SUBSTANTIVE REVIEW

A Systematic Review of HIV Risk Behaviors and Trauma AmongForced and Unforced Migrant Populations from Low and Middle-Income Countries: State of the Literature and Future Directions

Lynn Murphy Michalopoulos • Angela Aifah •

Nabila El-Bassel

� Springer Science+Business Media New York 2015

Abstract The aim of the current systematic review is to

examine the relationship between trauma and HIV risk

behaviors among both forced and unforced migrant

populations from low and middle income countries

(LMIC). We conducted a review of studies published from

1995 to 2014. Data were extracted related to (1) the rela-

tionship between trauma and HIV risk behaviors, (2)

methodological approach, (3) assessment methods, and (4)

differences noted between forced and unforced migrants. A

total of 340 records were retrieved with 24 studies meeting

inclusion criteria. Our review demonstrated an overall re-

lationship between trauma and HIV risk behaviors among

migrant populations in LMIC, specifically with sexual

violence and sexual risk behavior. However, findings from

10 studies were not in full support of the relationship.

Findings from the review suggest that additional research

using more rigorous methods is critically needed to un-

derstand the nature of the relationship experienced by this

key-affected population.

Resumen El objetivo de la revision sistematica actual es

examinar la relacion entre el trauma y de riesgo de VIH

comportamientos entre las poblaciones migrantes forzados

y no forzados, tanto de los paıses de ingresos bajos y

medios (LMIC). Se realizo una revision de estudios pub-

licados entre 1995 y 2014. Los datos fueron obtenidos en

relacion con (1) la relacion entre el trauma y las conductas

de riesgo de VIH, (2) enfoque metodologico, (3) los

metodos de evaluacion y, (4) las diferencias observadas

entre los migrantes forzados y no forzados. Un total de 340

registros fueron recuperados con 24 estudios que cumplıan

los criterios de inclusion. Nuestra revision demostro una

relacion general entre el trauma y las conductas de riesgo

de VIH entre las poblaciones migrantes en LMIC,

especıficamente de la violencia sexual y el comportamiento

sexual de riesgo. Sin embargo, los hallazgos de 10 estudios

no estaban en el apoyo total de la relacion. Los resultados

de la revision indican que la investigacion adicional uti-

lizando metodos mas rigurosos es crıticamente necesario

para comprender la naturaleza de la relacion experimentada

por esta poblacion clave afectados.

Keywords HIV sexual and drug risk behaviors � Migrant

populations � Trauma � Low and middle income countries

Introduction

In recent years, there has been a global demand to address

the specific HIV-related health needs of migrant popula-

tions [1–3]. Refugees, asylum seekers or internally dis-

placed persons (IDP) (forced migrants) often migrate due

to political violence or conflict, whereas labor migrants

(unforced migrants) chose to emigrate for economic rea-

sons [4]. In 2013, there were approximately 232 million

migrants, comprising 3.2 % of the world’s population [4,

5]. Over the past 20 years, both forced and unforced mi-

grants from low- and middle-income countries (LMIC)

have steadily increased [5–7] and have been identified as

key-affected populations for exposure to HIV [4]. Recent

estimates indicate one third of migrant populations in the

L. M. Michalopoulos (&) � A. Aifah � N. El-Bassel

Social Intervention Group, Global Health Research Center of

Central Asia, Columbia University School of Social Work, 1255

Amsterdam Avenue, Room 804, Mail Code 4600, New York,

NY 10027, USA

e-mail: lm2996@columbia.edu

123

AIDS Behav

DOI 10.1007/s10461-015-1014-1

world migrate from a developing country to another de-

veloping country and another third migrate from a devel-

oping country to a developed country [1, 8].

The link between HIV sexual risks and migration may

be due to frequent travel between work and home country,

with increased risks of sexual behavior with concurrent

multiple partners [9–11]. Moreover, risk environments

experienced by migrants in the host country such as

poverty, overcrowding, lack of health care and increased

physical and psychological stressors have also been found

to be associated with HIV sexual risks such as low condom

use and high alcohol use [12–15]. Most studies on migra-

tion, mobility and HIV have examined sexual risk behav-

iors [16–20]. Fewer studies have looked at the relationship

between migration and drug risk behaviors such as injec-

tion drug use and needle/syringe sharing [20–22].

Trauma, HIV and Migration

Several studies have examined trauma exposure occurring

pre-migration, throughout the migration process and post-

migration including interpersonal trauma, systematic human

rights violations, and accidents causing serious harm as

potential factors that may increase vulnerability to HIV risk

behaviors and subsequent HIV transmission among migrant

populations [23, 24]. Forced migrants from LMIC are at risk

of exposure to trauma associated with political unrest, tor-

ture, war, and other human rights violations [4, 25]. The

majority of wars and conflicts in the past 20 years have

occurred in LMIC, increasing the risk for adverse mental

health outcomes, substance use and vulnerability to HIV

sexual risk behaviors [26–28]. Unforced migrants from

LMIC are frequently employed in what has been termed 3-D

jobs, (dangerous, difficult and demeaning) where they are

vulnerable to hazardous working environments, exploita-

tion, violence and other potentially traumatic events [4, 24].

The relationship between trauma history and HIV risk

behaviors among Western populations has been well

established [29–33]. This literature supports the conceptual

model proposed by Miller [34] which explains the rela-

tionship between sexual abuse and HIV risks among

women. The model posits that trauma and trauma symp-

toms (e.g. post-traumatic stress disorder, depression,

anxiety, and dissociation) contribute to the use of mal-

adaptive coping mechanisms such as drug use to self-

medicate and engaging in self-destructive behaviors [34].

Similarly, this model can be adapted to explain the re-

lationship between trauma and HIV risk behaviors among

migrant populations. Specifically, we hypothesize that

traumatic events and mental health outcomes related to

trauma throughout the migration process are associated

with adverse coping behaviors such as risky sexual be-

haviors (i.e., multiple sexual partners, inconsistent condom

use with main and casual partners, engaging in sex trading,

etc.) and drug risk behaviors (sharing needles and other

drug equipment, alcohol abuse which may increase sexual

risk behaviors) [34, 35].

Based on the model offered by Miller [34], this paper is a

systematic review of published studies conducted globally

on the relationship between trauma history and HIV risk

behaviors among migrant populations from LMIC. By re-

viewing the current state of the literature, we attempt to

describe the nature of the relationship between trauma and

HIV risks among migrant populations from LMIC, identify

gaps in the literature and discuss future directions for re-

search on HIV risks and migration from LMIC. We

specifically examined: (1) the locations where the studies

were conducted, (2) type of migrant population: forced and

unforced, (3) type of research and methodological charac-

teristics, (4) instruments used in the studies to assess HIV

risks, trauma and trauma outcomes among migrant popula-

tions, and (5) the relationship between trauma and HIV risks.

Methods

Search Selection

We reviewed both quantitative and qualitative studies for

this paper and examined studies that included data on both

pre-migration trauma (in the case of refugees, asylum

seekers or IDP) and trauma occurring while in the host

country or place of work. Studies that examined substance

use among migrant populations, but not specifically ad-

dressing its relationship to HIV risk behaviors (such as

needle sharing or alcohol use increasing risk for multiple

sexual partners or lack of condom use) were excluded so

that the focus of the review could determine specific HIV

risk behaviors related to trauma. Peer-reviewed publica-

tions on migrant populations published from 1995 to 2014

were considered. Studies were included if they met the

following inclusion criteria: (1) forced OR unforced mi-

grant populations (labor migrants, refugees, asylum seek-

ers, IDP), (2) trauma defined as experiences of war, torture,

intimate partner violence, sexual violence, political op-

pression, human rights violations and disasters/accidents,

(3) HIV risk behaviors (sexual risk behavior, drug risk

behavior or HIV infection), and (4) participants originated

from a LMIC according to the World Bank’s definition of

LMIC [36]. The World Bank classifies the economy of

each country each year based on the gross national income

(GNI) per capita of the previous year [36]. Countries in-

cluded were those that were low income (GNI = $1,035 or

less), lower middle income (GNI = $1,036 to $4,085) and

upper middle income (GNI = $4,086-$12,615). Our ex-

clusion criteria included the following: (1) non-English

AIDS Behav

123

articles, (2) studies on migrant children, (3) studies ex-

amining sex workers and trafficked populations, (4) books,

(5) non-peer reviewed literature, (6) studies that included

non-migrant populations (with the exception of non-mi-

grant groups used as a comparison to the migrant group),

and (7) grey literature. Sex workers and trafficked

populations were excluded from the current review because

the circumstances were vastly different from other migrant

populations and difficult to compare to labor migrants and

other types of forced migrants. While we limited the re-

view to studies that examined populations migrating from

LMIC, we included studies where the migrants were cur-

rently living in high-income countries.

