Introduction

Migrations have significant effects on the immigrants’ general health and sexual health (SH) considering that every foreign country has different sexual practices and beliefs [1], and that these immigrants have to adapt to a new healthcare system. Hence, some diseases, specifically infectious ones, such as sexually transmitted infections (STIs), human immunodeficiency virus (HIV) infection/acquired immunodeficiency syndrome (AIDS), and hepatitis, are more easily transmitted in immigrants than in non-immigrants [2]. However, generally, knowledge about the epidemiological profile of STIs in the immigrant population is insufficient considering that these immigrants do not have access to healthcare services, which contributes to the under-notification of STIs [3].

According to the World Health Organization (WHO), deaths and disabilities related to the problems of SH represent one-third of the world’s morbidity burden among women of reproductive age (15–44 years old) and almost 20% of the overall disease morbidity burden [4]. The WHO also emphasized that more than one million individuals acquire an STI daily worldwide [3, 5]. In Haiti, morbidity is dominated by HIV/AIDS-related infections, particularly in women, with a prevalence of 1.2% [6]. It is estimated that 85% of HIV-positive adults in the Caribbean live in Haiti [7].

In Brazil, chlamydia and gonorrhea are the highest rates of curable infections in the sexually active population, with 1,967,200 and 1,541,800 cases, respectively. In the southern region of the country, the AIDS detection rate in the last 10 years has remained stable, with an average of 31.1 cases per 100,000 inhabitants [8].

Brazil has more than 73,094 Haitian immigrants [9], of whom between 2,500 and 7,000 live in the State of Rio Grande do Sul [10]. Despite this, the epidemiological profiles of STIs and other characteristics related to the SH of Haitians are unknown in Brazil, considering that a study that assessed the SH of Haitians has not been conducted yet.

This study aimed to evaluate the SH of the Haitian immigrant population living in the State of Rio Grande do Sul, identifying in a self-reported manner the prevalence of STIs, factors associated with STI presence, and changes in sexual behaviors related to migration.

Materials and Methods

Results

Among the 201 individuals who participated in the survey, 58.06% were men. There was no significant difference between the mean age of men (31 years) and women (30 years) (p = 0.04). Moreover, a higher proportion of women in the younger age group and a higher proportion of men in the older age group were observed. Women and men were similar regarding their marital status. A higher proportion of men were employed (78.50%). Although there was no difference on the educational level between sexes, most of the participants were in high school level of education, and 28% of men presented with higher educational level. The vast majority of participants received less than R$ 1.874,00 per month, with men presenting with higher income than women. Moreover, approximately 50% of women had no income (Table 1).

Regarding sexual partners, more than half (57.14%) had a sexual partner during the last 3 months, and only 3.01% had more than two sexual partners (all men). More than half (63.19%) of the participants reported to have a regular partner during the last 6 months. Most (64.9%) participants referred to using a contraceptive method, with the use of condom being the most common (42.79%). However, only half (49.16%) of them reported using condoms in the last sexual intercourse. Moreover, women used contraceptive methods less than men. The most mentioned sexual practices were vaginal penetration, hugging, and oral sex (64.18%, 47.26%, and 24.38%, respectively). Only 2.33% of the participants reported having sex with partners of both sexes, and 1.73% reported having sex with partners of the same sex (all men). The two main meeting places of couples today were restaurants/parties (31.43%) and schools (28.57%) (Table 2).

The presence of signs and symptoms during sexual intercourse was also reported more frequently by women, with pain (26.9%) and burning (15.4%) sensation being the two main symptoms reported, compared to men (1.9% and 3.7%, respectively) (Table 3). Moreover, 66.20% of women and 22.00% of men declared having had STI at least once in their lifetime, and 38.80% of these women and 9% of these men declared presenting an STI at the time of the interview (Figure 1). It should be emphasized that trichomoniasis was the most common STI reported by women.

Regarding the HIV test, 76.63% of the participants reported undergoing the HIV test at some point in their lives. However, for participants who knew the results of their HIV test, none of them have declared a positive result. Regarding the habits during sexual intercourse, 24.72% of the interviewees reported changes in their sexual behaviors (Table 3).

Although there was a difference in the proportion between the sexes regarding the presence of self-declared active STIs (Table 3), none of the factors studied were associated with the presence of STIs considering that the prevalence ratio was calculated using the modified Poisson regression model (Table 4).

Discussions

Recently, Haitian men more frequently immigrate to Brazil compared to Haitian women [12]. Women have a higher frequency of self-declared lifelong active STIs than men. Most of the participants refer to having a low number of sexual partners and fixed partnerships, and a low frequency of respondents have performed sexual intercourse with same-sex individuals. None of the interviewees reported having HIV, although most of the participants had already undergone the test. This is the first study to address the SH of Haitian immigrants in Brazil and one of the few studies addressing the SH of Haitian immigrants in Brazil in the literature.

