Migration and HIV – a double synergy

Migration and HIV infection in Malawi.

Anglewicz P, VanLandingham M, Manda-Taylor L, Kohler HP. AIDS. 2016 Aug 24;30(13):2099-105. doi: 10.1097/QAD.0000000000001150.

Objective: To evaluate the assumption that moving heightens HIV infection by examining the time-order between migration and HIV infection and investigate differences in HIV infection by migration destination and permanence.

Methods: We employ four waves of longitudinal data (2004-2010) for 4265 men and women from a household-based study in rural Malawi and a follow-up of migrants (2013). Using these data, we examine HIV status prior to migration. Migrants are disaggregated by destination (rural, town, and urban) and duration (return and permanent); all compared with individuals who consistently resided in the rural origin ('nonmigrants').

Results: HIV-positive individuals have significantly greater odds of migration than those who are HIV negative [odds ratio 2.75; 95% confidence interval (CI) 1.89-4.01]. Being HIV positive significantly increases the relative risk (RR) that respondent will be a rural-urban migrant [RR ratio (RRR) 6.28; 95% CI 1.77-22.26), rural-town migrant (RRR 3.62; 95% CI 1.24-10.54), and a rural-rural migrant (RRR 4.09; 95% CI 1.68-9.97), instead of a nonmigrant. Being HIV positive significantly increases the RR that a respondent will move and return to the village of origin (RRR 2.58; 95% CI 1.82-3.66) and become a permanent migrant (RRR 3.21; 95% CI 1.77-5.82) instead of not migrating.

Conclusion: HIV-positive status has a profound impact on mobility: HIV infection leads to significantly higher mobility through all forms of migration captured in our study. These findings emphasize that migration is more than just an independent risk factor for HIV infection: greater prevalence of HIV among migrants is partly due to selection of HIV-positive individuals into migration.

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Editor’s notes: Previous studies in sub-Saharan Africa have identified that migrants are at greater risk of living with HIV than their non-migrant counterparts. There is however a lack of knowledge of the direction of causality between migration status and HIV status. This longitudinal study enabled analysis of the direction of causality between HIV acquisition and migration.  Individuals living with HIV were significantly more likely to migrate in the future than people who were not living with HIV.  The effect was seen for all types of migration (rural to rural, rural to town (district capital) and rural to urban (regional capital).

The true association between HIV status and migration status may exceed that illustrated as some individuals who were HIV negative at baseline may have become HIV positive prior to migration. The patterns identified could be driven by better healthcare being available in an urban setting. Alternatively individuals may move to avoid HIV-associated stigma in the relative anonymity of an urban environment. Previous research in Malawi has also illustrated that marriage and migration are closely linked. Thus marital dissolution following HIV infection may in part explain the patterns seen.  Further qualitative studies are necessary to investigate such factors.

This study illustrates that an increasing emphasis needs to be placed on HIV prevention in the rural communities from which migrants originate, in addition to focusing on the risk in the urban areas. 

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