Quality Assessment

Litell, Corcoran, and Pillai [37] caution against the use of

total quality scores due to the complexity and often inac-

curacy of weighing all components of a quality score

equally. In addition, studies with migrant populations often

have methodological challenges which deem a single score

as potentially inaccurate of the validity of the study as a

whole. Finally, a quality score poses unique challenges

when there are qualitative, quantitative and mixed-methods

studies in a systematic review. As such, a quality score was

deemed inappropriate.

Search Strategy

Electronic searches of Pubmed, Psychinfo, Scopus, An-

throsource, Anthropology Plus, Sociological Abstracts,

Google Scholar and Web of Science were conducted on 10th

October 2014, focusing on studies from 1st January 1995 to

the date of the search initiation. The following broad search

terms were used for each database: ‘‘refugees’’ or ‘‘migrant’’

or ‘‘labor migrants’’ or ‘‘immigrants’’ or ‘‘asylum’’ or ‘‘forced

migration’’ or ‘‘internal displacement’’ combined with

‘‘PTSD’’ or ‘‘post-trauma* stress’’ or ‘‘genocide’’ or ‘‘torture’’

combined with ‘‘HIV risk*’’ or ‘‘substance abuse’’ or ‘‘sub-

stance use’’ or ‘‘HIV infections/transmission’’ or ‘‘alcohol’’).

Two databases, Anthrosource and Google Scholar, did

not accommodate such a broad strategy so slight modifi-

cations were used for the search terms but the modifica-

tions were still constructed on the inclusion criteria. After

searching all databases and the removal of duplicates, 340

publications were retained for abstract review. Out of this

pool, we conducted a full review of 39 manuscripts based

on eligibility criteria.

Data Extraction

Data were extracted by two independent reviewers (LMM

& AA) of 39 publications and included details about study

design, study setting, population demographics and results

for inclusion criteria variables of interest. The reviewers

were not blind to any aspect of this review. Data extraction

was done independently by LMM and AA and then results

were compared with any disagreement being discussed

until a consensus was reached.

We reviewed papers that specifically examined the re-

lationship between trauma history and/or trauma outcomes

(such as PTSD or other psychosocial problems), and sexual

or drug risk behaviors among migrant populations from

LMIC. Data extracted from each study included: (1) type

of migrant, (2) type of trauma, (3) trauma outcomes, (4)

HIV risk behaviors, (5) relationship between trauma and

HIV risk behaviors, (6) type of methodology used to ex-

amine the relationship between HIV risk behaviors and

trauma among migrants (e.g., qualitative, quantitative,

cross sectional, longitudinal, etc.), (7) sampling character-

istics, (i.e. sample size, source of sample, sampling strategy

and response rate noted by the author), (8) time since

trauma, if noted, and (9) how trauma and HIV risks were

assessed.

Results

Overview of Study Characteristics

Figure 1 presents a flow diagram outlining the systematic

review process. Searching for papers published since 1995

to October 2014, we found a total of 24 publications

meeting inclusion criteria on trauma and HIV risks among

migrant populations from low and middle income coun-

tries. The 24 studies provided data on 33,220 migrants.

Sample size of studies ranged from n = 15 to n = 24,219.

A similar number of studies were conducted in high in-

come (n = 10), low income (n = 8) and middle income

(n = 11) countries.1 Furthermore, the review was com-

prised of equal number of studies with study samples of

migrants from multiple countries (n = 12) and study

samples from one country of origin (n = 12). In addition,

the highest number of studies examined men and women

(n = 10), with slightly fewer men only (n = 8) and women

only (n = 6). An equal number of studies examined trau-

matic events that occurred only pre-migration (n = 9) and

only post-migration (n = 9), with fewer studies examining

traumatic events that occurred both pre- and post-migration

(n = 6). In the current review, 13 studies examined trauma

1 The total N is more than the total number of studies in this review to

account for the study samples that were from multiple countries in

each study. Income categories that had more than one of the same

category (e.g., two countries of emigration that are low income within

the same study) were only counted once because the exact number of

participants from each country was not clear in all studies.

AIDS Behav

123

related to sexual violence and 11 examined experiences of

human rights violations as a result of war or conflict, or

within the host country. In addition, 3 studies examined

trauma specifically related to violence against sexual mi-

norities and 2 examining trauma related to childhood

abuse. The majority of studies (n = 16) examined multiple

types of trauma and assessed interpersonal traumatic ex-

periences (n = 23) rather than natural disasters/accidents

(n = 2). Tables 1 and 2 provide full details on each of the

studies. Table 3 provides data on sample characteristics

across the studies.

Type of Migrants: Forced and Unforced

Among the studies reviewed, 12 were related to forced

migrants (3 internally displaced, 5 refugee/asylum seekers,

and 4 both), 10 related to unforced migrants and 2 mixed

groups. Only one study [38] compared forced and unforced

migrants. In addition, only 3 studies compared migrant

populations to non-migrant populations [38–40]. Among

unforced study populations, more studies were comprised

of external migrants (n = 8) compared to internal migrants

(n = 4). However, among forced study populations, there

was almost an equal number of studies comprised of ex-

ternal (n = 9) and internal (n = 8) migrants. Among

forced migrant populations, more studies examined mi-

grating from LMIC to another LMIC (n = 9), rather than

migration from LMIC to a high income country (n = 4).

However, among unforced populations, a similar number

of studies examined migration from LMIC to another

LMIC (n = 5), compared to migration from LMIC to a

high income country (n = 6). Of the 10 studies that ex-

amined unforced migrant populations only, 6 were com-

prised of only men, 3 only women, and one with both men

and women.

Methodological Approaches

Half of the publications utilized qualitative methods

(n = 12), while fewer were quantitative (n = 9), or used

mixed methodology (n = 3). Among the 12 quantitative

studies (including the 3 mixed methods), 5 utilized

Publica�ons selected by �tle from all databases:

N = 755

Publica�ons remaining for abstract reviewN = 340

Publica�ons included for in-depthfull text review:

N = 39

Removal of duplicates and ini�al screening of publica�ons by �tle:

N = 415

No. of publica�ons/ studies included in systema�c review:

N =24

Level 2 screening of publica�ons by full text review and excluded from further inspec�on because not all constructs were met: (trauma, HIV

risk, LMIC representa�on, migra�on)

N =15

Inclusion criteria: [migrant popula�on (labor migrant, refugee, asylum seeker, internally displaced person), HIV or HIV risk behavior, trauma or specific trauma outcome, from LMIC]

Level 1 screening of publica�ons by abstract:

N = 301

Fig. 1 Literature review flow

chart

AIDS Behav

123

Ta

ble

1O

ver

vie

wo

fst

ud

ies

inth

ere

vie

w

So

urc

eC

ou

ntr

yo

fim

mig

rati

on

Co

un

try

of

emig

rati

on

Ty

pe

of

mig

ran

tT

yp

eo

ftr

aum

aT

rau

ma

ou

tco

mes

(if

spec

ified

)

HIV

risk

beh

avio

r(i

f

spec

ified

)

Tra

um

a&

HIV

risk

beh

avio

r

rela

tio

nsh

ip

Qu

anti

tati

ve

Ag

adja

nia

n&

Av

og

o[3

8]

An

go

laA

ng

ola

Fo

rced

(war

,

no

n-w

ar)

&

un

forc

ed

(lo

ng

-tim

e

resi

den

ts)

mig

ran

ts

War

rela

ted

trau

ma

No

ne

spec

ified

Sex

ual

risk

Y/N

Alt

ho

ffet

al.

[41

]

Un

ited

Sta

tes

Ho

nd

ura

s;M

exic

o;

Gu

atem

ala;

Nic

arag

ua;

El

Sal

vad

or

Un

forc

ed

mig

ran

ts

(lab

or)

Ass

ault

inp

ast

mo

nth

No

ne

spec

ified

Sex

ual

risk

N

Ban

dy

op

adh

yay

&T

ho

mas

[46

]

Ch

ina

Ph

ilip

pin

es;

Ind

on

esia

;

Th

aila

nd

;N

epal

;S

ri

Lan

ka;

Ind

ia

Un

forc

ed

mig

ran

ts

(lab

or)

Sex

ual

vio

len

cein

ho

stco

un

try

No

tap

pli

cab

leS

exu

alri

skY

Cas

till

o-

Man

cill

aet

al.

