Section 6-1: Canadian Guidelines on Sexually Transmitted Infections – Specific Populations – Immigrants and refugees

Section 6 - Specific Populations

Immigrants and Refugees

Definitions

A legal immigrant is a person born outside of Canada who has been granted the right to live in Canada permanently by immigration authorities, whereas an illegal immigrant has not been granted such a right. A refugee is a person outside his/her country of nationality who is unable or unwilling to return because of persecution on account of race, religion, nationality, membership in a particular social group, or political opinion.Footnote 1

Epidemiology

Over 5 million Canadians were born outside of the country, and about 250,000 new immigrants arrive in Canada each year,Footnote 2,Footnote 5 but data on migrant health in Canada are limited. Recent immigrants underuse health services; it has not been established whether this is associated with cultural barriers, language barriers, reduced perceived needs, reduced needs (this healthy immigrant effect refers to recent immigrants being healthier than Canadian-born individuals) or socioeconomic barriers (e.g., lack of access to telephone, transportation to clinic, etc).Footnote 4 - 7 Many countries of origin have much higher rates of sexually transmitted infections (STIs) than Canada.Footnote 8,Footnote 9

Prevention and Control

Health care providers should pay special attention to the complex and stressful process that newcomers may have to undergo to integrate into a new society. Potential loss of social support and cultural identity during the transition may prove challenging. Illegal immigrants present even greater challenges because of the underground nature of their existence. They do not have health insurance and may avoid seeking medical attention for fear of being deported.

Clinical and public health services need to be sensitized to the following issues in the provision of affordable, comprehensive and culturally/linguistically appropriate sexual health counselling and STI prevention and management services for the immigrant and refugee populationFootnote 10Footnote 12:

  • Language, cultural and socioeconomic barriers may prevent access to STI and prevention services.
  • This population may experience social isolation from loss of social support.
  • Understanding social/sexual mixing patterns, health belief systems, practices and taboos is important in STI prevention, diagnosis, management and partner notification.
  • Health care providers need to be aware of stigma and discrimination so that individuals from high-prevalence countries are not stigmatized.
  • Mental health, including post-traumatic stress disorder, can influence behaviours and interaction with the health system.
  • Gender power differential and domestic violence can be barriers to prevention and partner notification.
  • Patients may have a history of torture and rape.
  • Patients my have a limited knowledge of STIs in Canada and other health resources.
  • There may be a travel-related risk of patients either carrying an STI from their place of origin or of acquiring an STI when they return home to visit friends/relatives. This population is less likely to seek pre-travel advice or post-travel care.

Evaluation

Risk Assessment

A non-judgmental and culturally sensitive STI risk assessment should be part of a comprehensive approach to the prevention and early detection of STIs. Issues to explore include the following:

  • The presence of opposite-sex and same-sex activity.
  • The range and frequency of various sexual practices, taking into account cultural and gender context (see Primary Care and Sexually Transmitted Infections chapter).
  • The patient’s history of STIs, including HIV, with awareness of the stigma and discrimination that come with these infections.
  • Injection drug use (IDU).
  • Suboptimal screening in pregnant women.
Screening

Based on the results of the risk assessment, conventional STI screening in asymptomatic individuals should be considered for those engaging in high-risk practices (see Primary Care and Sexually Transmitted Infections chapter):

  • Syphilis testing:
    • Syphilis serology (non-treponemal only) is a standard Citizenship and Immigration Canada (CIC) test requirement for immigrant and refugee applicants 15 years of age or over.
    • Possible false-positive syphilis tests should be kept in mind in individuals from areas of the world where pinta, yaws and bejel are prevalentFootnote 13 (see Syphilis chapter).
  • HIV serology (unless known to be seropositive):
    • Since 2002, HIV serology has been a standard CIC test requirement for immigrant and refugee applicants 15 years of age or over, and for a child with blood/blood product exposure, born to an HIV-infected mother or being considered as an international adoptee.
    • High-risk individuals who have not had a recent HIV antibody test should be counselled and tested accordingly (see Human Immunodeficiency Virus Infections chapter).
    • A child should be offered HIV testing unless there is a reason not to do so, especially if it is likely that the child was born to or breastfed by an undiagnosed HIV-infected mother.

At present, HIV and syphilis are the only mandatory STI tests for immigrant/refugee applicants. Some laboratories abroad may have quality-control issues, and some applicants may pay to obtain negative tests in order to facilitate their application.

