| TYPE Original Research PUBLISHED 29 November 2022 DOI 10.3389/frph.2022.953979 Sexual and reproductive health and access: Results of a rapid EDITED BY Saiqa Mullick, Wits Reproductive Health and HIV Institute, epidemiological assessment South Africa REVIEWED BY among migrant peoples in transit Maria Pyra, Howard Brown Health Center, United States through Darién, Panamá Lyle McKinnon, University of Manitoba, Canada Jennifer Toller Erausquin1,2, Joanne Sánchez3, Anyi Yu Pon4, *CORRESPONDENCE Amanda Gabster Mónica Jhangimal4, Eugenia Millender2, Yudith Peña5, agabster@gorgas.gob.pa Winroy Ng4, Adelys Reina4, Candy Nakad6, Joselid Quintana5, SPECIALTY SECTION Roberto Herrera Veces5, Grace Vistica4,7, This article was submitted to HIV and STIs, a section of the journal Frontiers in Reproductive Justo Pinzón-Espinosa2,8,9,10,11, Gonzalo Cabezas-Talavero5, Health Jennifer Katz5, Juan Miguel Pascale4,12, RECEIVED 26 May 2022 Fátima Rodríguez-Álvarez4 and Amanda Gabster2,4,13* ACCEPTED 31 October 2022 1 PUBLISHED 29 November 2022 Department of Public Health Education, School of Health and Human Sciences, University of North Carolina Greensboro, Greensboro, NC, United States, 2Center of Population Sciences for Health Equity, CITATION College of Nursing, Florida State University, Tallahassee, FL, United States, 3Complejo Hospitalario Erausquin JT, Sánchez J, Yu Pon A, Arnufo Arias de Madrid, Panamá City, Panamá, 4Gorgas Memorial Institute of Health Studies, Panamá Jhangimal M, Millender E, Peña Y, Ng W, City, Panamá, 5Community Development Network of the Americas, Panamá City, Panamá, 6Instituto de Reina A, Nakad C, Quintana J, Herrera Veces R, Medicina Tropical, Laboratorio de Protozoarios de Biología Molecular, Universidad Central de Vistica G, Pinzón-Espinosa J, Cabezas- Venezuela, Caracas, Venezuela, 7Tulane University School of Public Health and Tropical Medicine, New Talavero G, Katz J, Pascale JM, Rodríguez- Orleans, LA, United States, 8Sant Pau Mental Health Group, Institut d’Investigació Biomèdica Sant Pau Álvarez F and Gabster A (2022) Sexual and (IBB-San Pau), Hospital de la San Creu i Sant Pau, Universisat Autònoma de Barcelona, Barcelona, Spain, 9 Department of Medicine, School of Medicine, University of Barcelona, Barcelona, Spain, 10Department reproductive health and access: Results of a of Clinical Psychiatry, School of Medicine, University of Panamá, Panamá City, Panamá, 11Institut rapid epidemiological assessment among d’Investigació i Innovació Parc Tauli (I3PT), Sabadell, Spain, 12Faculty of Medicine, University of Panamá, migrant peoples in transit through Darién, Panamá City, Panamá, 13National Research System of Panamá (SNI), Panamá, Panamá Panamá. Front. Reprod. Health 4:953979. doi: 10.3389/frph.2022.953979 Background: The foot transit of migrant peoples originating from the COPYRIGHT Caribbean, South America, Asia, and Sub-Saharan Africa through the Darién © 2022 Erausquin, Sánchez, Yu Pon, Jhangimal, Forest (DF) in Eastern Panamá towards North America has increased in Millender, Peña, Ng, Reina, Nakad, Quintana, recent years from approximately 30,000 people/year to >133,000 in 2021. In Herrera Veces, Vistica, Pinzón-Espinosa, Cabezas-Talavero, Katz, Pascale, Rodríguez- the DF, there is no food/housing provision nor healthcare access. Very little Álvarez and Gabster. This is an open-access is known of sexual and reproductive health (SRH) among this population. article distributed under the terms of the This study used rapid epidemiological methods to describe the SRH situation Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other among migrant peoples in transit through the DF. forums is permitted, provided the original Methods: This cross-sectional study randomly selected migrant people in author(s) and the copyright owner(s) are transit (men and women) at a Migrant Reception Station in Darién, Panamá, credited and that the original publication in this journal is cited, in accordance with accepted between January 4–11, 2022. Data collection included a self-applied academic practice. No use, distribution or questionnaire (≥18 years); clinical screening (≥12 years); and HCG, reproduction is permitted which does not treponemal antibodies, and HIV(I/II) lateral-flow tests with blood samples comply with these terms. (≥12 years). Descriptive analyses were used to report findings. Results: In all, 69 men and 55 women participated in the self-applied questionnaire, 70 men and 51 women in clinical screening; 78 men and 63 women in HCG, treponemal antibody and HIV testing. Overall, 26.1% (18/69) men and 36.4% (20/55) women reported sexual intercourse within the past month. The last sex partner was casual among 43.0% (21/49) of men and 27.8% (10/36) of women; of those, 42.9% (9/21) of men and 80.0% (8/10) of Frontiers in Reproductive Health 01 frontiersin.org Erausquin et al. 10.3389/frph.2022.953979 women reported this sex was condomless. Among women, 20.0% (11/55) tested positive for pregnancy; 5 of these pregnancies were planned. Of those screened, a reproductive tract infection symptom was reported by 5.7% (4/70) of men and 58.8% (30/51) of women. A total of 32.7% (18/55) of men and 18.2% (8/44) of women reported no prior HIV testing. Of 78 men, HIV and treponemal antibodies were found among 1.3% (n = 1) and 2.6% (n = 2), and among 63 women, 3.2% (n = 2) and 3.2% (n = 2), respectively. Conclusions: This rapid epidemiological assessment found high recent sexual activity, low condom use with casual partners, and a need for increased HIV and syphilis testing and treatment. There is a need for increased testing, condom provision, and SRH healthcare access at migrant reception stations that receive migrant peoples in transit through Panamá. KEYWORDS sexual and reproductive health (SRH), migrant health care, sexual behavior, sexually transmitted infection (STI), Latin America & Caribbean Introduction gap in the Pan-American Highway near the Colombia- Panamá border. At this point, migrant peoples must cross Global migration has greatly increased in the past four on foot through the Darién Forest (DF; sometimes called the decades (1), with a particularly dramatic increase in the Darién Gap), a roadless, dense neotropical forest. The number of forcibly displaced people in the past 10 years (2). journey is dangerous and physically demanding; based on The current worldwide tally of migrant peoples is over 281 the route taken, food and other supplies carried, and the age million, and 1 in 95 people worldwide is forcibly displaced, and abilities of those traveling, the trek often takes 3–14 meaning that they had to move away from their home due to days to emerge from the DF in Panamá (8). The conflict, violence, or human rights violations (1). Within International Organization for Migration (UN Migration) forcibly displaced people, the United Nations High and Panamá’s National Migration Service estimated that over Commissioner for Refugees specifically defines four groups as 133,000 migrant peoples passed through the DF in 2021, populations of concern: refugees, people in refugee-like more than four times the previous highest annual count situations, asylum-seekers, and Venezuelans displaced abroad. [30,000 for the entire year 2016] (9–11). In the first nine International migration can be physically difficult, months of 2022, more than 150,000 migrant peoples passed dangerous, and chaotic. During transit, the health needs of through the DF (12). migrant peoples, and particularly their sexual and In Panamá, migrant peoples who emerge from the DF are reproductive health needs, grow as they are faced with met by the National Border Police (SENAFRONT) and conditions and vulnerabilities for which they are unprepared guided to Migrant Reception Stations (MRS). The MRS are (3). The migration process often disrupts supportive and part of a coordinated U.S.