Stigma Regarding HIV and Sexual Identity as Barriers to Accessing HIV Testing and Prevention Services Among Gay and Bisexual Migrants in Australia

Stigma is a significant contributor to the HIV diagnosis disparities experienced among migrants who are gay and bisexual men (GBM) living in high-income countries. We conducted interviews with 24 migrant GBM in Australia diagnosed with HIV from 2017 onwards, who since their diagnosis had become well-connected to sexual health services and participation in research. Interviews were conducted between October 2018 and December 2019. We aimed to identify how HIV and sexual identity stigmas were barriers to accessing HIV testing and prevention. These stigmas were deeply embedded into social, cultural, and institutional settings in participants’ countries of origin, resulting in poor HIV literacy, reluctance to access HIV-related services, including HIV testing, and fears of being identified as gay/bisexual publicly. Underpinned by internalised stigma, these fears and poor outcomes often persisted after moving to Australia. Other barriers to accessing HIV-related services in Australia included apprehension about a potential HIV-positive result and the possibility of visa cancellation, concerns about confidentiality, and a lack of confidence and support in navigating the healthcare system, including how to access pre-exposure prophylaxis. Addressing these multifaceted HIV testing and prevention barriers requires policies, systems, and interventions that increase health literacy about HIV testing, prevention, and treatment; build trust and confidence when navigating Australian health services; and reduce the impacts of HIV and sexual identity stigmas in migrants’ countries of origin on their experiences in Australia.


Introduction
Stigma is a social process of exclusion, where an individual or group possesses an attribute viewed at discrediting that contradicts what a broader social group deems normal or acceptable (Goffman, 1963). Stigma can occur at the structural level in the policies and actions of institutions (e.g., governments, media, religions, health services) and/or at the social level in the beliefs of and interactions shared between groups and individuals (e.g., interpersonal relations with friends, partners, and healthcare providers, or in the beliefs a society holds about a group of people) (Earnshaw & Quinn, 2012;Link & Phelan, 2001). Stigma operates in various forms, including experienced or enacted stigma (actual experiences of stigma and prejudice), perceived stigma (an individual's perceptions of stigmatising attitudes present in various settings), anticipated stigma (the expectations of being stigmatised and treated poorly by others), and internalised stigma (accepting negative stereotypes about one's identity as true or feeling ashamed of one's identity due to the way it is framed in society) (Broady et al., 2018;Quinn et al., 2014;Turan et al., 2017). Stigma can be intersectional; one person might experience multiple layers of stigma relating to several marginalised identities at once (Doyal, 2009).
Globally, migrants in high-income countries are disproportionately at risk of acquiring HIV (Aung et al., 2020;ECDC & WHO Europe, 2016). HIV stigma is a persistent driving force exacerbating this health inequality (Alvarez-del Acro et al., 2017;Blondell et al., 2015;Gari et al., 2013;Katz et al., 2013). Across many migrant populations, HIV stigma has consistently been found to act as a barrier to accessing sexual health services, HIV testing and prevention, and HIV treatment uptake, with fears of judgement from healthcare providers, limited understanding of healthcare systems, and concerns about confidentiality commonly reported (Agu et al., 2016;Blondell et al., 2015;Gari et al., 2013;Gray et al., 2018Gray et al., , 2019Hatzenbuehler et al., 2013;Katz et al., 2013;Lewis & Wilson, 2017;Manirankunda et al., 2009;Mey et al., 2017;Mullens et al., 2018;Phillips et al., 2020;Ross et al., 2018;Ziersch et al., 2021). In migrants' countries of origin, there are often broad social and structural barriers relating to stigma that impede their capacity or desire to engage with health services. For example, sociocultural norms that denigrate HIV, a lack of openness and discussion about HIV and sex in social, sexual, and healthcare contexts, and inadequate sexual health services mean that migrants may come to new countries with limited health literacy and internalised fears of HIV (Gray et al., 2018;Mullens et al., 2018;Phillips et al., 2020).
In Australia, gay, bisexual, and other men who have sex with men (GBM) account for the majority (67%) of HIV notifications each year (Institute, 2020), and this is concentrated in migrant GBM. While there was a 45% decline among Australian-born GBM in HIV notifications between 2014 and 2018, there was a 3% increase among migrant GBM, particularly those born in Asia and Latin America (Aung et al., 2020). Given this epidemiology, there has been an increased focus on disparities in HIV and sexual health for migrants. In addition to HIV stigma, migrant GBM may have to contend with deeply embedded stigma regarding homosexuality in their countries of origin (Körner, 2007;Phillips et al., 2020;Ziersch et al., 2021). As a result, some migrant GBM can be fearful of judgement, shaming, and being identified as gay publicly, and as such may repress and hide their sexual identities in order to be seen as "normal" (heterosexual) in their country of origin (Phillips et al., 2020). This intersection of HIV stigma and sexuality-based stigma can produce health inequalities for migrant GBM, including lower HIV and sexually transmitted infection (STI) testing and less use of biomedical HIV prevention strategies such as HIV pre-exposure prophylaxis (PrEP), especially among those without subsidised access to Australia's universal healthcare system, Medicare (Blackshaw et al., 2019;MacGibbon et al., 2021;Medland et al., 2018;Ryan et al., 2019). In Australia, anyone who attends publicly funded sexual health clinics can access free STI testing regardless of visa or citizenship status. However, while anyone can obtain a script for PrEP using sexual health clinics, migrants who do not have Medicare are generally unable to access PrEP pills at the publicly subsidised cost.
Despite migrant GBM being disproportionately at risk of acquiring HIV in Australia, there has been limited qualitative research conducted into their specific understandings and experiences relating to both HIV and sexual identity (except, for example, Phillips et al., 2020). It is important to understand Australian migrant GBM's experiences of both sexual identity and HIV because it is likely these attributes are innately interconnected. HIV is commonly transmitted through anal sex, which implicates GBM as a community, promoting a perception that HIV is associated with male homosexuality. Over time, this has meant stigmas regarding HIV and homosexuality have become conflated in public discourse and that GBM have inevitably had to contend with negotiating sexuality in conjunction with HIV prevention and transmission. There are also further gaps in the literature because most of what is available is quantitative (and describes disparities and outcomes but does not provide nuanced insight into experiences), international, and/or it explores migrants as a broad population without specifically attending to the experiences of migrant GBM in Australia as a unique population. To address this issue, we utilise qualitative interviews to explore the experiences of GBM migrants 1 3 born in non-English-speaking countries who were diagnosed with HIV after migrating to Australia. This paper is focused on participants' understandings and practices relating to sexual identity and HIV prior to diagnosis, in the context of their migration experience. Our aim was to provide insight into the social, cultural, structural, and behavioural circumstances contributing to new HIV diagnoses among migrant GBM.

Methods
We conducted interviews with 24 migrant GBM who had been diagnosed with HIV from 2017 onwards in Sydney, Australia. Interviews were conducted between October 2018 and December 2019. Ethical approval was received from the Human Research Ethics Committees of UNSW and ACON.

Eligibility
To be eligible, participants must have been born in a non-English-speaking country in Asia, Latin America, Africa, the Middle East, or Eastern Europe; been diagnosed with HIV in Australia on or after 1 January 2017; been diagnosed at or had visited one of six HIV sexual health clinic; and be able to participate in the interview in English, Mandarin, Thai, Vietnamese, Spanish, or Brazilian-Portuguese. Participants gave verbal consent at the recruiting site for their contact details to be forwarded to the study coordinator to arrange an interview. Participants were given a $30 gift card for their participation.

Data Collection
Semi-structured interviews were conducted with 24 men in a private room at a community organisation or a sexual health clinic. Interviews in English were conducted by two members of the study team (SP and EA). Interviews in languages other than English were conducted by four cultural support workers from a multicultural HIV and hepatitis organisation who were provided with training in qualitative interviewing techniques and who fluently spoke the preferred language of the participant. Eighteen interviews were completed in English, three in Spanish, one in Thai, one in Mandarin, and one in Brazilian-Portuguese. Interviews were generally between 60 and 90 min in length, were audio-recorded, transcribed verbatim, and de-identified. The six interviews conducted in non-English languages were transcribed into the language by the person who conducted the interview and then translated. Interviews covered participants' experiences in their country of origin in relation to sexual identity and HIV, their social and sexual networks, sexual behaviour, HIV testing and prevention practices, and HIV knowledge since the migration to Australia.