For individuals with anogenital symptoms, it is important to keep in mind the following when considering appropriate investigation:

  • Chancroid and lymphogranuloma venereum (LGV) are common in parts of Africa, Asia, the Caribbean and Latin America (see Chancroid and Lymphogranuloma Venereum chapters).
  • For assessment of genital ulcers, see Genital Ulcer Disease chapter.
  • Quinolone-resistant gonorrhea is particularly prevalent in Asia, the Pacific Islands, Australia, Israel, the United Kingdom, parts of the United States and Canada (see Gonococcal Infections chapter).
Hepatitis B and C

Currently, hepatitis B and C testing are not required for the immigration and refugee application process in Canada. However, the prevalence of chronic hepatitis B infection in Asia, Africa, Eastern Europe and Latin America is much higher than in Canada. In asymptomatic individuals from high-prevalence regions, hepatitis B screening should be undertaken for either hepatitis B surface antigen carriage and the antibody to hepatitis B surface antigen (for immunity) or the antibody to hepatitis B core antigen (for past exposure to the virus). Further hepatitis B testing may be performed depending on the results of the screening tests. Household and sexual contacts of a hepatitis B carrier should be assessed. Those who have not been exposed to hepatitis B or previously immunized should receive a three-dose series of the hepatitis B vaccine (see Canadian Immunization GuideFootnote 14 and Hepatitis B Virus Infections chapter).

The prevalence of chronic hepatitis C infection in Asia, Africa and the Mediterranean is much higher than in Canada.Footnote 15 Hepatitis C is primarily transmitted parenterally. Recently, transmission of hepatitis C has been increasingly reported in Europe among men who have sex with men who are not injection drug users, in association with fisting, LGV, HIV and other STIs.Footnote 16Footnote 21 As with all patients, hepatitis C should be considered in immigrants and refugees with any of the following risk factorsFootnote 19Footnote 32:

  • Any history of IDU.
  • Receipt of contaminated blood/blood products in some countries, even after 1990, because of inadequate quality control in the laboratory or inadequate blood screening.
  • Procedures (e.g., injection, surgery, transfusion, ceremonial rituals, acupuncture) involving sharing of contaminated equipment in parts of the world with high hepatitis C virus (HCV) prevalence.
  • Exposure to hepatitis C in a prison setting.
  • Needlestick or sharp injuries.
  • Non-sterile tattooing and body piercing.
  • Hemodialysis.
  • Sharing personal items contaminated with blood from an HCV-infected individual (e.g., razors, nail clippers, toothbrush).
  • Sharing intranasal equipment for snorting drugs.
  • Hepatitis B infection.
  • HIV infection.
  • Being a child born to a mother infected with HCV.
  • Undiagnosed liver disease.

Sexual transmission is usually inefficient, and the risk of hepatitis C is slightly increased in individuals with the following risk factors:

  • A sexual partner with HCV.
  • Multiple sexual partners.
  • HIV and other STI co-infections.
  • Practicing anal intercourse.

Specimen Collection and Laboratory Diagnosis

(See Laboratory Diagnosis of Sexually Transmitted Infections chapter. See individual chapters for specific STIs/syndromes.)

  • Same as for all patients.
  • Please note that specimen collection can be affected by a history of female genital mutilation. The genital structure may appear different, and visualization of the cervix may not be possible with a standard-size speculum. Performing a bimanual pelvic examination may also be difficult, especially if the introitus has been sutured.
  • In many cultures, screening compliance is poor if swabs are used because of the invasive nature of specimen collection. Some immigrants and refugees have very limited opportunity to interface with the health system, especially some patients who may have cultural sensitivities toward health care providers of the opposite sex. Urine nucleic acid amplification test screening of high-risk individuals can enhance compliance and patient comfort.

Management and Treatment

(See individual chapters for specific STIs/syndromes.)

Same as for all patients.

  • It is important to address sociocultural and economic factors that may affect treatment adherence. Language barriers may contribute to difficulty following instructions on why and how to take medications, practice safer sex etc. In some cultures, it may be difficult to discuss monogamy or condom use.
  • It is important to obtain a history of traditional/herbal medicine to minimize toxicities and drug interactions.

Reporting and Partner Notification

(See individual chapters for specific STIs/syndromes.)

Same as for all patients.

  • It is important to address sociocultural factors that may affect partner notification. Language barriers may contribute to difficulty understanding the importance of partner notification. In some cultures, fear of domestic violence can be an issue with partner notification.

Follow-up

  • Same as for all clients.
  • Clients who receive their first dose of hepatitis B vaccination should be reminded to return to complete the immunization series.

References

Report a problem or mistake on this page
Please select all that apply:

Privacy statement

Thank you for your help!

You will not receive a reply. For enquiries, contact us.

Date modified: