Predictors of migration in an HIV hyper-endemic rural South African community: evidence from a population-based cohort (2005–2017)

Abstract

Globally, South Africa hosts the highest number of people living with HIV (PLHIV) and the unique legacy of internal labour migration continues to be a major driver of the regional epidemic, interrupting treatment-as-prevention efforts. The study examined levels, trends, and predictors of migration in rural KwaZulu-Natal Province, South Africa, using population-based surveillance data from 2005 through 2017. We followed 69 604 adult participants aged 15–49 years and recorded their migration events (i.e., out-migration from the surveillance area) in 423 038 person-years over 525 397 observations. Multiple failure Cox-regression models were used to measure the risk of migration by socio-demographic factors: age, sex, educational status, marital status, HIV, and community antiretroviral therapy (ART) coverage. Overall, 69% of the population cohort experienced at least one migration event during the follow-up period. The average incidence rate of migration was 9.96 events and 13.23 events per 100 person-years in women and men, respectively. Migration rates declined from 2005 to 2008 then peaked in 2012 for both women and men. Adjusting for other covariates, the risk of migration was 3.4-times higher among young women aged 20–24 years compared to those aged ≥ 40 years (adjusted Hazard Ratio [aHR] = 3.37, 95% Confidence Interval [CI]: 3:19–3.57), and 2.9-times higher among young men aged 20–24 years compared to those aged ≥ 40 years (aHR = 2.86, 95% CI:2.69–3.04). There was a 9% and 27% decrease in risk of migration among both women (aHR = 0.91, 95% CI: 0.83 – 0.99) and men (aHR = 0.73, 95% CI 0.66 – 0.82) respectively per every 1% increase in community ART coverage. Young unmarried women including those living with HIV, migrated at a magnitude similar to that of their male counterparts, and lowered as ART coverage increased over time, reflecting the role of improved HIV services across space in reducing out-migration. A deeper understanding of the characteristics of a migrating population provides critical information towards identifying and addressing gaps in the HIV prevention and care continuum in an era of high mobility.

Exploring the syndemic interaction between social, environmental and structural contexts of HIV infection in peri-mining areas in South Africa: a qualitative study

“…7 Circular migration or the location of mines in impoverished remote communities also allows mining companies to pass the burden of healthcare back onto these poor rural areas. 8 The informal peri-mining communities that have sprawled around the mines provide easy access to alcohol, drugs and the sex industry, contributing to the spread of sexually transmitted diseases, including HIV. [10][11][12] The social issues around migrancy and masculinity and living conditions of mineworkers have contributed to a rapid transmission of HIV/AIDS and sexually transmitted infections.…”

Migrant men and HIV care engagement in Johannesburg, South Africa

“…The associations between migration and HIV acquisition, care engagement, and HIV-related outcomes are complex and incompletely understood [ 5 , 21 ]. Some research has shown that people already living with HIV are more likely to migrate [ 22 , 23 ]. Other evidence shows that some migrants may be healthier when they leave their homes of origin, often called the “healthy migrant” hypothesis [ 24 ].…”

“…South Africa’s decentralized health system is ill-suited for facilitating people changing clinics because it is difficult to easily transfer patient data across facilities [ 27 ]. Migrants also face other intersecting psychosocial and structural challenges which affect HIV and healthcare engagement, such as the disruption of relocation [ 22 ], lifestyle changes [ 5 ], unstable or lack of employment [ 21 ], isolation and difficult living conditions [ 25 ], lack of residency or citizenship documentation [ 28 ], and fear and language issues [ 29 ]. While some migrants nonetheless seek care in South Africa’s public healthcare system [ 30 ], research suggests that international migrants may also access healthcare at sites that are community-based or religiously-affiliated, especially where there are no fees or requirements for identity documentation or residence status [ 31 ].…”

“…For example, large trials to improve HIV testing uptake among men in South Africa have found substantial barriers to reaching men in communities with high mobility patterns [ 40 ]. A demographic surveillance study from rural South Africa showed that 69% of the adult population cohort migrated out of the study area at least once during a 13 year follow-up period [ 22 ]. Most of these men seek employment opportunities in cities in Gauteng Province, where Johannesburg is located, and yet research describing migrants within these urban destination sites remains limited and often comes from ethnographic rather than HIV studies [ 41 , 42 ].…”

“…Movement into and within South Africa, particularly from rural to urban centers, continues to rise along with the country’s rapid socio-economic growth [ 22 ] and accelerating urbanization throughout the region [ 43 ]. There is a growing recognition of the need to make HIV care more accessible to migrants in order to achieve UNAIDS 95–95-95 goals [ 32 ].…”