Analysis
Interviews were analysed using reflexive thematic analysis (Braun & Clarke, 2019). The process began with a close reading of each transcript to ensure familiarity with the data. Transcripts were then imported into NVivo version 12 for coding. As each transcript was re-read, recurring patterns from the data were categorised into a set of codes. After this point, codes that connected to each other were grouped thematically. For this paper, data relating to HIV and sexual identity in participants' countries of origin, and networks and sexual identity, and barriers to HIV testing, condoms, discussing sexual health, and PrEP uptake after migration to Australia are utilised. All analyses were conducted by SP. The interviewers met regularly to exchange reflections and ideas and to check that interpretations were accurate. Where interpretations did not match, the issue was raised in meetings with all members of the research team to explore possible solutions. Upon receiving advice and opinions, SP ultimately decided which interpretation to take. All members of the research team work as clinicians, epidemiological and social researchers, or at HIV and gay community organisations. Together, the research team has decades of expertise in HIV prevention and transmission and working with people living with HIV, GBM, and migrants.

Sample
The demographics of the sample are presented in Table 1. Of the 24 men who participated, 21 identified as gay and three as bisexual. Ages ranged from 19 to 64 with a median of 33 (IQR 25-37). Nine were born in Southeast Asia (three in the Philippines, two in Thailand, two in Vietnam, one in Malaysia, and one in Cambodia), eight in Latin America (three in Mexico, two in Colombia, one in Ecuador, one in Peru, and one in Brazil), five in Northeast Asia (two in Taiwan, two in mainland China, and one in South Korea), and one each in South Asia (India) and Eastern Europe (Russia). Half came to Australia on a student visa. At the time of the interview, thirteen had access to Medicare and 11 did not. The majority had tertiary education. All participants had an undetectable viral load (UVL) and were well connected to HIV care at the time of their interview.

Stigma Regarding HIV and Homosexuality
Participants grew up in 15 different countries, each with their own unique social, cultural, health, economic, and political contexts. Yet, despite this contextual diversity, almost all participants frequently called attention to the deeply entrenched stigma regarding both HIV and homosexuality in their countries of origin. The similarities between participants' descriptions regarding stigma clearly showed that it was ubiquitous across the countries in which participants were raised. Participants' use of language was particularly telling of this stigma. Many said that it was taboo to discuss HIV in their countries of origin and that people living with HIV were marginalised, considered dirty, and were outcasts. Regarding homosexuality, most participants said that it was considered wrong and a sin to be gay/bisexual and that homophobia was common. Conservative religious values, homophobic laws, familial expectations, and cultural norms had a significant influence on structural and social stigma, instilling a culture of intolerance of homosexuality. In particular, participants born in Asian countries explained that the expectation to follow the idealised trajectory of marriage and procreation the family desired was immense and that this trajectory did not include being gay/ bisexual. It was not uncommon for these participants to explain that the family was the first-order priority and that the desires of the individual were the second-order priority.
I wasn't sexually active 'cause I was studying, living with family. I'm really careful, and very conservative in my sexual desires. And considering family background, Philippino culture is really conservative and in terms of being gay, it's an embarrassment for the As a result of these expectations, participants believed that coming out as gay publicly might expose the family to shame and coming out as gay to the family might expose the participant to being socially outcast. Crucial to participants' descriptions was that HIV and homosexuality stigmas were innately connected-that they informed each other and had a compounding effect in how participants understood sexuality, HIV prevention, and self. For example, one participant described how he had internalised negative attitudes towards his sexuality and that this had consequences on his engagement with HIV.

With my background, things are so kind of obscure and you don't want anyone to know, and you have to be very secretive about things, so how can you make yourself not feel dirty or bad yourself? So yeah, most people [in country of origin] will explore but won't feel very nice about them in the beginning… So then I don't know anything about HIV because I was already scared of having sex (35, Latin America)
Though not all participants made direct links between HIV and homosexuality like this participant, many described both stigmas as impacting their perceptions.