-Panamá effort to control the flow familiar social structures, and may involve precipitous loss of of migrant peoples. With the aid of U.S. tools and training, financial means of support and security provided by family biometric measurements are taken of all migrants at the MRS and friends, and disintegration of law and order (4). to identify suspected terrorists and maintain documentation Migration and other humanitarian contexts create of migrating people (13). As described in our study protocol circumstances that inhibit migrant peoples’ access to sexual (14), time spent at the MRS varies based on the individual’s and reproductive health (SRH) services and simultaneously nationality, demographic characteristics, and needs. Stays at increase vulnerability to sexual violence, coercion, and the MRS can be as short as a few days for citizens of exploitation; transactional or survival sex; sexually transmitted countries with expedited processes (including Cuba and infections; and unintended pregnancies (4, 5). These Haiti), to several weeks or months. vulnerabilities are intensified among unauthorized or To date, much of what is known about the healthcare needs undocumented migrants and asylum seekers (6). Additionally, of migrant peoples passing through the Darién Forest and the humanitarian settings often have very limited access to sexual continued journey north comes from journalistic reports and and reproductive (SRH) healthcare (7). anecdotes (15, 16). However, there is a dearth of information A rapid escalation in population movement is apparent in about the current state of sexual and reproductive health the Americas, where migrant peoples from around the world among migrant peoples in transit in this area. Therefore, the travel through South and Central America headed to North current study aims to describe the sexual and reproductive America. Though other portions of the journey may involve health of migrant peoples in transit and to identify targets for traveling via airplane, boat, bus, or train, there is a 106-km future intervention. Frontiers in Reproductive Health 02 frontiersin.org Erausquin et al. 10.3389/frph.2022.953979 Methods samples (14), and took part in the sexual and reproductive clinical survey and exam. Additional details about data Study setting collection including the self-administered questionnaire are available in our published study protocol and supplementary This study was undertaken in a Migrant Reception Station materials (14). (MRS) in the Darién province of eastern Panamá. The study protocol received ethical approval from the Comité de Bioética de la Investigación del Instituto Conmemorativo Laboratory methods Gorgas de Estudios de la Salud (260/CBI/ICGES/21). Blood samples were centrifuged. Lateral flow immunochromatography tests (CTK Biotech, Beijing, China) Study participants were performed for HIV (I/II), syphilis (treponemal seroreactivity) and pregnancy (HCG). HIV positive samples Participants were randomly selected at the MRS in Darién. were tested again with a second brand (Abbott Diagnostics, Travel groups (typically 2–8 persons) were introduced to the Scarborough, United States), as per national guidelines. study; the study objectives and methods were briefly Samples with two positive results were analyzed for CD4 explained. One person from adults in the travel group (≥18 levels using Vistect Advanced (Omega Diagnostics Scotland, years) and one person from children/youth in the travel group UK), which identifies samples with CD4 below 200 cells/mm3 (<18 years) was selected randomly to