[39

]

Un

ited

Sta

tes

Mex

ico

Un

forc

ed

mig

ran

ts

(un

kn

ow

n)

Sex

wit

ho

ut

con

sen

tin

pas

tm

on

thN

on

esp

ecifi

edS

exu

alri

sk,

alco

ho

l,an

d

dru

gri

sk

N

Joh

n-L

ang

ba

[45

]

Bo

tsw

ana

An

go

la;

Bu

run

di;

Dem

ocr

atic

Rep

ub

lic

of

Co

ng

o;

Nam

ibia

;R

wan

da;

So

mal

ia;

Su

dan

;U

gan

da;

Zim

bab

we

Fo

rced

mig

ran

ts

(ref

ug

ees)

Rap

e,se

xu

alth

reat

s,ex

plo

itat

ion

,

hu

mil

iati

on

,as

sau

lts,

mo

lest

atio

n,

do

mes

tic

vio

len

ce,

ince

st,

inv

olu

nta

ryp

rost

itu

tio

n,

tort

ure

,

atte

mp

ted

rap

e

Dep

ress

edm

oo

d

sym

pto

mat

olo

gy

;

lear

ned

hel

ple

ssn

ess

Sex

ual

risk

beh

avio

r

Y/N

Kim

etal

.[4

3]

Dem

ocr

atic

Rep

ub

lic

of

Co

ng

o

Dem

ocr

atic

Rep

ub

lic

of

Co

ng

o;

Su

dan

Fo

rced

mig

ran

ts

(in

tern

ally

dis

pla

ced

&

refu

gee

wo

men

)

Pre

mig

rati

on

trau

ma

du

eto

po

liti

cal

vio

len

ce/w

arse

xu

alb

ased

vio

len

ce

No

tap

pli

cab

leS

exu

alri

skY

/N

Lin

etal

.[4

8]

Ch

ina

Ch

ina

Un

forc

ed

mig

ran

ts(r

ura

l

tou

rban

lab

or)

Ch

ild

ho

od

sex

ual

abu

seN

on

esp

ecifi

edA

lco

ho

lu

se

and

sex

ual

risk

Y

Pat

elet

al.

[28

]U

gan

da

Ug

and

aF

orc

edm

igra

nts

(In

tern

ally

dis

pla

ced

)

His

tory

of

abd

uct

ion

;se

xu

alab

use

;

rap

e

No

tap

pli

cab

leS

exu

alri

skY

Sp

eig

elet

al.

[44

]

Bo

tsw

ana;

Ken

ya;

Mo

zam

biq

ue;

Nep

al;

Rw

and

a;S

ud

an;

So

uth

Su

dan

;T

anza

nia

;

Ug

and

a;Z

amb

ia

Zim

bab

we;

Nam

ibia

;

So

mal

ia;

So

uth

Su

dan

;

Dem

ocr

atic

Rep

ub

lic

of

Co

ng

o;

Bh

uta

n;

Eri

trea

;

Bu

run

di;

Rw

and

a

Fo

rced

mig

ran

ts

(Ref

ug

ees

and

inte

rnal

ly

dis

pla

ced

)

Co

nfl

ict

inh

om

eco

un

try

,

gen

eral

ized

vio

len

ce,

vio

lati

on

of

hu

man

rig

hts

or

man

-mad

eo

r

nat

ura

ld

isas

ters

,n

on

con

sen

sual

sex

No

tap

pli

cab

leS

exu

alri

skY

/N

AIDS Behav

123

Ta

ble

1co

nti

nu

ed

So

urc

eC

ou

ntr

yo

fim

mig

rati

on

Co

un

try

of

emig

rati

on

Ty

pe

of

mig

ran

tT

yp

eo

ftr

aum

aT

rau

ma

ou

tco

mes

(if

spec

ified

)

HIV

risk

beh

avio

r(i

f

spec

ified

)

Tra

um

a&

HIV

risk

beh

avio

r

rela

tio

nsh

ip

Qu

alit

ativ

e

Cam

lin

etal

.

[51

]

Ken

ya

Ken

ya

Un

forc

ed

mig

ran

ts

(in

tern

alla

bo

r)

Inti

mat

ep

artn

erv

iole

nce

;d

eath

of

spo

use

du

eto

HIV

/AID

S

No

tsp

ecifi

edA

lco

ho

lab

use

and

sex

ual

risk

Y

Cam

pb

ell

[50]

So

uth

Afr

ica

So

uth

Afr

ica;

Les

oth

o;

Bo

tsw

ana;

Mo

zam

biq

ue

Un

forc

ed

mig

ran

ts

(un

der

gro

un

d

wo

rker

so

n

go

ldm

ines

)

Min

e-re

late

dac

cid

ents

So

cial

wit

hd

raw

al,

pro

ble

ms

con

cen

trat

ing

and

nig

htm

ares

or

flas

hb

ack

s

Alc

oh

ol

abu

se

&se

xu

alri

sk

Y

Eza

rdet

al.

[26

]K

eny

a;L

iber

ia;

Ug

and

a;

Iran

;P

akis

tan

;

Th

aila

nd

Su

dan

,S

om

alia

,L

iber

ia,

Ug

and

a,A

fgh

anis

tan

,

My

anm

ar

Fo

rced

mig

ran

ts

(ref

ug

ees

and

inte

rnal

ly

dis

pla

ced

)

Co

nfl

ict

inh

om

eco

un

try

,g

end

er-

bas

edv

iole

nce

Po

st-t

rau

mat

ic

stre

ssd

iso

rder

Sex

ual

risk

Y

Lu

oet

al.

[53

]T

ajik

ista

n;

Ru

ssia

Taj

ikis

tan

Un

forc

ed

mig

ran

ts

(in

tern

alan

d

exte

rnal

)

Vio

len

cein

liv

ing

and

wo

rkin

g

env

iro

nm

ent:

arre

sts

and

bea

tin

gs

fro

mp

oli

ce,

atta

cks

fro

m

skin

hea

ds

and

ult

ran

atio

nal

ists

Sen

seo

f

po

wer

less

nes

s

Alc

oh

ol

and

sex

ual

risk

beh

avio

r

N

Man

net

al.

[52]

Un

ited

Sta

tes

Mex

ico

Un

forc

ed

mig

ran

ts

(lab

or)

Tra

um

atic

earl

yli

feex

per

ien

ces:

ph

ysi

cal

and

emo

tio

nal

abu

se

Dep

ress

ion

;

resi

gn

atio

n;

suic

idal

tho

ug

hts

Alc

oh

ol

and

dru

gab

use

;

retr

osp

ecti

ve

sex

ual

risk

beh

avio

r

Y

Mu

hw

ezi

etal

.

[58

]

Ug

and

aU

gan

da

Fo

rced

mig

ran

ts

(in

tern

ally

dis

pla

ced

)

War

trau

ma,

gen

der

bas

edv

iole

nce

Su

icid

alth

ou

gh

ts;

psy

cho

log

ical

trau

ma

du

eto

rap

e

Alc

oh

ol

abu

se

&se

xu

alri

sk

Y

Och

oa

&

Sam

pal

is[5

7]

Can

ada

Lat

inA

mer

ican

Co

un

try

(no

t

spec

ified

)

Fo

rced

(ref

ug

ee)

and

un

forc

ed

(per

man

ent

resi

den

ts)

Gen

der

-bas

edv

iole

nce

inw

ork

and

per

son

alre

lati

on

ship

s

Iso

lati

on

;la

cko

f

soci

aln

etw

ork

so

r

sup

po

rt;

fear

,

anx

iety

Sex

ual

risk

beh

avio

r

Y

Oje

da

etal

.[4

2]

Mex

ico

Mex

ico

(dep

ort

edfr

om

Un

ited

Sta

tes)

Fo

rced

(dep

ort

edfr

om

cou

ntr

yo

f

imm

igra

tio

n)

Tra

um

are

late

dto

forc

edm

igra

tio

nS

ham

e,re

sen

tmen

t,

lon

elin

ess

Dru

gu

sean

d

dru

gri

sk

beh

avio

r

Y

Rh

od

eset

al.

[56

]

Un

ited

Sta

tes

Mex

ico

;E

lS

alv

ado

r;

Gu

atem

ala

Un

forc

ed

mig

ran

ts

(un

kn

ow

n)

Vio

len

ced

ue

tose

xu

alit

yo

r

eng

agin

gin

sam

ese

xb

ehav

ior

Iso

lati

on

;

ho

pel

essn

ess

Sex

ual

risk

beh

avio

r

Y

Ste

elet

al.

