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Epidemiologic research among migrant populations is limited by logistical, methodological, and ethical challenges, but it is necessary for informing public health and humanitarian programming.
We describe a methodology to estimate HIV prevalence among Venezuelan migrants in Colombia.
Respondent-driven sampling, a nonprobability sampling method, was selected for attributes of reaching highly networked populations without sampling frames and analytic methods that permit estimation of population parameters. Respondent-driven sampling was modified to permit electronic referral of peers via SMS text messaging and WhatsApp. Participants complete sociobehavioral surveys and rapid HIV and syphilis screening tests with confirmatory testing. HIV treatment is not available for migrants who have entered Colombia through irregular pathways; thus, medicolegal services integrated into posttest counseling provide staff lawyers and legal assistance to participants diagnosed with HIV or syphilis for sustained access to treatment through the national health system. Case finding is integrated into respondent-driven sampling to allow partner referral. This study is implemented by a local community-based organization providing HIV support services and related legal services for Venezuelans in Colombia.
Data collection was launched in 4 cities in July and August 2021. As of November 2021, 3105 of the target 6100 participants were enrolled, with enrollment expected to end by February/March 2022.
Tailored methods that combine community-led efforts with innovations in sampling and linkage to care can aid in advancing health research for migrant and displaced populations. Worldwide trends in displacement and migration underscore the value of improved methods for translation to humanitarian and public health programming.
DERR1-10.2196/36026
The economic crisis and political instability in the Bolivarian Republic of Venezuela has led to mass migration in the Americas, displacing approximately 5.4 million Venezuelans as of September 2020, according to the most recent estimates [
Gaps in HIV diagnostics and treatment in Venezuela since 2015 have limited the availability of reliable estimates of HIV burden. In 2018, the Pan American Health Organization (PAHO) estimated that 69,308 people living with HIV (PLHIV), 87% of whom were registered to receive antiretroviral therapy (ART), were not receiving them owing to nationwide drug shortages [
Colombia currently receives the largest number of displaced Venezuelans in the region. As of February 2021, approximately 1.7 million were living in Colombia [
This paper describes a protocol for community-led HIV surveillance among Venezuelan migrants residing in Colombia. The protocol expands upon a network-based sampling method by integrating case finding and linkage to care through medicolegal partnerships. The findings aim to inform local treatment distribution plans [
The BIENVENIR Project (Bienestar de Venezolanos quienes son Inmigrantes y Refugiados) is a cross-sectional design that uses a hybrid sampling and case finding approach, coupled with medicolegal services to link individuals with HIV diagnosis to HIV treatment and care, regardless of migration status.
Key informant interviews with stakeholders (n=29), including humanitarian and health providers, government officials, and medical providers, were conducted in English and Spanish between June and October 2020. In-depth interviews (n=31) and 1 focus group discussion (n=9) with Venezuelans living in Colombia were conducted in Spanish between April 2021 to June 2021. Data collection was conducted remotely by phone or video teleconference to reduce COVID-19 transmission risks. Formative research served to provide contextual information about the humanitarian situation and programming; availability of HIV prevention and care for Venezuelans in Colombia; the impact of COVID-19 pandemic on these issues and research; and to inform decisions related to the incentives, sampling, and development of survey measures. Qualitative findings will also be used to guide subsequent interpretation of surveillance findings. Finally, formative interviews helped to ensure the study is culturally relevant and appropriate.
Data collection activities are conducted in 2 territories, encompassing the neighboring cities of (1) Bogotá and Soacha and (2) Barranquilla and Soledad (
Distribution of Venezuelan migrants in Colombia by department. Source: Colombian Department of Migration, 2021.
Respondent-driven sampling (RDS), a chain referral sampling method that employs limited referrals within peer networks to achieve target sample sizes, is used to accrue the study sample. RDS is widely used across international settings to sample populations that lack a sampling frame. Research has shown that with sufficient recruitment depth, biases associated with initial peer referrals are minimized [
Sampling commenced at the end of July and August 2021 in Bogotá/Soacha and Barranquilla/Soledad, respectively, and is ongoing. Recruitment started with 19 “seeds” (9-10 per territory)—well-networked individuals who were selected from the target population. Seeds were purposively selected on the basis of being well-respected and influential among peers, socially networked (know at least 10 Venezuelans outside of their household), and diverse in characteristics (eg, age, gender, geographic residence within each city). To minimize cluster effects, we identified and enrolled seeds who did not know each other and who likely did not have overlapping networks. Additional seeds may be initiated at a later date if prior seeds fail to produce peer referrals or if recruitment slows.