be invited to participate. and thereby meeting the WHO definition of advanced HIV Participation was voluntary. Sample size was calculated by disease (18). Mid-flow urine samples were tested for leukocyte Z 2 Pð1  PÞ esterase. All female participants were offered a pelvic exam; n¼ , where n is the sample size, Z the confidence d2 those who consented and had discharge were offered statistic, P is expected prevalence and d is the precision, diagnosis for bacterial vaginosis (Amsel criteria) and yeast resulting in an intended sample of 120 participants <18 years (microscopy KOH test). and 160 participants ≥18 years. We expected the prevalence of pregnancy to be 10% (17); this prevalence was used for sample size calculation. Result and treatment Participants were offered results of testing and adequate Procedures treatment [according to national guidelines (19)] within 3 h of being included in the study. Our guidelines for on-site We obtained approval from the Ministry of Health, and the treatment of conditions identified as part of the study are Ministry of Security (National Migration Service and the described in our protocol paper (14). All participants were National Border Service) to work in the MRS. Participants offered a meeting with a psychologist and psychiatrist. were selected as described above. Adults of legal age (≥18 years) were taken to a place where the study objectives and procedures could be explained in private so others would not influence participation. Adults were asked to sign their own Statistical analyses consent forms. Children (<12 years) were accompanied by an We conducted descriptive analyses including frequencies adult guardian when the study was explained; the adult and percentages for categorical variables and median and guardian signed a consent form. Adolescents (12–17 years) interquartile range for continuous variables. For categorical and their guardians were explained the study in a private variables, we also conducted bivariable analyses (Chi square location, separately, and were each asked to sign an informed tests comparing men to women) to examine potential gender assent or consent form, respectively. The current analysis differences. All analyses were conducted using Stata 17.0 focused only on data from adolescents and adults. A total of (StataCorp LP, College Station, United States). 12 people withdrew from the study, including 4 minors <17 years old; their data were not analyzed here. After receiving informed consent and assent, participants (≥18 years) self-applied a questionnaire on a tablet computer Results (14); participants who needed assistance had a trained study volunteer read the questions and record the participant’s Data collection was completed at a Migrant Reception responses on the tablet computer. Participants then gave Station in Darién, Panamá, between January 4–11, 2022. blood (2 EDTA tubes) and mid-flow urine (20–50 ml) During that period, the MRS housed or received 688 migrant Frontiers in Reproductive Health 03 frontiersin.org Erausquin et al. 10.3389/frph.2022.953979 peoples 18 years and older and 708 migrant peoples 12 years TABLE 1 Demographic characteristics (self-reported by adults age ≥18 years). and older. Men, n Women, n p-value (%) (%) (difference between genders) Demographic characteristics Age n = 69 n = 55 0.86 Results of descriptive analyses for demographic Median: 31 Median: 30 (IQR: 27–39) (IQR: 27–35) characteristics are shown in Table 1. In all, 69 men and 55 median: 31 years women were included in the self-applied questionnaire, 70 (IQR: 19–56) men and 51 women in the clinical screening and 78 men and 18–25 14 (20.3) 12 (21.8) 63 women consented/assented to laboratory testing of blood. 