A survey conducted in Chapecó region, which aimed to evaluate the epidemiological profile of Haitian immigrants, consisted of 573 individuals (men, 54.1% [12], a proportion lower than that found in the study conducted in Rio Grande do Sul). Although the increase in the Haitian female population has been reported, the proportion of men who participated in the previous studies was significantly higher compared to women, a result consistent in the present study, suggesting that researchers have difficulty accessing the female population. However, the highest proportion of men could be explained by the fact that they first immigrate before women to look for work and a place of residence, eventually bringing their wives and children when they are already stable [13, 14] Most immigrants have a good educational level, which has been confirmed in two other studies. The first one, which was conducted in Chapecó, reveals that most Haitians have completed high school or second grade [12]. In the second study, Da Silva reported that most Haitian immigrants have studied for more than 10 years, which is equivalent to high school educational level in Brazil [13].

Considering that studies assessing the SH of immigrants in Brazil have not been conducted yet, conducting compare studies is relatively difficult. However, a study comprising another population was conducted. According to a study [15] conducted in the triple border of the Amazon, Brazil, in which interviews and STI/HIV tests were used, the following STIs were observed in men and women: gonorrhea (1.1% and 0.3%, respectively), chlamydia (1.4% and 4.8%, respectively), active syphilis (3.2% and 2.6%, respectively), hepatitis C virus (0.7% and 0.7%, respectively), and HIV infection (1.4% and 0.0%, respectively). According to the study by Norris et al., HIV and syphilis screening tests were also performed, with a prevalence of HIV and syphilis of 9% and 12% in men and 6% and 11% in women, respectively [16]. The results of both the previous studies are inconsistent with the result of the present study. These differences are attributed to the significant differences in the population studied, with a widespread HIV epidemic in African countries and some Caribbean countries [17, 18]. However, a study on migration and women’s health revealed that the health of immigrants has significantly worsened [19] considering that they are significantly discriminated as women and as immigrants [20, 21, 22, 23]. Additionally, they are significantly at risk of sexual abuse, rape, and violence, specifically when they are staying in refugee camps [19, 24], which may explain the higher frequencies of STIs observed.

Regarding sexual behaviors, although condom use has not been associated with the presence of STI, it is important to emphasize that more men reported using condoms than women. This fact is consistent with the study conducted by Martins et al. in Brazil that assessed the prevalence of STI, demonstrating the lack of condom use in women [25]. It has been concluded that women frequently have no protection and choices regarding their sexual practices because they submit themselves to their partners; thus, they are highly exposed to different types of transmitted diseases [25]. A common example is women living in developing countries who submit themselves to their partners during marital sexual intercourse, making them vulnerable to STI/HIV infection [26].

The vast majority of Haitian immigrants reported having only one sexual partner in the last 6 months. They also reported having heterosexual intercourse, with vaginal penetration as the most common sexual practice. These data are found in the traditional literature. Furthermore, considering that the frequency of STI was significantly high in this study, sexual intercourse with several partners and homosexual relationships are generally considered as risk factors for the transmission of STI/HIV [27]. Although these data were also found in the studies of Benzaken et al. and Borges, the first study conducted in the Amazon reported that only 38.5% of the individuals who participated in the study have reported condom use [15]. The second study consisted of immigrants from sub-Saharan Africa living in Lisbon and showed [28] that most immigrants declared themselves as heterosexual.

It is noteworthy that, in addition to the factors previously described, the study also found that 35.10% of immigrant women reported changes in their sexual behaviors. Specifically, they reported having increased sexual libido since they immigrated to Brazil. A study conducted in Turkey [29] confirmed this result, which seems to be frequently observed in studies conducted with individuals immigrating to Europe. The author explains that the change in social relations found in the West mainly affects immigrant women. A migrating woman feels significantly secured not only because she earns money and becomes financially independent but also because she is now living away from her native village, which sometimes controls an individual’s morality [29]. Hence, a migrating woman has a lower stress level, consequently increasing her sexual libido. However, this phenomenon has corresponding risk, known as acculturation, which has been studied in several immigrant groups [30, 31].

Limitations and Strengths

Some important limitations of the present study should be highlighted. There was a significant difficulty in accessing Haitian immigrants considering their insufficient knowledge about the existence of population research and their fear of participation because of the belief that the study might cause problems regarding their stay in the country; hence, this study has a small sample size. Despite the estimated 2.5 to 7,000 Haitian immigrants in Rio Grande do Sul, only 201 participants were included in the study. It should also be emphasized that SH is a controversial subject for the population studied. Therefore, the sensitivity and discomfort that the participants felt when answering the questions negatively affected their participation in the study. As a result, potential participants were provided with sufficient time in deciding whether they would like to participate in the study. This might lead to classification bias because we cannot exclude that individuals with active infection have not reported the presence of infection or were unaware of their condition due to insufficient healthcare access were. Although immigrants can access the Brazilian public healthcare services, cultural barriers such as language and culture may negatively affect their healthcare access and outcomes.

This study is the first to address the topic of sexual health in Haitian immigrants. Through this study, SH actions in immigrants—for example, strengthening the orientation for condom use as a contraceptive method—can be implemented. This study also serves as a reference in further conducting several studies that perform rapid diagnostic HIV/STI testing in this specific population in Brazil.

Conclusion

In conclusion, this study shows that a higher frequency of STIs is observed in Haitian female immigrants compared to Haitian male immigrants. However, considering that several risk factors for STIs were determined in this study due to the participants’ significant differences, further studies with larger sample sizes are required to accurately determine the risk factors associated with the prevalence of STI in this vulnerable group, and studies incorporating HIV/STI tests to determine the presence of STI are also necessary.