Inadequacy of Health Services and Invisibility of Gay/ Bisexual Communities and Identities
Participants commonly reported that, in connection to widespread stigma, there was a lack of public visibility of HIV and homosexuality, inadequate sexual health services and health promotion, and limited acceptance of gay communities and identities. For example, the below participant explained that there were limited campaigns for HIV testing in his country of origin and very discreet gay communities that rarely received attention in public health.

Not as much as it is here [Australia] I would say because there's no governmental campaigns, especially for gay men, to be going for regular tests or getting diagnosed. There is no particular movement. But it's mostly pocketed within very small, like, the
LGBT community is very discreet not very conspicuous in the social health structure (39, Southeast Asia) Participants often compared the services and spaces available in their countries of origin to those in Australia, reporting that their more positive experiences after arriving in Australia made them realise how comparatively inadequate their experiences had been in their country of origin. While overall the majority of participants said they lacked adequate sexual health services and gay community visibility, there was some diversity in the way participants described what was available to them. In relation to sexual health services, one participant from Mexico explained that there was free access to HIV treatments for people living with HIV and another from Taiwan explained that his country did provide education about HIV and STI prevention. In relation to sexual identity, two participants from Mexico and Cambodia explained that there was some support for gay communities and identities (at least in more metropolitan areas), but this was almost always qualified by an acknowledgement that many GBM had significant fears voicing their sexual identity publicly.

Consequences of Stigma on HIV Knowledge, Testing, and Prevention
The inadequacy of health services and stigma relating to HIV and homosexuality in participants' countries of origin had direct consequences on HIV testing, prevention, and knowledge. Only nine participants said they regularly tested (at least twice per year) for HIV in their country of origin; the majority had never tested or had only tested once before arrival in Australia. Participants described several barriers to testing in their country of origin (Table 2).
Most participants reported that they had low HIV literacy in their country of origin, with some having internalised public rhetoric that positioned HIV as terminal, that people living with HIV should be avoided, and/or that being diagnosed with HIV would lead to being exiled from family, social networks, and community.

I will say I only understand what HIV is just last year [after migration]. Before, in [country of origin]
, all the media, they're warning people, is so strong. It seems like HIV or AIDS people very yucky and must be avoided. Don't talk to them. Don't touch them. That the information I got from my country (44,Southeast Asia) Yet, despite general reports of experiencing barriers to HIV testing and having poor HIV literacy, and despite the ubiquity with which stigma and the inadequacy of services were described, there was nonetheless some diversity in HIV testing practices (as evidenced by the nine participants who did test regularly). These different practices often depended on the norms and availability of services in countries of origin. For example, all three participants from Mexico tested for HIV at least twice per year, and all similarly described that testing was generally accessible in Mexico, notwithstanding that they still reported experiences or anticipation of stigma when accessing services.
Many participants did not know of any other HIV prevention options aside from condoms. Most reported that they mostly used condoms with casual partners, but most had nonetheless participated in anal sex without condoms infrequently. Given the taboo nature of HIV and sexual health in their country of origin, participants felt uncomfortable discussing condoms and HIV status with sexual partners and generally avoided the topic.

Consequences of Stigma on Sexual Identity
Stigma also had direct consequences on participants' motivations for acting on their sexual identity and desires, and participation in gay/bisexual life. Most participants were not openly gay in their country of origin or had very limited and discreet friendships with other GBM. Only a minority of participants felt attached to or felt safe enough to attend spaces relevant to their respective gay communities in their country of origin.
It's not very well seen to be gay and you march [during gay pride] in the main street, and one side of the street is a church and family marching, on the other side is the pro-gay and the community marching. So we never go to the march because it gets violent; it's not a celebration. And you're afraid of going there and exposing yourself to whatever might happen (35,Latin America) Men often recalled that there was either no gay community they knew about, or they did not attend venues for GBM because they were concerned about being identified and stigmatised. However, despite common descriptions of stigmatising and invisibilising environments regarding sexual identity, there was some nuance in relation to participants' practices. For example, two participants from Mexico and one from Thailand-arguably places known to have at least some gay community representation-explained that they had core friendships with other GBM and attended queer events with them, and the participant from Thailand said that he worked in a gay bar for a period.