[23

]S

wed

enS

om

alia

;U

gan

da;

Eth

iop

ia;

Eri

trea

;K

eny

a;Z

amb

ia;

Zai

re(D

RC

);T

anza

nia

Fo

rced

mig

ran

ts

(ref

ug

ees)

Co

nfl

ict

inh

om

eco

un

try

,to

rtu

re,

sex

ual

vio

len

ce,

exp

osu

reto

com

bat

,lo

sso

flo

ved

on

es

Po

st-t

rau

mat

ic

stre

ssd

iso

rder

Sex

ual

risk

Y

AIDS Behav

123

Ta

ble

1co

nti

nu

ed

So

urc

eC

ou

ntr

yo

fim

mig

rati

on

Co

un

try

of

emig

rati

on

Ty

pe

of

mig

ran

tT

yp

eo

ftr

aum

aT

rau

ma

ou

tco

mes

(if

spec

ified

)

HIV

risk

beh

avio

r(i

f

spec

ified

)

Tra

um

a&

HIV

risk

beh

avio

r

rela

tio

nsh

ip

Wir

tzet

al.

[54

]R

uss

iaA

rmen

ia,

Uk

rain

e,

Uzb

ekis

tan

,T

ajik

ista

n,

Ru

ssia

,A

fgh

anis

tan

,

Aze

rbai

jan

Fo

rced

mig

ran

ts

(in

tern

ally

dis

pla

ced

&

refu

gee

s)

Ho

mo

ph

ob

icv

iole

nce

inh

om

e

cou

ntr

y;

xen

op

ho

bic

har

assm

ent

and

vio

len

cefr

om

law

enfo

rcem

ent

inh

ost

cou

ntr

y

Sh

ame

and

fear

Sex

ual

risk

beh

avio

r

Y

Zea

etal

.[5

5]

Co

lom

bia

Co

lom

bia

Fo

rced

mig

ran

ts

(in

tern

ally

dis

pla

ced

)

Ex

po

sure

toar

med

con

flic

t,

exp

erie

nce

so

fv

iole

nce

,an

ti-g

ay

vio

len

ce,

sex

ual

coer

cio

nan

d

vio

len

ce

Men

tal

hea

lth

con

seq

uen

ces

asso

ciat

edw

ith

dis

pla

cem

ent

and

arm

edco

nfl

ict

Sex

ual

risk

beh

avio

r

Y

Mix

edm

eth

od

s

Ak

insu

lure

-

Sm

ith

[47]

Un

ited

Sta

tes

Sie

rra

Leo

ne;

Lib

eria

Fo

rced

mig

ran

t

(ref

ug

ees

&

asy

lum

seek

ers)

Lo

ng

-ter

mv

iole

nce

fro

mco

un

try

of

ori

gin

,fe

mal

eg

enit

alcu

ttin

g,

rap

e

du

rin

gw

ar

Po

st-t

rau

mat

ic

stre

ssd

iso

rder

Dru

g/a

lco

ho

l

abu

se&

sex

ual

risk

N

Tan

aka

etal

.

[49

]

Tan

zan

iaD

emo

crat

icR

epu

bli

co

f

Co

ng

o

Fo

rced

mig

ran

ts

(ref

ug

ees)

Fo

rced

sex

inre

fug

eeca

mp

;co

nfl

ict

inh

om

eco

un

try

No

ne

spec

ified

HIV

infe

ctio

n;

sex

ual

risk

beh

avio

r

Y/N

Wei

ne

etal

.[2

4]

Ru

ssia

Taj

ikis

tan

Un

forc

ed

mig

ran

ts

(lab

or)

Dif

ficu

ltw

ork

con

dit

ion

s,

dis

crim

inat

ion

,v

iole

nce

,an

d

wit

ho

ut

leg

alri

gh

ts(i

mp

lied

);

(dir

ect

and

ind

irec

ttr

aum

a)

Po

st-t

rau

mat

ic

stre

ssd

iso

rder

Alc

oh

ol

abu

se

&se

xu

alri

sk

Y/N

AIDS Behav

123

Ta

ble

2M

eth

od

olo

gic

ald

escr

ipti

on

of

stu

die

s

So

urc

eC

ou

ntr

yo

f

imm

igra

tio

n

Co

un

try

of

emig

rati

on

Res

earc

h

des

ign

Ass

essm

ent

met

ho

ds

Sam

pli

ng

char

acte

rist

ics

Mea

sure

su

sed

Dat

aco

llec

tio

nT

ran

slat

ion

met

ho

ds

Sam

ple

size

So

urc

eo

fsa

mp

leS

amp

lin

g

stra

teg

y

Qu

anti

tati

ve

Ag

adja

nia

n&

Av

og

o[3

8]

An

go

laA

ng

ola

Cro

ss

sect

ion

al

No

ne

spec

ified

Ho

use

ho

ld

surv

ey

No

ne

spec

ified

1,0

81

men

&

wo

men

2p

eri-

urb

an

mu

nic

ipal

itie

s

Pro

bab

ilit

y

Alt

ho

ffet

al.

[41

]

Un

ited

Sta

tes

Ho

nd

ura

s;

Mex

ico

;

Gu

atem

ala;

Nic

arag

ua;

El

Sal

vad

or

Lo

ng

itu

din

al

(3q

uar

terl

y

surv

eys

ov

er

30

mo

nth

s)

Dev

elo

ped

for

stu

dy

Su

rvey

Tra

nsl

ated

&

bac

k

tran

slat

ed

11

3m

enR

ecru

itm

ent

site

sco

mm

on

amo

ng

Lat

ino

mal

em

igra

nts

Res

po

nd

ent

dri

ven

sam

pli

ng

Ban

dy

op

adh

yay

&T

ho

mas

[46

]

Ch

ina

Ph

ilip

pin

es;

Ind

on

esia

;

Th

aila

nd

;

Nep

al;

Sri

Lan

ka;

Ind

ia

Cro

ss

sect

ion

al

Dev

elo

ped

for

stu

dy

Su

rvey

No

ne

spec

ified

1,9

93

wo

men

No

tst

ated

Pro

bab

ilit

y

sam

pli

ng

Cas

till

o-

Man

cill

aet

al.

[39

]

Un

ited

Sta

tes

Mex

ico

Cro

ss

sect

ion

al

Dev

elo

ped

for

stu

dy

Sel

f-

adm

inis

tere

d

surv

ey

Qu

esti

on

nai

re

inE

ng

lish

or

Sp

anis

h

32

0w

om

en2

urb

anp

rim

ary

care

/

gy

nec

olo

gy

clin

ics

No

n-

pro

bab

ilit

y

pu

rpo

siv

e

sam

pli

ng

Joh

n-L

ang

ba

[45

]

Bo

tsw

ana

An

go

la;

Bu

run

di;

Dem

ocr

atic

Rep

ub

lic

of

Co

ng

o;

Nam

ibia

;

Rw

and

a;

So

mal

ia;

Su

dan

;

Ug

and

a;

Zim

bab

we

Cro

ss

sect

ion

al

Ad

apte

dG

old

stan

dar

dS

GB

V

qu

esti

on

nai

re;

lear

ned

hel

ple

ssn

ess

scal

e;h

op

kin

s

sym

pto

m

chec

kli

st;

adap

ted

sex

ual

risk

beh

avio

rsc

ale

Su

rvey

qu

esti

on

nai

re

Tra

nsl

atio

n

pro

cess

of

mea

sure

sn

ot

dis

cuss

ed

40

2w

om

enR

ecru

ited

fro

m

Du

kw

ire

fug

ee

cam

p

No

n-

pro

bab

ilit

y

Kim

etal

.[4

3]

Dem

ocr

atic

Rep

ub

lic

of

Co

ng

o

Dem

ocr

atic

Rep

ub

lic

of

Co

ng

o;

Su

dan

Cro

ss

sect

ion

al

No

ne

spec

ified

Qu

esti

on

nai

reN

on

esp

ecifi

ed1

,28

8w

om

enID

Pca

mp

&h

ost

com

mu

nit

y

Pro

bab

ilit

y

Lin

etal

.[4

8]

Ch

ina

Ch

ina

Cro

ss

sect

ion

al

Ch

ild

sex

ual

abu

se

scal

ev

alid

ated

for

Ch

ines

e

po

pu

lati

on

Sel

f-

adm

inis

tere

d

qu

esti

on

nai

re

No

ne

stat

ed4

78

wo

men

Rec

ruit

edfr

om

esta

bli

shm

ents

and

per

son

al

serv

ice

sect

ors

No

n-

pro

bab

ilit

y

pu

rpo

siv

e

Pat

elet

al.

