PhD defence Ella Van Landeghem

Supervisors

• Dr. Christiana Nöstlinger (ITM)

• Prof. dr. Bernadette Hensen (ITM)

• Prof. dr. Milena Belloni (UA ) 

Summary

Despite significant advances in HIV prevention, including the introduction of pre-exposure prophylaxis (PrEP), access to and use of these tools has not been equitably distributed. In Belgium, migrants — or people with a non-Belgian nationality— carry a disproportionate burden of new HIV diagnoses, yet remain strikingly underrepresented among PrEP users. While PrEP is reimbursed and available in Belgium, the structural, social, and institutional conditions shaping whether migrants can actually access it remain poorly understood. Previous studies and public health interventions have tended to focus on individual-level barriers such as knowledge deficits or risk perception, without capturing how intersecting systems of inequality produce and sustain differential access. This dissertation examines the structural and intersectional mechanisms driving PrEP disparities among migrants in Belgium, drawing on intersectionality theory to move beyond individual-level explanations toward a critical analysis of how policies and governance, healthcare organization, racism, and stigma interact to constrain HIV prevention access for differently positioned migrant groups.

The research employed an inductive, qualitative, community-based multi-method design consisting of three integrated sub-studies. Data were collected between October 2020 and June 2022 in Belgium. Sub-study 1 conducted eight key informant interviews with healthcare providers and community stakeholders, and 23 in-depth interviews with migrant men and transgender women who have sex with men, analysed using a constructivist grounded theory approach. Sub-study 2 adopted a participatory action research design, collaborating with three community researchers to conduct seven group discussions with Sub-Saharan African diaspora communities, analysed using reflexive thematic analysis. Sub-study 3 performed a secondary intersectional analysis of the combined dataset from both sub-studies, using the framework method to systematically examine how interconnected systems of power shaped participants' differentiated experiences and PrEP trajectories across cases.

Findings reveal that PrEP access barriers operated through complex intersectional pathways rather than as isolated factors. Legal status emerged as a foundational axis of exclusion: people without residence status faced both direct ineligibility for reimbursement and indirect deterrents including fear of institutional contact and administrative burden. Participatory findings demonstrated that Sub-Saharan African diaspora communities were not "hard to reach" but largely "hardly reached" — feeling excluded from PrEP promotion efforts and often unaware of PrEP's existence. The intersectional analysis identified three mechanisms through which multiple structural determinants converged: the intersection of restrictive migration policies with healthcare organization; the convergence of cultural taboos, stigma, and racialization processes; and socio-economic precarity leading to competing priorities that displace HIV prevention from everyday survival concerns. These mechanisms produced qualitatively distinct experiences of exclusion that compounded rather than simply added vulnerability across differently positioned migrant groups.

These findings have important implications for HIV prevention policy and practice in Belgium. Effective responses to PrEP disparities require reorienting prevention services away from individual risk paradigms toward structural interventions that address the root conditions shaping migrants' lives. This includes reconsidering how PrEP is promoted and delivered, investing in community-led approaches, and acknowledging that healthcare access cannot be improved in isolation from broader migration and social protection policy. This dissertation contributes to social health sciences by demonstrating the analytical value of intersectionality for understanding biomedical prevention disparities, and offers concrete recommendations for creating more equitable PrEP access pathways that centre the communities most affected.