Reasons for Migration
Participants migrated to Australia to seek what they viewed as better career and study opportunities, to move permanently with family or a partner, to enjoy the lifestyle they believed existed, and/or to migrate to a more socially progressive place than their country of origin. There were reflections from some participants recounting that, in conjunction with migrating for the above reasons, an added benefit of their choice was that they had increased opportunities to explore their sexuality and engage more with their gay/ bisexual sexual identity. These participants explained that once they migrated, their connections to other GBM and attendance at gay/ bisexual venues increased. They also explained that they were happily surprised at how people lived an openly gay/ bisexual life in Australia, compared to a more secretive life in their country of origin.
However, there were clear differences between those who were interested in exploring their sexualities and those who wanted to continue to "pass" as heterosexuals. The latter group of men, who will be described in more detail below, Fear, shame, embarrassment, or concern about being exposed as gay/ bisexual

Affiliation with Gay/Bisexual Identity
Although some participants considered their migration an opportunity to participate in gay/bisexual life, about threequarters generally did not affiliate closely with a gay/bisexual identity. Among these three-quarters, connection to gay/ bisexual life came only through using hook-up apps such as Grindr, through only a few gay/bisexual friends, or it did not exist at all. These participants did not affiliate with a gay/ bisexual identity because they were reluctant to have others know of their sexual orientation, often explaining that they lived "normal" lives, and focused on work, study, and family. The social networks of these participants included their work and/or study friends only. Like others, this participant held a belief that being seen as gay might cast him as feminine and less than "normal", and as such saw no need to advertise his sexual identity. These participants distanced themselves from the stereotypes they saw as commonly attributed to gay/bisexual men. About one-third of this group remained mostly secretive about their sexual orientation in Australia. Due to lacking an affiliation with gay/bisexual life, these participants had rarely engaged with HIV services and resources in Australia prior to their diagnosis, resources that most commonly circulated in settings that attracted GBM more closely affiliated with their sexual identity (for example, in the information disseminated through LGBTIQ community organisations).

When I was diagnosed with HIV, I needed to know more about it. I needed to get to know more people who are living with HIV. And that's how I got involved with [LGB-TIQ community organisation]. But before that diagnosis, I wasn't connected, I didn't need to be, so I wasn't getting that information about HIV (37, Latin America)
Consequently, these participants had (continued) limited knowledge of HIV and had seen fewer resources that educated about, and encouraged connections to, HIV services, thus potentially producing poorer sexual health outcomes.

Effects of Internalised Stigma on Sexual Identity
There were some examples of participants stating that the sociocultural norms related to sexual identity in their countries of origin had a direct influence on their choice to continue supress sexual orientation in Australia. Here, the link between internalised stigma and its impacts was clearly implied. When asked why he kept his sexual identity to himself, one participant said:

Asian society doesn't accept it at the moment. I've been here [Australia] for 30 years. I was living in a straight community. So I was never out of the closet. My society, my community background back home wouldn't tolerate this. So it just has to be some sort of secret movement here. I wouldn't go to parade. I don't want to participate (64, Southeast Asia)
There were also a few examples of participants recognising the challenge of unlearning internalised stigma relating to sexual identity. For example, one participant, who did have more interest in exploring his sexuality in Australia, said: When you start exploring your sexuality, and with our backgrounds, you don't want anyone to know you're gay and you have to be very secretive, so how can you make yourself feel the Australian openness not to feel dirty or bad yourself? So most people will explore but won '

t feel very nice about them [sexual encounters] in the beginning. My cousin's been very hard to accept himself in Australia because we have all these years of conditioning that being gay is bad and you'll bring dishonour to your families (35, Latin America)
However, generally, there were few direct links made by participants about their sexual identity and whether or not they had any internalised stigma of it. In most examples, rather than explicitly articulating that they had internalised stigma, the way they contested a life in which sexual identity might be a feature and their reluctance to be identified as gay/bisexual clearly reflected common social and cultural understandings in their country of origin.

