Legal status, sex work engagement and inequities in the HIV pre-exposure prophylaxis cascade among migrant women in 11 European countries

Background: Migrant women account for a substantial proportion of new HIV diagnoses in Europe, yet remain underrepresented in HIV prevention research. Little is known about how legal status and national policy context shape engagement with PrEP among migrant women, particularly those without secure documentation. We assessed the PrEP cascade and HIV prevention preferences among migrant women, examining how legal status, sex work engagement and national reimbursement policies drive inequities in access. Methods: We conducted a community-led, cross-sectional survey (June-July 2025) of 521 HIV-negative migrant women recruited offline via community-based organisations. Multivariable logistic regression examined associations between legal status, sex work, country-level PrEP reimbursement policies and PrEP cascade outcomes. Results: Among 521 participants, 259 (49.7%) lacked secure legal status (119 asylum seekers, 89 refugees and 51 undocumented migrants) and 90 (17.3%) were engaged in sex work. Overall, 40.1% (95% CI 35.9-44.5) were aware of PrEP and 24.6% (20.9-28.6) intended to use it, yet only 6.0% (4.1-8.4) were current users; 36.7% (23.8-51.7) of PrEP-experienced women had discontinued use. Compared with naturalised citizens or documented residents, undocumented migrants (aOR = 2.57, 95% CI = 1.19-5.64), asylum seekers (3.67, 1.98-6.93) and refugees (2.28, 1.22-4.31) had higher odds of PrEP awareness. Sex workers had higher odds of current PrEP use (5.50, 1.61-20.42). Residing in countries with full PrEP reimbursement was independently associated with higher uptake (4.96, 1.30-26.11). Although condoms were the most preferred method (60.3%), interest in daily oral and long-acting injectable PrEP was evident, particularly among undocumented women and sex workers. Conclusion: A four-fold gap between PrEP intention and actual uptake among migrant women reflects a failure of universal health coverage, driven by restrictive migration governance and health financing. Achieving HIV equity requires decoupling PrEP eligibility from documentation status and expanding community-led delivery.