[28

]U

gan

da

Ug

and

aC

ross

sect

ion

al

Dev

elo

ped

for

the

stu

dy

;H

IVte

st

Str

uct

ure

dfa

ce

tofa

ce

inte

rvie

w

adm

inis

tere

d

Tra

nsl

ated

to

loca

l

lan

gu

age

and

bac

k

tran

slat

ed

38

4w

om

en&

men

Gu

luD

istr

ict

Tra

nsi

tca

mp

s

inU

gan

da

Co

mb

inat

ion

of

pro

po

rtio

nal

&n

on

-

pro

po

rtio

nal

qu

ota

AIDS Behav

123

Ta

ble

2co

nti

nu

ed

So

urc

eC

ou

ntr

yo

f

imm

igra

tio

n

Co

un

try

of

emig

rati

on

Res

earc

h

des

ign

Ass

essm

ent

met

ho

ds

Sam

pli

ng

char

acte

rist

ics

Mea

sure

su

sed

Dat

aco

llec

tio

nT

ran

slat

ion

met

ho

ds

Sam

ple

size

So

urc

eo

fsa

mp

leS

amp

lin

g

stra

teg

y

Sp

eig

elet

al.

[44

]

Bo

tsw

ana;

Ken

ya;

Mo

zam

biq

ue;

Nep

al;

Rw

and

a;

Su

dan

;S

ou

th

Su

dan

;

Tan

zan

ia;

Ug

and

a;

Zam

bia

Zim

bab

we;

Nam

ibia

;

So

mal

ia;

So

uth

Su

dan

;

Dem

ocr

atic

Rep

ub

lic

of

Co

ng

o;

Bh

uta

n;

Eri

trea

;

Bu

run

di;

Rw

and

a

Cro

ss

sect

ion

al

Sta

nd

ard

qu

esti

on

nai

refo

r

HIV

beh

avio

ral

surv

eill

ance

Su

rvey

adm

inis

tere

d

by

an

inte

rvie

wer

No

ne

spec

ified

;

inea

chsi

te

the

qu

esti

on

nai

re

was

pre

test

ed

and

mo

difi

ed

wh

en

nec

essa

ry

24

,2

19

men

&

wo

men

Ref

ug

eeca

mp

s

and

surr

ou

nd

ing

com

mu

nit

ies;

27

sep

arat

e

com

mu

nit

ies

in

10

cou

ntr

ies

Pro

bab

ilit

y

Qu

alit

ativ

e

Cam

lin

etal

.

[51

]

Ken

ya

Ken

ya

Cro

ss

sect

ion

al

In-d

epth

sem

i-

stru

ctu

red

inte

rvie

ws

bas

ed

on

life

his

tory

app

roac

h

Sem

i-st

ruct

ure

d

inte

rvie

ws;

par

tici

pan

t

ob

serv

atio

n

and

fiel

dn

ote

s

Inte

rvie

ws

bac

k

tran

scri

bed

in

lan

gu

age

&

tran

slat

edto

En

gli

shfo

r

anal

ysi

s

55

men

&w

om

enP

arti

cip

ant

ob

serv

atio

nin

com

mo

n

mig

rati

on

des

tin

atio

ns

and

tran

sit

hu

bs

No

n-

pro

bab

ilit

y

pu

rpo

siv

e

Cam

pb

ell

[50]

So

uth

Afr

ica

So

uth

Afr

ica;

Les

oth

o;

Bo

tsw

ana;

Mo

zam

biq

ue

Cro

ss

sect

ion

al

No

ne

spec

ified

In-d

epth

inte

rvie

w

No

ne

spec

ified

42

men

Joh

ann

esb

urg

go

ldm

ine

No

tst

ated

Eza

rdet

al.

[26

]K

eny

a;L

iber

ia;

Ug

and

a;Ir

an;

Pak

ista

n;

Th

aila

nd

Su

dan

,S

om

alia

,

Lib

eria

,

Ug

and

a,

Afg

han

ista

n,

My

anm

ar

Cro

ss

sect

ion

al

Dev

elo

ped

for

the

stu

dy

Key

info

rman

t

inte

rvie

ws,

focu

sg

rou

ps,

dir

ect

ob

serv

atio

ns

of

site

s

rele

van

tto

sub

stan

ceu

se

inth

ree

of

the

site

s

All

inte

rvie

ws

con

du

cted

by

are

sear

cher

wit

han

inte

rpre

ter

or

fiel

dw

ork

ers

57

8m

en&

wo

men

Inte

rnal

ly

dis

pla

ced

cam

ps

and

Urb

anar

eas

Pu

rpo

siv

ean

d

sno

wb

all

Lu

oet

al.

[53

]T

ajik

ista

n;

Ru

ssia

Taj

ikis

tan

Cro

ss

sect

ion

al

Dev

elo

ped

for

stu

dy

Min

imal

ly

stru

ctu

red

inte

rvie

ws

and

focu

sed

fiel

d

ob

serv

atio

ns

Inte

rvie

ws

con

du

cted

in

Taj

iko

r

Ru

ssia

n,

som

ew

ith

a

tran

slat

or

60

men

Th

eR

epu

bli

can

HIV

/AID

S

Pre

ven

tio

n

Cen

ter

and

refe

rral

sfr

om

a

loca

lp

hy

sici

an

No

n-

pro

bab

ilit

y

pu

rpo

siv

e

sam

pli

ng

AIDS Behav

123

Ta

ble

2co

nti

nu

ed

So

urc

eC

ou

ntr

yo

f

imm

igra

tio

n

Co

un

try

of

emig

rati

on

Res

earc

h

des

ign

Ass

essm

ent

met

ho

ds

Sam

pli

ng

char

acte

rist

ics

Mea

sure

su

sed

Dat

aco

llec

tio

nT

ran

slat

ion

met

ho

ds

Sam

ple

size

So

urc

eo

fsa

mp

leS

amp

lin

g

stra

teg

y

Man

net

al.

[52]

Un

ited

Sta

tes

Mex

ico

Cro

ss

sect

ion

al

Lif

eh

isto

ry

inte

rvie

ws

Un

stru

ctu

red

and

sem

i-

stru

ctu

red

inte

rvie

w

Inte

rvie

ws

con

du

cted

and

anal

yze

d

inS

pan

ish

15

men

Tw

ocl

inic

s

pro

vid

ing

HIV

care

inN

C

No

n-

pro

bab

ilit

y

pu

rpo

siv

e

sam

pli

ng

Mu

hw

ezi

etal

.

[58

]

Ug

and

aU

gan

da

Cro

ss

sect

ion

al

No

ne

spec

ified

Ind

epth

inte

rvie

ws

(McG

ill

Illn

ess

Nar

rati

ve)

No

ne

spec

ified

32

men

&w

om

enT

eso

sub

reg

ion

dis

tric

tso

f

Kat

akw

i&

Am

uri

a

No

n-

pro

bab

ilit

y

pu

rpo

siv

e

Och

oa

&

Sam

pal

is[5

7]

Can

ada

Lat

inA

mer

ican

cou

ntr

y(n

ot

spec

ified

)

Cro

ss

sect

ion

al

In-d

epth

inte

rvie

ws

exp

lori

ng

sev

eral

them

es

In-d

epth

inte

rvie

ws

and

no

n-

par

tici

pan

t

ob

serv

atio

n

All

inte

rvie

ws

con

du

cted

in

Sp

anis

h

25

wo

men

Tw

oh

ealt

han

d

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AIDS Behav

123

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AIDS Behav

123

probability sampling. In addition to the 5 studies that uti-

lized probability sampling methods, one used respondent

driven sampling methods, but did not meet all of the as-

sumptions to generalize to the population [41]. In addition,

all of the studies used a cross-sectional design. None of the

studies in the current review examined HIV prevention

interventions among the study sample.

Assessment of Trauma

All of the studies used self-report for both trauma event

history and trauma symptoms. A number of different in-

struments were used to assess trauma events and trauma

symptoms across studies. Out of the 12 studies that used

quantitative methods (including the 3 mixed methods), 6

studies developed measures to assess for traumatic expe-

riences and symptoms, 5 used previously developed and

validated instruments, and 1 used experience of war mi-

gration as an indicator of traumatic events (see Table 2).

Gender differences related to trauma were also noted

across studies, with the examination of gender-based and

sexual violence predominant among female only studies

(n = 7), while among male only studies, violence against

sexual minorities (n = 3) and work accidents/dangerous

working conditions (n = 2) was predominant. In addition,

a key distinction across studies in the current review was

the focus on trauma events or trauma symptoms. The ma-

jority of studies examined both trauma symptoms (PTSD,

anxiety, depression) and traumatic events and the subse-

quent relationship to HIV risk behaviors (n = 14), while

fewer examined the relationship between traumatic event

only and HIV risk behaviors (n = 10) and one study only

examined the relationship between trauma symptoms and

HIV risk behaviors. None of the studies specified time

since the trauma occurred.

Assessment of HIV Risk Behaviors

Across both quantitative and qualitative studies, the ma-

jority examined HIV risk behaviors related to sexual risks

(n = 13), while fewer studies focused on alcohol abuse

and sexual risk behaviors (n = 10). In addition, 4 studies in

the review assessed for injection drug risk behaviors and

sexual risk behaviors, while 1 examined injection drug use

Table 3 Characteristics of the 24 articles reviewed

Characteristics of the studies

Sexa Only men (n = 8); only women (n = 6); both (n = 10)

Age range 15–55 years

Regions of immigrationa,b Africa (n = 9; N = 28,825)

Asia (n = 4; N = 3109)c

Europe (n = 3; N = 655)

Latin America (n = 2; N = 85)

North America (n = 6; N = 546)

Country income leveld Low Lower-middle Upper-middle High

8 2 9 10

Regions of emigrationa,b Africa (n = 12; N = 29,577)

Asia (n = 4; N = 2931)

Europe (n = 1; N = 133)

Latin America (n = 7; N = 579)

North America (n = 0; N = 0)

Country income leveld Low Lower-middle Upper-middle High

15 10 9 1

Legal Statusa Forced migrant (n = 11); unforced migrant (n = 11); both (n = 2)

Design Characteristics

Sample size range 15–24,219 subjects

Assessmenta Survey/questionnaire only (n = 9); interview (n = 9); mixed (n = 6)

a ‘n’ denotes the number of articlesb ‘N’ denotes sample size versus the number of studiesc Ezard et al. (2011) included the same number of countries from Africa and Asia, 3 and 3 respectively, as such we opted to add this article to the

Asia total for immigration since there was a larger sample size for those in Asian countriesd For the country income levels, each category was weighted or calculated for each study; wherein one study with several countries in a

particular income level was counted as a single representation for that category

AIDS Behav

123

solely as an HIV risk behavior [42]. In terms of sexual

risks, 7 out of the 9 quantitative studies assessed for

number of sexual partners and consistency of condom use.

Four studies examined age at sexual debut [24, 28, 40, 43].

Three studies examined current symptoms or history of

sexually transmitted infections [24, 28, 43] and only 2

assessed the sexual risk of one’s main partner [39, 44].

Further, only one study examined both the practice of ‘‘dry

sex’’ (a practice in some Southern and Central African

countries, where women purposefully dry out their vagina

before engaging in intercourse) and transactional sex as an

HIV sexual risk behavior [28].

Across studies, HIV sexual and drug risk behaviors were

assessed in a number of ways. Out of the quantitative

studies, only 2 used validated instruments to assess HIV

risk behaviors. The remaining used indicators ranging from

1 indicator related to number of sexual partners in the past

12 months (e.g., [43, 45]) to a range of over 72 questions

about sexual practices [46]. In addition, 9 studies utilized

self-report measures for HIV risk behaviors, with the ex-

ception of 2 studies. Kim et al. [43] used both self-report

and also assessed for HIV and sexually transmitted infec-

tion (specifically syphilis) through rapid on-site testing,

while Patel et al. [28] assessed for HIV infection through

rapid onsite testing.

Relationship Between Trauma and HIV Risk

Behaviors: Quantitative Findings

The majority of studies (n = 13) from the review demon-

strated a relationship between trauma, psychosocial out-

comes related to trauma and HIV risk behaviors among

migrant populations (see Table 1); however, 7 studies

found a limited relationship between HIV risks and trauma,

and 4 studies found no relationship.

Labor Migrants

Among the quantitative studies, 2 were comprised of fe-

male labor migrants in China and examined sexual vio-

lence in relation to HIV. Using probability sampling

methods, Bandyopadhyay and Thomas [45] found that

domestic helpers in Hong Kong who experienced sexual

violence perceived themselves to be more at risk for HIV

infection than those who did not experience sexual vio-

lence. Similarly, Lin et al. [47] found that among labor

migrant women in the entertainment or personal service

industry in Beijing, child sexual abuse was a significant

predictor of sexual risk behaviors. Results also indicated

that child sexual abuse significantly predicted an increase

in alcohol use before sex [47].

Unlike the quantitative findings among female labor

migrant populations in the current review, results among

male labor migrants conducted by Weine et al. [24] were

not in full support of our hypothesis. Using a mixed

methods approach Weine et al. [24] sampled married male

seasonal labor migrants from Tajikistan who had immi-

grated to Russia and were working in bazaars and con-

struction sites. Findings indicated that experiencing and

hearing about others experiencing a traumatic event were

both directly correlated to PC-PTSD score; however, the

PC-PTSD score did not predict HIV sexual risk behaviors

and alcohol abuse [24]. Further, results of this study indi-

cated that hearing about someone experiencing a traumatic

event was associated with HIV risk behaviors; whereas,

directly experiencing a traumatic event was not [24]. Fi-

nally, Althoff et al. [41] found that assault in the past

month was not associated with multiple short gap part-

nerships among Latino labor migrants living in the United

States.

Forced Migrants

The relationship between trauma and HIV risk behaviors

was more complex among studies comprised of forced mi-

grants. Spiegel et al. [40] through systematic random sam-

pling found that refugees from the Democratic Republic of

Congo had significantly higher odds of having multiple

sexual partners compared to the surrounding host popula-

tions, i.e., Tanzania and Zambia. However, refugees from

Burundi, South Sudan, and Rwanda had significantly less

odds of having multiple sexual partners compared to the

surrounding host populations, i.e. Tanzania and Uganda.

There were no significant differences in HIV risk behaviors

between refugees and host communities among the other 6

paired sites examined. Tanaka et al. [48] found that Con-

golese refugees living in a camp in Tanzania had more non-

regular sexual partners after displacement than before,

although this was not statistically significant. However,

male and female refugees were significantly more likely to

engage in transactional sex for food or money after dis-

placement [48]. Further, although the prevalence was low

and insignificant, injection drug use increased post-dis-

placement among Congolese refugees. Results indicated

that those who endorsed injection drug use also engaged in

risky injection drug use behavior (i.e., sharing needles) [48].

Through random sampling, Agadjanian and Avogo [38]

compared HIV sexual risk behaviors among long-term

residents, non-war migrants and war-migrants living in

Angola. Results of their study indicated that HIV risk be-

haviors among men increased across the spectrum of long-

term residents, non-war migrants and war-migrants, sup-

porting the hypothesis of the current review. However,

sexual risk behaviors among women decreased across the

three groups, although not significantly. Among refugee

women from a number of sub-Saharan African countries

AIDS Behav

123

living in a refugee camp in Botswana, John-Langba [44]

found that sexual violence was significantly related to

sexual risk behaviors; however, physical violence and

physical intimidation was not related to sexual risk be-

haviors. In addition, symptoms of depression were not re-

lated to sexual risk behaviors.

Using random sampling, Kim et al. [43] conducted an

assessment with women living in an IDP camp and

neighboring river populations in the Democratic Republic

of Congo. As one of two studies in the current review to

examine HIV prevalence, results indicated that HIV in-

fection was higher among the IDP population compared to

the river population. In addition, consistent with other

findings of this review, among the internally displaced

population, a history of sexual violence during the conflict

was associated with HIV infection. However, a dose re-

sponse relationship (i.e. increase in number of traumatic

events and likelihood of HIV infection) was not found.

Similar to Kim et al., Patel [28] assessed trauma and

relation to HIV infection among internally displaced male

and female refugees living in camps in Uganda. Among

men the highest predictor of HIV infection was non-con-

sensual sexual debut. Among women, non-consensual de-

but was a significant predictor of HIV infection; however

the highest predictor among women was practicing dry sex.

Finally, Akinsulure-Smith [46] examined the relationship

between trauma and HIV sexual and drug risk behaviors

among West African refugees and asylum seekers living in

New York City. Study findings indicated that psycho-

logical symptoms related to trauma were not associated

with condom use, number of sexual partners, sexually

transmitted infection history or substance use.