Barriers to HIV Testing in Australia
HIV testing in Australia was infrequent. Only eight participants said they tested regularly (at least twice per year) in Australia before their diagnosis. For two-thirds of participants (16), their first HIV test in Australia was their diagnosis. However, participants who had greater access to HIV testing or who tested more regularly in their countries of origin tended to also either test more regularly in Australia or expressed an intention to test more regularly (but were then diagnosed). These examples indicate that, in contrast to the negative effects of stigma, having more positive experiences in countries of origin may reinforce stronger health-seeking behaviours for some GBM after migration. Nonetheless, participants described several barriers to HIV testing in Australia, some of which were similar to testing barriers in countries of origin (Table 3).

Barriers to Condoms and Discussing Sexual Health in Australia
When first asked about their use of condoms, most participants said they mostly used condoms with casual partners prior to their diagnosis. In contradiction, many later identified specific events where they did not. Common among many participants was a lack of discussion around HIV status, condoms, and sexual health with sexual partners.

So this is the thing: I've hooked up with many guys but we've never really talked about HIV. Like seriously I never met a guy that actually talked about HIV or any STI. If we use condom, we just pull it out.
If he doesn 't,he just don't. So,yeah,we don't talk about STIs at all (21,Southeast Asia) Several key barriers to using condoms and/or discussing sexual health were raised (Table 4).

Barriers to PrEP Uptake in Australia
Knowledge and use of PrEP in this sample were low. Just over half (14) learned about PrEP only after arriving in Australia, often citing public advertisements or discussions with gay friends or sexual partners as information sources. Six found out about PrEP only after they were diagnosed. Two participants had commenced PrEP after migrating to Australia, and four participants had intended to commence but were subsequently diagnosed with HIV. Apart from a general lack of knowledge of PrEP, participants raised three often intersecting barriers to PrEP uptake (Table 5).
Although the participant quoted in the perceived inaccessibility barrier said he did research on PrEP, this was not the case for others, who never pursued researching it because they assumed it would be inaccessible to them due to Medicare ineligibility. Notably, though not necessarily a barrier to PrEP uptake itself, some participants also described some difficulty practicing their gay/bisexual sexuality as a recent migrants in Australia specifically in relation to negotiating PrEP use. This participant indicated that as a recent migrant to a country in which condomless sex on PrEP had become normative; he had some difficulty asserting his preferred condom-based HIV prevention strategy.