26–31 20 (29.0) 19 (34.6) No participants identified as transgender, nonbinary, or 32–39 19 (27.5) 12 (21.8) another gender. Participants’ region of origin showed ≥40 16 (23.2) 12 (21.8) statistically significant differences by gender: Caribbean origin Birth country n = 68 n = 53 <0.01* for 13.2% (9/68) of men and 52.8% (28/53) of women; North Caribbean 9 (13.2) 28 (52.8) or South America for 51.5% (35/68) of men and 34.0% (18/ 53) of women; Asia for 5.6% (4/68) of men and 0.0% (0/53) South America 35 (51.5) 18 (34.0) of women; and Sub-Saharan Africa for 29.4% (20/68) of men Asia 4 (5.6) 0 (0.0) and 13.2% (7/53) of women. East or Central Africa 20 (29.4) 7 (13.2) The median age was 31 years for men and 30 years for Highest level of education n = 68 n = 53 <0.01* women. Educational attainment showed variation by gender, Never had formal 9 (13.2) 28 (52.8) education with the majority of women having no formal education Grades 1–6 (Primary) 35 (51.5) 18 (34.0) (52.8%; 38/53) while the majority of men had attended primary school grades 1–6 (51.5%; 35/68). Nearly one-third of Grades 7–12 4 (5.9) 0 (0.0) (Secondary) men (29.4%; 20/68) but only 13.2% (7/53) of women reported Post-secondary school 20 (29.4) 7 (13.2) post-secondary education. A majority of men were single, Marital status n = 63 n = 50 <0.01* divorced, widowed, or separated (61.9%) and 38.1% were Single, divorced, 39 (61.9) 15 (30.0) married/cohabiting; this trend was the reverse for women widowed, or separated (30.0% single and 70.0% married/cohabiting). In terms of Married or in union 24 (38.1) 35 (70.0) safety of dwelling, similar proportions of men (36.4%; 24/66) Did participant have a safe n = 66 n = 54 0.37 and women (42.6%; 23/54) reported that they did not have a place to sleep at night in safe place to sleep in the last month. Main reasons for the past month? traveling included war or conflict (33.3% among men; 16.4% Never 24 (36.4) 23 (42.6) among women) and other violence (16.7% among men and Sometimes 29 (43.9) 17 (31.5) 20.0% among women). Women also frequently cited work Always 13 (19.7) 14 (25.9) (30.9% among women) as a reason for traveling. Main reason for travelling n = 66 n = 55 0.11 War or conflict 22 (33.3) 9 (16.4) Other violence 11 (16.7) 11 (20.0) Recent sexual behavior, condom use, STI Work 8 (12.1) 17 (30.9) symptoms and testing Family 8 (12.1) 6 (10.9) Poverty 9 (13.6) 6 (10.9) Results of descriptive analyses for sexual behaviors and Other reason 8 (12.1) 6 (10.9) reported violence are shown in Table 2. A total of 26.1% (18/ 69) men and 36.4% (20/55) women reported sexual *p<0.05 for difference between genders. intercourse in the past month. Of those, among men, 50.0% (9/18) reported to have one sex partner and 44.4% (8/18) 3 sex partners; among women, 90.0% (18/20) reported one sex 57.1% (28/49) of men and 72.2% (26/36) women; of those, partner and 10.0% (2/20) 3 sex partners. Last sex partner was 42.9% (9/21) of men and 80.0% (8/10) of women reported reported to be casual (a stranger, a friend or travel not using a condom with their last casual partner. A total of companion, a person of authority, a sex worker, or another 32.7% (18/55) of men and 18.2% (8/44) of women reported person other than a regular sex partner or husband/wife) never having an HIV test prior to this study. among 43.0% (21/49) of men and 27.8% (10/36) of women Clinical screening (data not shown) revealed that of those and formal (a regular sex partner or husband/wife) among screened, 58.8% (30/51) of women and 5.7% (4/70) of men Frontiers in Reproductive Health 04 frontiersin.org Erausquin et al. 10.3389/frph.2022.953979 TABLE 2 Sexual behaviors, access to condoms, STI symptoms, and HIV TABLE 2 Continued testing (self-reported by adults age ≥18 years). Men, Women, p-value Men, Women, p-value n (%) n (%) (difference n (%) n (%) (difference between between genders) genders) Do you feel like since you n = 53 