migrants, and subsequently for their host nations. These include high rates of smoking, alcohol consumption and cardiovascular disease.29–31
A feature of CEE migration to the UK is that many people migrate for relatively short but recurring periods.1 Similarly, our respondents returned home frequently. In a borderless EU, management of chronic health conditions and surveillance of communicable diseases will increasingly involve transnational collaborations. Systems to monitor and facilitate transnational healthcare and disease surveillance for migrant communities are needed. Improving health outcomes for migrants are likely to benefit both the receiving (host) and home countries.32 This study helps illuminate our understanding of the sexual lifestyles, sexual and reproductive health risks, and health service needs of these migrant communities. Results from this study will help inform service planning and identify where STI and HIV interventions should be targeted. It also provides baseline data to help evaluate the effectiveness of interventions and provides a useful adjunct to interpreting data derived from other community- and clinic-based surveys.
The accession of 10 CEE countries to the EU has resulted in the largest migratory influx in peacetime British history.
This is the first study to provide estimates of sexual behaviour patterns in these new communities.
High rates of partner acquisition, paying for sex and injecting drug use were reported; behaviours associated with increased risk of HIV and STI transmission.
Reports of prior STIs were lower in CEE migrants to London than in the general British population, however, 1.1% reported being HIV positive.
Heterosexual CEE migrants demonstrate assortative sexual mixing.
We are grateful for the expert guidance provided by our expert and community advisory boards, for the hard work and commitment of the fieldworkers who collected the data. We thank the staff and management at the Mortimer Market Centre, the Archway Sexual Health Clinic and the Margaret Pyke Centre; the websites that fielded the questionnaire; the many commercial, social and educational premises that facilitated recruitment for our fieldworkers; and everyone who took part in the study. This study was supported by the MRC Sexual Health and HIV Research Strategy Committee; the views expressed are those of the authors and not necessarily those of the MRC or the Health Departments.
Funding This research was supported by the MRC Sexual Health and HIV Research Strategy Committee (Grant: G0601703). The sponsor had no role in study design; the collection, analysis or interpretation of the data; the writing of the report; or the decision to submit the paper for publication.
Competing interests None.
Patient consent Obtained.
Ethics approval This study was conducted with the approval of the Camden & Islington Community Research Ethics Committee, UK (07/H0722/110).
Provenance and peer review Not commissioned; externally peer reviewed.