Discussion
Our study highlights that, among migrant GBM in Australia, stigma towards both HIV and homosexuality increases vulnerability to acquiring HIV by creating barriers to HIV prevention and testing. Participants commonly described how stigma in their countries of origin was deeply embedded into multiple social and structural settings and engendered discriminatory health service experiences, silenced discussion and education about HIV, and restricted visibility of gay/bisexual sexual identities and spaces. Stigma resulted in poor HIV knowledge, low HIV testing and engagement with health services, limited communication with sexual partners to reduce HIV risk,  and limited connections to other GBM and sexual identity spaces. Some participants had internalised the stigma in their countries of origin, continuing to fear and avoid HIV testing and health services, feeling uncomfortable discussing sexual health with sexual partners and health professionals, not perceiving a need to access PrEP, and lacking strong affiliation to a gay/bisexual identity after arrival in Australia. Several studies have reported on how migrants, as a broad population, face stigma in their countries of origin and the consequences this can have after migration on their health-seeking behaviours (Agu et al., 2016;Blondell et al., 2015;Gray et al., 2019;Hatzenbuehler et al., 2013;Körner, 2007;Lewis, 2017;Philipps et al., 2020;Ziersch et al., 2021). For GBM, such stigmas are compounded and intersectional. Not only do migrant GBM confront stigmas related to being gay/bisexual, but they also confront stigmas relating to HIV by association, which suggests that by virtue of being part of a population disproportionately diagnosed with HIV, GBM may be exposed to its stigma even if they do not live with the virus (Broady et al., 2020). This multi-layered stigma appeared to be mainly related to experiences in migrant GBM's countries of origins that were internalised (creating lingering fear and misconceptions) rather than the stigma that was enacted onto them in Australia. The barriers reported by participants to HIV testing, discussing sexual health and using condoms, and/ or accessing PrEP in Australia were multifaceted. Some barriers were likely related to stigma, some related to participants' status as a migrant, some related to personal interpretations of sexual behaviour, and some were interconnected and likely related to a mix of these. Barriers related to internalised stigma included ongoing discomfort discussing HIV prevention with partners, a continued fear of HIV testing, and anxiety about already having acquired HIV and preferring not to find out. For some men, an HIV diagnosis would be so distressing that they would prefer to remain uninformed about their status. Their anticipated distress was caused by an internalisation of the negative positioning of HIV in their country of origin. Although no participants reported experiences of stigma enacted by health providers in Australia, some anticipated that they may be exposed to stigma if they accessed services. Such barriers further highlight that internalised stigma can linger long-term, even after people migrate away from places with high levels of structural and social stigma, and can have enduring consequences on people's health outcomes.
There were several barriers to HIV testing and prevention associated with participants' status as migrants. Some participants identified how moving to a new country with different norms made them feel pressured to adopt unfamiliar sexual norms, such as not using condoms, a key barrier to HIV prevention. Condomless sex in the context of high levels of viral suppression and uptake of PrEP (i.e., relying on biomedical prevention rather than behavioural risk reduction) has become highly normative in Australia (which is observed-PrEP overtook condoms as the primary HIV prevention strategy in Australia in one study, see Holt et al., 2018). Some participants, however, struggled to negotiate with sexual partners and convey their preference for condoms. Previous research has similarly found that some GBM have been challenged by the proliferation of PrEP to reconsider what constitutes responsible HIV prevention and that some report difficulty negotiating emergent sexual norms (Girard et al., 2019;Haire et al., 2021;Philpot et al., 2020). Given their status as migrants from countries with different HIV prevention norms, including discussion of HIV prevention with sexual partners not being common, these migrant GBM may have experienced more acute difficulties adapting to new norms after migration. Similarly, though we did not collect sufficient data on these issues to describe them in detail, difficulties negotiating sex with partners potentially highlight language and power differentials between migrants and Australian-born GBM.
Some HIV testing barriers are attributable to participants' migrant status, including having competing interests for settling into life in Australia, a lack of knowledge of Australian health services, and fear of losing a temporary visa (e.g., student visa). In some cases, these barriers highlight that migrants face challenges as new residents in countries that mean sexual health becomes a secondorder priority. In other cases, these barriers highlight the perceived access inequities that migrants assume exist in Australian healthcare based on visa status. For example, some participants assumed the health system would be too costly or not available to them as migrants (if not permanent residents or eligible for Medicare), and as such never investigated opportunities to access free sexual health testing that is available at publicly funded clinics regardless of visa status. Having fears of losing a visa indicates that migrants may perceive that they lack control in determining their future in Australia, particularly if diagnosed with HIV (Körner, 2007). In Australia, though not widely known among the general population, a person's current visa cannot be revoked due to an HIV diagnosis, but significant barriers emerge for future permanent visa applications (Forbes & Frommer, 2014). Participants may have been reticent to test for HIV due to the perceived threat to their visa status if diagnosed HIV-positive, and the consequent impact on their autonomy to live in Australia.
Barriers related to personal interpretations of sexual behaviour included a low perception of risk, prioritising pleasure ahead of considering HIV risk, trusting a partner, perceived lack of relevance of PrEP, and concerns about taking unnecessary medication given infrequent sex. For example, participants who reported that they frequently used condoms or were sexually conservative did not access HIV testing because they did not believe they engaged in enough HIV risk. These issues relating to not testing for HIV, not using condoms, and not accessing PrEP have been reported by broader populations of GBM regardless of country of origin (Gianacas et al., 2015;Marcus & Gillis, 2017;Philpot et al., 2020;Prestage et al., 2012). They are unlikely to exclusively apply to migrant GBM, but they nonetheless indicate that individuals can have personal interpretations of the need to access HIV testing and PrEP and use condoms based on their perceptions of their sexual behaviour and beliefs about medications.
The data from this study show that addressing internalised stigma regarding HIV and sexual identity is central to improving HIV and health outcomes for migrant GBM. Continued global advocacy that aims to improve health services and reduce discriminatory attitudes towards HIV and homosexuality in countries from which GBM migrants originate is one key component of countering the effects of stigma. From the perspective of what can be done in Australia, efforts made to increase HIV testing among migrant GBM might include tailored health promotion that educates about the confidential, non-judgemental, and accessibility of publicly funded sexual health clinics. PrEP uptake can be encouraged through promoting and expanding equitable access to low-cost PrEP options for migrants who do not have access to Medicare. Finally, previous research has argued that not enough health promotion is appropriately tailored towards the level of HIV knowledge and cultural/language specificities of migrant populations, nor done in a culturally safe way through community involvement, peer networks, and codesign (Del Amo et al., 2004;Gray et al., 2021;McMahon & Ward, 2012;Nkulu-Kalengayi et al., 2021;World Health Organization, 2008). As such, education efforts that aim to increase HIV knowledge among migrant GBM need to be culturally and linguistically tailored, done in accordance with migrant GBM's level of HIV knowledge, and in a way that bolsters participation in the community itself.