Seeds participate in all study activities and are asked to invite 4 adult Venezuelan peers (recruits) to participate in study activities, which is the first sampling wave. Eligible and participating recruits are then asked to refer up to 4 more peer Venezuelans. At the end of each study visit, participants undergo a brief training on how to distribute coupons and refer peers to the study. Participants have the option to use paper or electronic coupons via SMS text messages or WhatsApp to refer peers. Coupons contain study contact information and unique codes that anonymously link seeds/recruiters to recruits for analysis. Although documentation of regular migration status is necessary to acquire a phone in Colombia, 70% of Venezuelan migrants in Colombia report using mobile phones [
RDS is monitored in real time by using the RDS-Analyst platform [
Participation consists of a sociobehavioral survey and dual rapid testing for HIV and syphilis infection, followed by confirmatory testing. At entry, participants undergo screening for eligibility and written consent procedures in a private office space. Participants completed a literacy screener using the Spanish language version of the Rapid Estimate of Adult Literacy in Medicine–Short Form [
We use a secure system for managing participant tracking and data within the study. This system was developed internally for observational (including RDS) and clinical trial research and was customized to this study [
Survey measures included individual, social, and structural domains, drawing upon previously developed measures, as applicable (
Domains and measures included in the survey questionnaire.
Domain | Measures |
Demographics |
Basic demographics adapted from the Colombia Demographic Health Survey [ Food (in)security as measured by the US Food and Drug Administration food security scale [ |
Migration and displacement |
Displacement history (timing, location of residence in Colombia, and migration status, eg, regular or irregular) |
Health |
Recent health history Self-rated health [ Body mass index (self-reported height and weight) Depression symptoms measured by the Patient Health Questionnaire for Depression and Anxiety [ Alcohol measured by Alcohol Use Disorders Identification Test-Concise [ COVID-19 symptoms and testing history |
HIV: behavioral risks and uptake of HIV prevention and care |
HIV acquisition risk behaviors adapted from World Health Organization biobehavioral survey guidelines for populations at risk for HIV [ Access to and engagement in HIV services: HIV testing, HIV prevention [ HIV care continuum: self-reported diagnosis of HIV, engagement in HIV care including CD4 testing, viral load testing, and suppression [ Access to, uptake, and adherence to HIV treatment adapted from the Adult AIDS Clinical Trials Group survey measures [ |
Social measures |
Discrimination using the Everyday Discrimination Scale (short version) [ Violence victimization using the Assessment Screen to Identify Survivors Toolkit for Gender-Based Violence screen for displaced populations [ |
Respondent-driven sampling |
Social network size questions used for respondent-driven sampling weighting procedures [ |
Biological measures include rapid HIV and syphilis screening using Standard Diagnostics BIOLINE HIV/Syphilis Duo with finger-prick blood specimens. Standard Diagnostics BIOLINE HIV/Syphilis Duo has a reported sensitivity of 99.8% and specificity of 100% for anti-HIV antibody detection and a reported sensitivity of 90% and specificity of 99.9% for anti–
Lawyers employed by
The process to obtain a
To support efforts to identify new or undiagnosed infections, we employed a hybrid RDS–case finding approach. Case finding follows World Health Organization and Centers for Disease Control and Prevention guidelines for partner notification services and were adapted to reflect community recommendations to mitigate risk of violations of privacy, breaches in confidentiality, and coercive medical practices [
Assuming a 1% HIV prevalence among general population, based on reports from local providers that suggest a range of 0.5% prevalence among adults to 1.5% prevalence in antenatal care surveillance, alpha .05, 0.005 margin of error, and design effect of 2 that has been suggested for RDS [
Basic descriptive analysis will be performed to estimate the prevalence of key demographic and health characteristics of the sample population. Primary analysis will focus on estimation of HIV prevalence among the general population of Venezuelans residing in the 2 territories, with estimates separately for each territory. Among participants living with HIV infection (prevalent or new diagnoses), we will assess engagement in the HIV care continuum, including the proportion who report being aware of their infection, engaged in HIV care, currently on ART, completing viral load testing in the last 6 months, and having suppressed viral load [
Study activities were reviewed and approved by the ethical review committee at the Universidad el Bosque in Bogotá, Colombia, and the Institutional Review Board at Johns Hopkins School of Public Health (28223). The protocol was also reviewed in accordance with Centers for Disease Control and Prevention human research protection procedures. Formative research with stakeholders was deemed not human subjects research and commenced prior to other study activities.
This study uses multiple strategies to address unique social risks that underlie research with migrant populations, which go beyond risks typically associated with HIV surveillance. Risks for migrant populations largely encompass concerns for social harms related to stigma and discrimination as well as barriers to access to services, particularly for those with irregular migration status. First, we use a vague study title,
The onset of the COVID-19 pandemic occurred between the funding of this project and the initiation of the study activities. Study launch was delayed during the early peaks of the pandemic, and formative research was conducted through secure remote methods at that time. A separate and extensive COVID-19 biosecurity protocol was developed for in-person data collection, and it aligns with local policies. The biosecurity protocol was submitted to all ethical and protocol review committees, and it underwent additional review and approval by an independent Human Subjects Research Restart Committee at Johns Hopkins University before in-person research commenced.