n = 37 0.16 Age at first marriage/ n = 56 n = 47 0.07 left your country of origin cohabitation or last country of residence, <18 years 21 (37.5) 26 (55.3) it is harder to access ≥18 years 35 (62.5) 21 (44.7) condoms? Gender of sex partners in n = 60 n = 46 0.95a No 31 (58.5) 15 (40.5) lifetime Yes 10 (18.9) 7 (18.9) Only men 2 (3.3) 43 (93.5) Does not apply 12 (22.6) 15 (40.5) Only women 53 (88.3) 0 (0.0) STI symptoms in past n = 52 n = 40 <0.01* Men and women 3 (5.0) 2 (4.4) month Transmen 0 (0.0) 0 (0.0) Unusual discharge from 0 (0.0) 6 (15.0) the penis or vagina Transwomen 0 (0.0) 0 (0.0) Sores or warts on the 3 (5.8) 0 (0.0) With no one 2 (3.3) 1 (2.2) genital area Recent Sexual Behavior, Condom Use & Access Painful or frequent 1 (1.9) 3 (7.5) Have you had sexual n = 69 n = 55 0.22 urination intercourse in the last 4 Itching and redness in 1 (1.9) 3 (7.5) weeks? the genital area Yes 18 (26.1) 20 (36.4) Abnormal vaginal odor 0 (0.0) 3 (7.5) Number of sex partners in n = 18 n = 20 0.02* Anal itching, soreness, 0 (0.0) 0 (0.0) the last 4 weeks or bleeding 1 (50.0) 18 (90.0) Abdominal pain 0 (0.0) 6 (15.0) 2 1 (5.6) 0 (0.0) Enlarged lymph nodes in 0 (0.0) 0 (0.0) 3 8 (44.4) 2 (10.0) the groin area Relationship with all n = 14 n=7 0.03* None of the above 48 (92.3) 22 (55.0) partners in last 4 weeks symptoms (mark all that apply) Date of last HIV test n = 55 n = 44 0.19 Stranger 0 (0.0) 2 (10.5) Within the last year 16 (29.1) 21 (47.7) Regular sex partner 1 (5.6) 0 (0.0) More than 1 year ago 15 (27.3) 13 (29.6) Spouse 10 (55.6) 4 (21.0) Never 18 (32.7) 8 (18.2) Friend or someone who 2 (11.1) 0 (0.0) I don’t know 4 (7.3) 2 (4.6) is accompanying you on the trip Prefer not to say 2 (3.6) 0 (0.0) Authority figure (e.g., a 0 (0.0) 0 (0.0) Other than HIV, have you n = 54 n = 42 0.58 politician or a leader) ever received treatment for another STI (gonorrhoeae, Sex worker 1 (5.6) 0 (0.0) chlamydia, syphilis, herpes, Other 0 (0.0) 1 (5.3) trichomonas) The last time you had sex n = 49 n = 36 Within the last year 4 (7.4) 4 (9.5) (either anal or vaginal) did More than 1 year ago 7 (13.0) 1 (2.4) you use a condom? Never 39 (72.2) 32 (76.2) Among those who reported n = 21 n = 10 0.05 last sex was with a casual I don’t know 2 (3.7) 2 (4.8) partner: Prefer not to say 2 (3.7) 3 (7.1) Did not use condom 9 (18.4) 8 (22.2) *p<0.05 for difference between genders. Yes, used condom 12 (24.5) 2 (5.6) a comparison calculated with response categories opposite sex; same sex; men Among those who reported n = 28 n = 26 0.76 and women; no one. last sex was with a formal partner: Did not use condom 15 (30.6) 15 (41.7) Yes, used condom 13 (26.5) 11 (30.6) reported a current reproductive tract infection symptom. Among women screened, vaginal discharge was the most (continued) common symptom (40.0%; 12/30). Of those reporting vaginal Frontiers in Reproductive Health 05 frontiersin.org Erausquin et al. 10.3389/frph.2022.953979 discharge, 25.0% tested positive for leukocyte esterase in Other STI vulnerabilities prior to and urine; 36.4% were positive for Amsel criteria; and 45.4% during migration: transactional sex and had hyphae/pseudohyphae evocative of C. albicans upon concurrent partnerships KOH evaluation using microscopy. Laboratory testing revealed that of 78 men, HIV and syphilis were found Results of descriptive analyses for transactional sex and among 1.3% (n = 1) and 2.6% (n = 2) respectively. Among concurrent partnerships are shown in Table 3. About thirteen 63 women tested, 3.2% (n = 2) were positive for HIV and percent (12.7%; 7/55) of men and 8.3% (3/41) of women 3.2% (n = 2) were positive for syphilis. All HIV positive reported ever receiving money, goods, favors, presents, drugs, samples were identified as advanced HIV disease, with CD4 or housing in exchange for sex. More than 1 in 4 (26.8%; 15/ counts <200 cells/mm3. 