Limitations
Participants in this study were well connected to sexual health services and had undetectable viral loads, thus representing a sample more highly engaged in sexual health and research (at least since their diagnosis). Findings may not translate to migrant GBM who are less engaged in these spaces. This study is based in Australia and may not be relevant to all countries, particularly those with different health system structures, though it may have some similarities with high-income countries that have universal healthcare. In particular, the transnational experiences of the migrant GBM in this study are likely to be different when compared to countries that have different sociocultural specificities (for example, not having same-sex marriage legalised), populations of migrants, and legal systems and visa regulations. Also, the majority in this sample had tertiary education, whereas a more socially comprehensive sample may have highlighted further health literacy disparities. We have not reported on participants' descriptions of living with HIV in this paper, which is important to describe to better understand the experiences of migrant GBM living with HIV. However, these data are in preparation elsewhere. While we had the capacity to conduct some interviews in participants' preferred language, most were conducted in English, allowing for adequate if imperfect expression of experiences.

Conclusion
In this qualitative study, stigma regarding HIV and homosexuality had a clear and direct impacts on migrant GBM's practices and understandings. Stigma in countries of origin was multifaceted, interconnected, and pervasive across social, cultural, and institutional settings. It directly led to poor HIV knowledge, low HIV testing, fears of HIV and accessing sexual health services, limited affiliation with a gay/bisexual identity, and fears of being exposed as gay/ bisexual in both their countries of origin and for many after migration to Australia. While no participants reported being stigmatised by clinicians in healthcare contexts in Australia, many nonetheless perceived that they might be due to their experiences in their country of origin, which reinforced their reticence to fully engage. Moreover, having a status as a migrant in Australia reduced participants' capacity to access sexual health services. There are several challenges to addressing the health disparities experienced by migrant GBM in the context of HIV prevention and transmission. Increased HIV education and addressing internalised stigma regarding HIV and sexual identity are likely to contribute to bridging these gaps.
Author Contribution All authors contributed to the design and implementation of the study. Eithandee Aung recruited study participants with support from sexual health clinics. Steven Philpot and Eithandee Aung conducted interviews. Steven Philpot conducted the analyses. Steven Philpot led the first draft of the manuscript, and all co-authors contributed comments and revisions to subsequent drafts. All authors read and approved the final manuscript.
Funding Open Access funding enabled and organized by CAUL and its Member Institutions. This project was supported by a research grant from the Australian Government Department of Health and the New South Wales Ministry of Health.
Data Availability Data are not shared.
Code Availability Not shared.

Declarations
Ethics Approval This study was performed in line with the principles of the Declaration of Helsinki. Ethical approval was received from the Human Research Ethics Committee of the Prince of Wales Hospital (18/064 (HREC/18/POWH/120)) and an HIV community organisation, ACON (RERC 2018/28).

Consent to Participate
Informed consent was obtained by all participants in this study.

Conflict of Interest The authors declare no competing interests.
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