As of November 8, 2021, 3278 people have been screened and 3105 participants have been enrolled across sites, inclusive of 20 seeds, and we have reached a maximum recruitment depth of 12 waves thus far (
Respondent-driven sampling network graphs of participants in Bogotá and Soacha. The large red triangular nodes represent seeds, and the small blue circular nodes represent recruits.
Respondent-driven sampling network graphs of participants in Barranquilla and Soledad. The large red triangular nodes represent seeds, and the small blue circular nodes represent recruits.
Demographic and other characteristics of the study participants as of November 8, 2021.
Characteristics | Territory | |||||||
|
Bogotá and Soacha (n=1684) | Barranquilla and Soledad (n=1421) | Total (N=3105) | |||||
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Age (years), median (IQR) | 32 (26-41) | 33 (26-41) | 32 (26-41) | ||||
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|
|||||||
|
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Bogotá | 861 (51.1) | 0 (0) | 861 (27.7) | |||
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Soacha | 822 (48.8) | 0 (0) | 824 (26.5) | |||
|
|
Barranquilla | 0 (0) | 861 (60.6) | 861 (27.7) | |||
|
|
Soledad | 0 (0) | 560 (39.4) | 558 (18) | |||
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Regular | 522 (31) | 250 (17.6) | 772 (24.9) | |||
|
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Irregular | 1162 (69) | 1171 (82.4) | 2333 (75.1) | |||
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Male | 562 (33.5) | 351 (24.7) | 913 (29.5) | |||
|
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Female | 1091 (65.1) | 1041 (73.3) | 2132 (68.8) | |||
|
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Transgender or Nonbinary | 24 (1.4) | 29 (2) | 53 (1.7) | |||
|
High literacy (Rapid Estimate of Adult Literacy in Medicine–Short Form>6, reference<6), n (%) | 1485 (89.4) | 889 (63) | 2374 (77.3) | ||||
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Lifetime injecting drug use (reference: no) | 37 (2.2) | 22 (1.5) | 59 (1.9) | ||||
|
Reports sex with a cis man (reference: no; denominator cis men and trans women, n=941) | 53 (9.3) | 27 (7.3) | 80 (8.5) | ||||
|
Sex work (last 12 months) | 32 (1.9) | 30 (2.1) | 62 (2) | ||||
|
Lifetime HIV test (reference: no) | 1027 (61.2) | 681 (48) | 1708 (55.1) | ||||
|
Past diagnosis of HIV (reference: last test negative or unknown; n=3099) | 7 (0.4) | 9 (0.6) | 16 (0.5) |
Early evaluation of enrollment and participant data show early signals that the methods described here are both feasible and acceptable for research in this context. The hybrid RDS–case finding approach is an innovation in RDS research, with the goal of increasing our ability to identify new or undiagnosed infections among partners and providing linkage to care. Modification of RDS to permit electronic referral of peers via SMS text messages and WhatsApp enables safe referral of peers while maintaining social distancing in the context of COVID-19. Use of text-message referrals builds on common communication pathways and appears to efficiently support peer referral. Given the tenuous access to HIV treatment of Venezuelans in Colombia with irregular migration status, the integration of medicolegal services in posttest counseling aims to increase access to HIV care, decrease time to ART initiation, as well as reduce untreated syphilis. The high recruitment rate thus far is a testament to the efficiencies of RDS and to the model of community-led research implementation and comprehensive service provision inclusive of HIV prevention and linkage to care, legal services, and other ancillary services. These findings will have direct relevance to Colombia, but methods and lessons learned from this study can be adapted for use across diverse settings with numerous health outcomes. With almost 272 million international migrants globally and over 82 million forcibly displaced persons, of whom 55 million are internally displaced due to conflict and insecurity as of 2020 [
antiretroviral therapy
Bienestar de Venezolanos quienes son Inmigrantes y Refugiados
Pan American Health Organization
people living with HIV
respondent-driven sampling
We acknowledge with gratitude the support and collaboration of Abu S Abdul-Quader, Dante Bugli, Kevin Clarke, Eva Leidman, Horacio Ruiseñor-Escudero, and Paul Young from US Centers for Disease Control and Prevention; Ricardo Luque Núñez from the Ministry of Health and Social Protection in Colombia; and Federico Duarte and Saskia Loochkartt from the United Nations High Commissioner for Refugees. This work was supported by the Centers for Disease Control and Prevention under the terms of cooperative agreement NU2GGH002000-03-01. The Centers for Disease Control and Prevention investigators do not interact with human participants or have access to identifiable data or specimens for research purposes. The contents of this paper are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention or the Department of Health and Human Services.
ALW, PS, and KP conceptualized the design of the study; JRG designed the medicolegal triage system and is the site principal investigator in Colombia; MS coordinates the overall study; JO, JJL, JFR, CQ, AV, YM, and FR supervised and coordinated data collection at each site; JC designed and engineered automated respondent-driven sampling processes and data management system; AJH and WH provide technical support; ALW and MS wrote the initial drafts of this manuscript; and all authors reviewed and contributed to this paper. All authors have approved this paper.
None declared.