Intersecting vulnerabilities, diverging pathways: an intersectional analysis of PrEP access disparities among migrant populations in Belgium.

OBJECTIVE: This study explored how intersecting vulnerability factors reduced migrants' access to HIV Pre-exposure prophylaxis (PrEP) in Belgium, moving beyond single-factor analyses to examine complex, interconnected barriers. METHODS: Drawing on data from a larger study, we conducted a qualitative multi-method study using key informant interviews (n = 8), in-depth interviews with migrant men and a transgender woman, all of whom have sex with men (n = 23) and group discussions with Sub-Saharan African diaspora communities (n = 7 discussions; 51 participants). Data were collected during 2021-2022 and analysed using the framework method with intersectionality theory as the analytical lens. RESULTS: PrEP access barriers operated through three intersectional pathways rather than isolated factors. First, "Papers, precarity and the price of prevention": the intersection of migration policies with sexual orientation created systematic healthcare exclusion: legal precarity generated fear of institutional contact, while the absence of health insurance formally restricted PrEP reimbursement. Economic hardship compounded these barriers, with survival pressures potentially increasing HIV vulnerability through engagement in survival sex work. Second, "Spoken about, not spoken to": the convergence of community-level sexual and cultural norms with experiences of structural racism produced information gaps and a paradox of simultaneous targeting by and exclusion from HIV prevention efforts, reinforced by HIV-related and sexuality-related stigma. Third, "First survive, then prevent": the accumulation of restrictive policies, underfunded services and institutional rigidity created a hierarchy of needs in which basic survival rationally displaced HIV prevention from participants' priorities. Rather than offering predictive trajectories, these pathways function as exploratory mechanisms highlighting broader structural patterns. CONCLUSIONS: Intersectional disadvantages create qualitatively different experiences that compound rather than simply add vulnerability. Effective intervention must address structural inequities and root causes rather than individual risk factors, recognizing that health decisions occur within broader systems of power and privilege.