Trauma and HIV Risk Behaviors: Major Qualitative

Findings

Labor Migrants

Similar to the quantitative studies, the majority of

qualitative findings indicated a relationship between trau-

ma and HIV risk behaviors among labor migrant popula-

tions. For example, male labor migrants living in South

Africa reported that they do not use condoms because they

believed the risk of trauma (through work accidents) was

more likely to cause harm than the risk of HIV transmis-

sion [49]. Internal female labor migrants from Kenya who

experienced intimate partner violence or widowhood due to

AIDS reported an increased risk of transactional sex for

survival, opportunities for non-gendered normative be-

haviors such as alcohol abuse and increased sexual risk

behavior and limited self-efficacy with low condom use

[50]. Further, a common theme among several Mexican

male labor migrants living with HIV reported that HIV

infection was a result of traumatic events, subsequent

mental health problems and sexual risk behavior [51].

In the current review, 2 studies examined the relation-

ship between trauma and HIV risk behavior among labor

migrants from Central Asia. Luo et al. [52] compared ex-

ternal and internal Tajik labor migrants. Results indicated

that external Tajik migrants experienced harsh working and

living conditions and more alcohol abuse; however, both

external and internal migrants experienced concurrent sex

partners through sex workers and reluctance to use con-

doms [52]. As noted above in the quantitative findings,

Weine et al. [24] found that direct trauma exposure was not

related to HIV sexual risk behaviors. Qualitative findings

from their study revealed experiencing trauma seemed to

serve as a protective factor against HIV sexual risk be-

havior by increasing condom use and the discussion of

sexual risks with partners. Hearing about others’ experi-

ences of trauma was associated with a constant sense of

fear of brutality from police and nationalists that, in turn,

increased sexual risk behaviors.

Displacement Due to Homophobia/Men Who Have Sex

with Men

Although the results of studies in the current review that

examined the relationship between trauma and HIV risk

among men who have sex with men could potentially fit into

labor migrant or forced migrant population findings, we felt

it was important to distinguish the association among this

specific population. The three qualitative studies that ex-

amined the relationship between trauma and HIV risk be-

havior among displaced or migrant men who have sex with

men indicated themes in support of our hypothesis. Namely,

trauma experiences related to homophobia in one’s country

of origin [53, 54] and/or in the host country [53–55] as well

as exposure to armed conflict [54] increased sexual risk

behavior among Latino migrants living in the United States

[55], Central Asian migrants living in Russia [53] and in-

ternally displaced migrants in Colombia [54]. Themes that

violence reinforced a negative self-image leading to sexual

risk behavior and not worrying about HIV infection due to

isolation were predominant [55].

Forced Migrants

Among forced migrants, the qualitative studies (or qualita-

tive portion of a mixed methods approach) were consistent

with our hypothesis. Female refugees from the DRC re-

ported they were not able to refuse sex without a condom

[48]. Similarly, Latina migrants from Canada who experi-

enced gender-based violence in their personal relationships

and at work reported feelings of fear and anxiety which led

to the inability to negotiate condom use [56].

AIDS Behav

123

Individual and group interviews from multiple countries

assessed through qualitative rapid assessment methods

found that displacement by conflict increased one’s risk to

substance abuse and sexual risk behaviors [26]. For ex-

ample, in Liberia using drugs to relieve and dull post-

trauma symptoms increased engaging in sexual risk be-

haviors [26]. In addition, risky injection drug risk behavior,

such as sharing needles and equipment was predominant to

deal with emotional problems among refugees from Iran

[26]. Mexican male injection drug users forcibly deported

from the United States indicated that they used drugs to

deal with emotional pain of trauma [42]. However, while

both safe and unsafe injection practices were reported, it is

unknown if there was a direct relationship between trauma

experiences and unsafe injection drug use practices (i.e.

HIV drug risk behaviors).

Forced migrants in Uganda also frequently reported that

prolonged war exposure resulted in alcohol abuse, as well

as engaging in risky sexual behaviors to cope with emo-

tional pain [57]. Similarly, almost 40 % of respondents in

the qualitative study conducted by Steel et al. [23] dis-

cussed a relationship between trauma, psychological

symptoms and sexual risk behaviors. Specifically, respon-

dents discussed the increase in drug use and risky sexual

behaviors resulting from feelings of hopelessness from the

trauma. Akinsulure-Smith [46] found that rape during war

was a common theme that was noted among participants as

a risk factor for HIV transmission.

Discussion

Similar to findings from western non-migrant populations

[29–32], the current review suggests that traumatic expe-

riences are associated with HIV risk behaviors among

migrant populations from LMIC. More specifically, sexual

violence was consistently associated with HIV sexual risk

behaviors and HIV infection across the studies [43, 44, 47].

This finding supports our hypothesis and the theory guiding

this review [34], although findings from our review are not

limited to women [33, 58]. Sexual violence in particular is

associated HIV risk behaviors rather than other traumatic

events possibly due to resulting maladaptive coping

mechanisms, specifically sexual risk behaviors, to cope

with trauma symptoms, such as dissociation, intrusion, and

hyperarousal. This is an important finding as many of the

participants of the current review experienced sexual vio-

lence as both unforced [45, 47, 54] and forced migrants

[43, 44], suggesting sexual violence and subsequent mental

health outcomes as a critical target of prevention and in-

tervention efforts among migrant populations.

Another important finding of the review is the asso-

ciation between trauma symptoms and HIV risk behaviors.

Across the quantitative studies we reviewed in this paper,

none found a relationship between trauma symptoms and

HIV risk behaviors [24, 44]. However, among the

qualitative studies, trauma and subsequent mental health

problems leading to HIV risk behaviors were consistently

noted [23, 55, 57]. Qualitative findings in support of this

relationship suggest that the discrepancy may lie in mea-

surement of trauma symptoms in the quantitative studies.

Only 5 of the quantitative studies in the current review

mentioned a process to ensure validation of instruments for

the specific population. Lack of validation of measures

weakens the overall findings as literature has indicated that

trauma symptoms, particularly PTSD, may not be a rele-

vant or applicable construct among non-Western low and

middle income populations [59, 60]. This is especially

critical as half of the studies in the current review (n = 12)

examined the relationship between trauma and HIV risk

behaviors among study samples of migrants from multiple

countries and cultural contexts.

Inconsistent Findings with the Hypothesis

Traumatic events other than sexual violence, such as ex-

posure to accidents and war were also associated with HIV

risk behaviors in the current review [23, 26, 28, 49],

although not consistent across studies. We would like to

highlight some of the studies to indicate potential reasons

for the inconsistency. First, there was not a significant

difference in HIV sexual risk behaviors found among fe-

male war migrants living in Angola compared to non-war

migrants and long-term residents [38]. While this may

indicate that trauma is not associated with sexual risk be-

haviors among female forced migrants, trauma exposure

among war-migrants, non-war migrants and long-term

residents in the study was unknown. Agadjanian and

Avogo [38] acknowledge that the distinction between war-

migrant, non-war migrant and long-term resident is blurred

in terms of trauma exposure, especially in Angola, where

ongoing political violence and conflict has been prevalent

for decades. Perhaps among women in the study, non-war

migrants and long-term residents also experienced trau-

matic events, indicating the lack of differences found in

HIV risk behaviors between the groups. Without an

assessment of traumatic events or trauma symptoms, it is

unknown whether there was a difference in trauma expe-

riences between war migrants, non-war migrants and long-

term residents among men or other differences among the

groups contributing to the relationship. Similar to results

from Agadjanian and Avogo [38], the inconsistent results

comparing number of multiple sexual partners between

refugees and host communities in sub-Saharan Africa could

be due to the unknown factor of trauma exposure in each of

the groups [40].

AIDS Behav

123

Weine et al. [24] did not find a relationship between

experiencing trauma and HIV risk behaviors among labor

migrants. However, HIV risk behaviors were indicated

among labor migrants who heard about trauma happening

to others. Conversely, experiencing trauma reduced HIV

risk behaviors. Differences in experiencing trauma and

witnessing trauma and subsequent association with HIV

risk behaviors could be due to differences in trauma

symptoms related to each. Previous research among trauma

survivors has indicated that specific post-traumatic stress

symptom clusters (i.e. avoidance, numbing, arousal and

intrusion) can differentially impact HIV risk behavior [31].

Those who experienced trauma may have more symptoms

of avoidance and thus less likely to engage in sexual risk

behaviors; whereas those who hear about traumatic expe-

riences may develop more symptoms of arousal increasing

their risk for sexual risk behaviors. As stated in the

qualitative findings, those who heard about traumatic ex-

periences were more anxious and feared potential traumatic

events, which may have increased physiological and

emotional dysregulation (i.e. hyperarousal symptoms)

leading to potentially impulsive sexual behaviors [31]. As

the degree of symptom clusters was unknown, there is a the

need for future research to distinguish between hearing

about and experiencing trauma specifically among labor

migrants to gain a better understanding of this relationship.

Similar to Weine et al. [24], findings comparing external

and internal Tajik migrants did indicate a difference in HIV

risk behaviors. Although Luo et al. [52] suggest that ex-

ternal migrants experienced more traumatic experiences,

both groups engaged in sexual risk behaviors. However, the

findings were based on qualitative interviews indicating an

inability to generalize the findings. At the same time, lack

of support for the association between male labor migrants

in Central Asia from two studies suggests the need for

future research in this area.

Kim et al. [43] did not find a dose/response relationship

between sexual violence and HIV infection experienced by

displaced women in the DRC. Number of traumatic events

would not necessarily increase the likelihood of sexual risk

behaviors, while number of forced sexual events with unlikely

use of condoms would inevitably increase one’s risk of HIV

infection. Kim et al. did not examine the relationship between

sexual violence and HIV risk behaviors. Perhaps, sexual

violence was, in fact, associated with HIV risk behaviors but

not HIV infection. However, there was no significant differ-

ence found in sexual risk behaviors between the non-displaced

and displaced women, but sexual violence was significantly

higher among the displaced population, suggesting incon-

clusive findings for the aims of the current review.

Finally, Akinsulure-Smith [46] did not find a relation-

ship between trauma and HIV risk behaviors among West

African refugees and asylum seekers. However, the study

was comprised of a small purposive sample possibly

lacking in sufficient power to demonstrate a relationship

between trauma and HIV risk taking. At the same time, a

strength of the study was that it utilized ACASI, increasing

the reliability of the responses, especially with the sensitive

nature of the trauma and HIV risk behaviors.

Methodological Strengths and Limitations

A number of methodological strengths and limitations

across the studies should be noted. In terms of strengths,

the inclusion of both quantitative and qualitative method-

ologies in the current review provided both rich in-depth

data to help explain the nature of the relationship between

trauma and HIV risk behaviors, while the quantitative

findings further substantiated the relationship. In addition,

almost half of the quantitative studies used probability

sampling increasing our ability to generalize the findings.

In addition, with the exception of two studies [28, 43],

all of the studies utilized self-report which could bias the

results in a number of ways. Relying solely on self-report

could increase the endorsement of risk behaviors and/or

trauma exposure in order to receive aid among migrant

populations who are in need of psychosocial services that

may be previously lacking or unavailable [61]. On the

other hand, self-report methods could decrease the en-

dorsement of behaviors due to the sensitive nature of drug

use behaviors, sexual practices and trauma history.

In terms of research design, all of the quantitative

studies in the current review were cross sectional and none

were longitudinal, limiting our ability to make a causal

connection between trauma and HIV risk behaviors. None

of the studies in the review focused on HIV prevention that

addresses trauma and HIV risk behaviors. It is remarkable

that more than 30 years into the global pandemic, HIV

prevention efforts addressing this critical intersection

among such a key- affected population is lacking. Clearly,

there is a need for such studies. Moreover, research is also

lacking on assessment of alcohol use, non-injection and

injection drug use, and trauma among this key affected

population. As this review demonstrates, most of the

studies focused on sexual risks and trauma. Finally, few

studies examined trauma that occurred pre-migration and

post-migration (n = 6); therefore, it is unknown whether

previous trauma from country of origin and ongoing

stressors and traumatic events experienced in the new

country were associated with HIV risk behaviors.

Implications and Recommendations for Future

Research

The review has shown that there are a limited number of

studies on the relationship between trauma and HIV risks

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123

among migrant populations from LMIC, despite the

growing number of forced and unforced migrants globally

[5, 6]. The review has also revealed that the majority of

research in this area has been conducted among migrant

populations from sub-Saharan Africa, indicating the need

for research among populations from other LMIC. This

makes sense as sub-Saharan has been heavily burdened by

the HIV epidemic. However, the global increase in the

number of migrants in LMIC due to political conflicts and

economic disruptions [62], which has been reflected in the

increased risk of trauma and diseases such as HIV in Asia,

the Middle East, and Eastern Europe underscore the need

for future research in these regions as well among this key-

affected population.

Lindert et al. [63] found that labor migrants currently

living in higher income countries had better mental health

outcomes than labor migrants living in LMIC. Further, a

higher gross national product of the host country was re-

lated to better mental health outcomes among labor mi-

grants but not refugees [63]. The studies that we included

in our review did not address potential differences on HIV

risks and trauma experiences among LMIC and high in-

come countries. We recommend that future research should

examine potential differences in trauma exposure and HIV

risk behaviors, accounting for specific aspects of the host

country that may protect or place migrant populations at

risk and identify major risk and structural factors. Along

the same lines, with 12 studies focusing on internal mi-

grants, potential differences between internal migration and

external mobility should be examined. Migration to a new

country may pose additional risk for discrimination, stigma

and marginalization that may contribute to adverse psy-

chosocial health outcomes and potential HIV risk behav-

iors [4]. Examining all these differences among different

countries may better inform the link between trauma and

HIV risks among migrant populations and identify major

structural barriers that can explain this link.

In terms of HIV risk assessment, only two studies in-

cluded biological testing for HIV and a sexually transmit-

ted disease (syphilis). Moreover, in most of the studies

reviewed, the HIV risk behaviors focused on sexual be-

haviors and alcohol abuse, while injection drug risk be-

haviors or, in fact, use of any illicit drugs were virtually

ignored across the majority of studies. In order to obtain a

better understanding of some of the co-morbidities that

migrants face, research on HIV risks and trauma should

utilize biological data on HIV status and STIs and include

assessments on injection and non-injection drug use among

forced and unforced migrants in LMIC.

Because of the cross sectional nature of the studies re-

viewed, it is unclear from the findings whether trauma

events or psychosocial outcomes of trauma are related to

HIV risk behaviors among migrant populations. Results

from the qualitative findings may inform the nature of the

relationship, demonstrating that both, in fact, play a role.

Some of the qualitative findings noted that risky behaviors

that put one at risk for HIV transmission were a way to

cope with trauma symptoms. On the other hand, others

noted that a traumatic event or fear of a traumatic event led

to a sense of resignation or hopelessness which would in-

crease HIV risk behaviors. More research on the casual link

between trauma exposure and HIV risks is needed, which

will require longitudinal research designs.

Three of the qualitative studies in the current review

specifically focused on male migrants who have sex with

men [53–55]. The fact that all three of the studies were

published within the past 4 years and were qualitative sug-

gests that research is growing among this population. Vio-

lent experiences, discrimination and stigma related to

homophobia, in addition to other migrant-related traumas

can compound mental health outcomes and subsequent HIV

risk behaviors among migrant men who have sex with men

from LMIC, as suggested by the findings of the current re-

view. Future research should examine this relationship

through quantitative methods in order to generalize the

findings and develop relevant HIV prevention interventions.

The current review demonstrated that the majority of

studies among women have examined the trauma of sexual

violence. Women not only comprise about half of the

world’s labor migrants, they are increasingly migrating on

their own as the sole income provider for their family and

are at risk for a number of different types of traumatic

experiences [4]. While extremely important for research

efforts, previous research has focused on the relationship

between trauma and HIV risks among female sex workers

(e.g., [64–66]). Indicated by the current review, research in

this area among other occupations among women globally

has been lacking.

In our review, we found that none of the studies target

HIV prevention to address trauma and HIV risks among

migrant workers in LMIC. Forced and unforced migration

populations are increasing globally with evidence of higher

HIV risks. As such, there is a great need for HIV preven-

tion efforts which are trauma-informed, while research

efforts continue to tease out the specific nature of the re-

lationship between trauma and HIV risk behaviors among

migrant populations from LMIC. Given the degree of di-

versity in migrant populations, traumatic experiences, and

impact of culture on psychosocial outcomes, different types

of interventions will be necessary to reduce HIV risk, de-

pending on the particular context of each setting. The

limited number of studies in the review that utilized and/or

indicated adaptation methods demonstrates the need for

more rigor in cross-cultural research, especially within

studies where the sample was comprised of migrants from

multiple countries. In conclusion, this review underscores

AIDS Behav

123

the need for efforts to improve the quality and scientific

level of research examining the link between HIV and

trauma among forced and unforced migrants in LMIC.

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