56) men and 14.7% (5/34) of women reported having sex TABLE 3 Transactional Sex and concurrent partnerships (self-reported by adults age ≥18 years). Men, n Women, n p-value (difference between (%) (%) genders) History of Transactional Sex When, if ever, have you received money, goods, favors, presents, drugs, or housing for sex? n = 55 n = 41 0.20 Before leaving my last country of residence 4 (7.3) 1 (2.4) After leaving my last country of residence but before arriving in Panamá 3 (5.5) 0 (0.0) After I entered Panamá 0 (0.0) 1 (2.4) Both before leaving my country of residence and after leaving my country of residence 0 (0.0) 1 (2.4) Never 48 (87.3) 38 (92.7) When, if ever, have you given money, goods, favors, presents, drugs, or housing for sex? n = 55 n = 39 0.96 Before leaving my last country of residence 3 (5.5) 2 (5.1) After leaving my last country of residence but before arriving in Panamá 0 (0.0) 0 (0.0) After I entered Panamá 0 (0.0) 0 (0.0) Both before leaving my country of residence and after leaving my country of residence 2 (3.6) 1 (2.6) Never 50 (90.9) 36 (92.3) History of Concurrent Partnerships In your lifetime, have you had sex with someone who is not your formal partner, while you n = 56 n = 34 0.18 were in a partnership? No 41 (73.2) 29 (85.3) Yes 15 (26.8) 5 (14.7) When was this? n = 14 n=4 0.83 Before leaving country of origin 9 (64.3) 3 (75.0) In transit to another country or to Panamá 1 (7.1) 0 (0.0) In a country of residence 4 (28.6) 1 (25.0) After arriving in Panamá while in the Gap or in the MRS 0 (0.0) 0 (0.0) Did you use a condom? n = 14 n=4 0.68 No 5 (35.7) 1 (25.0) Yes (during all or part of the act) 9 (64.3) 3 (75.0) Have you been in a relationship and your partner had another partner while you were with n = 57 n = 37 0.16 them? No 53 (93.0) 31 (83.8) Yes 4 (7.0) 6 (16.2) When was it that your partner had sex with another person while you were with them? n=3 n=6 0.83 Before leaving country of origin 0 (0.0) 1 (14.3) In transit to another country or to Panamá 2 (66.7) 3 (42.9) In a country of residence 1 (33.3) 1 (14.3) After arriving in Panamá while in the Gap or in the MRS 0 (0.0) 1 (14.3) Frontiers in Reproductive Health 06 frontiersin.org Erausquin et al. 10.3389/frph.2022.953979 with someone who was not their formal partner while they were country of origin (16.7%; 1/6), in transit (50.0%; 3/6), in in a partnership; among these, 35.7% of men and 25.0% of country of residence (16.7%; 1/6), or in Panamá (16.7%; 1/6). women reported not using a condom with the secondary There were no statistically significant differences in reports of partner. Nearly all of these experiences occurred in the these experiences by gender. respondent’s country of origin or country of residence (men: 92.9%, 13/14; women: 100%, 4/4). In addition, 7.0% (4/57) of men and 16.2% (6/37) of women reported having ever been Sexual assault and perceived safety in a relationship and their partner had another partner at the same time. Among men who reported a non-monogamous Results about sexual assault and perceived safety are presented partner, this occurred in transit (66.7%; 2/3) or in a country in Table 4. Of the 52 men and 45 women who responded about of residence (33.3%; 1/3). Among women who reported a perceived safety from sexual assault, 40.4% (n = 21) of men and non-monogamous partner, this occurred before leaving 44.4% (n = 20) of women felt somewhat or completely unsafe TABLE 4 Perceived safety from sexual assault and history of sexual assault (self-reported by adults age ≥18 years). Men, n (%) Women, n (%) p-value (difference between genders) Before leaving country of residence, how safe did you feel from sexual assault in your n = 52 n = 45 0.58 everyday life? Not at all safe 14 (26.9) 13 (28.9) Somewhat unsafe 7 (13.5) 7 (15.6) Neither safe nor unsafe 5 (9.6) 1 (2.2) Completely safe 22 (42.3) 22 (48.9) It varies by the situation 4 (7.6) 2 (4.4) Since you left your last country of residence, how safe have you felt from sexual assault in 0.50 your everyday life? Not at all safe 14 (26.9) 17 (39.5) Somewhat unsafe 8 (15.4) 5 (11.6) Neither safe nor unsafe 4 (7.7) 5 (11.6) Completely safe 20 (38.5) 14 (32.6) It varies by the situation 6 (11.5) 2 (4.6) Since you arrived in Panamá, how safe have you felt from sexual assault in your everyday n = 52 n = 42 0.62 life? Not at all safe 14 (26.9) 15 (35.7) Somewhat unsafe 7 (13.5) 8 (19.0) Neither safe nor unsafe 4 (7.7) 3 (7.1) Completely safe 21 (40.4) 14 (33.3) It varies by the situation 6 (11.5) 2 (4.8) Lifetime sexual assault or rape n = 54 n = 45 0.49 Yes, more than one time 1 (1.8) 4 (8.9) Yes, once 4 (7.4) 2 (4.4) No, this has not happened to me 45 (83.3) 34 (75.6) Dońt know/cannot remember 2 (3.7) 3 (6.7) I prefer not to say 2 (3.7) 2 (4.4) Age of first rape or sexual assault (years) n=5 n=6 median: 20 (IQR 16–24) median: 17 (IQR 15–19) 0.28 When did this happen? 0.50 Before leaving my country of origin 3 (60.0) 4 (66.7) In another country of residence 1 (20.0) 2 (33.3) In transit to Panamá 0 (0.0) 0 (0.0) While in Panamá (on the trail or at an ERM) 0 (0.0) 0 (0.0) I prefer not to say 1 (20.0) 0 (0.0) Frontiers in Reproductive Health 07 frontiersin.org Erausquin et al. 10.3389/frph.2022.953979 before leaving their last country of residence. Of men, 42.3% (n = 22) sexual encounter of pregnant women was within the last 28 days and 51.2% (n = 22) of women felt unsafe while traveling from their for 36.4% (n = 4) and 54.5% (n = 6) > 28 days. Among women, last country of residence before arriving in Panamá and 40.4% (n 39.2% (20/51) were using contraceptives at time of study. = 21) men and 54.8% (n = 23) of women felt unsafe from sexual assault while traveling through the DF. Participants were also asked about sexual assault (being Discussion “forced or frightened by another person into doing something sexually that you did not want to do”). Of those who reported Our study showed high recent sexual activity, low condom use lifetime sexual assault, 60.0% (n = 3) of men and 66.7% (n = with casual partners, and a need for increased access HIV and 4) of women reported that this occurred in their last country syphilis testing and treatment. In addition, we found high of residence; 0.0% of respondents reported sexual assault prevalence of reproductive tract symptoms, particularly among during migration or during their time in Panamá. women. Taken together, these findings indicate a need for increased testing, condom provision, and SRH healthcare access at Migrant Reception Stations that receive migrant peoples in transit in Panamá. Pregnancy history and contraceptive use The findings of this study should be considered in light of several limitations. First, this was a rapid epidemiological assessment Finally, results of pregnancy testing and questions about conducted over a short period of time in January 2022. There is pregnancy are shown in Table 5. A total of 20.0% (n = 11) of often a lull in migration flow through Panamá around the women tested positive for pregnancy; two women did not know of December and January holidays. However, COVID-19 slowed their pregnancy prior to testing. Five of the 11 pregnancies were migration in 2020, followed by a boom of people passing planned. Of pregnant women, 72.7% (n = 8) had one sex partner throughout most of 2021, and a lull again in December 2021. in the past year, and 27.3% (n = 3) had 2 or more partners; the last Migrant peoples also anticipated policy changes affecting migrants and immigrants to Mexico and the US in early 2022. As a result, the TABLE 5 Pregnancy (self-reported by adults age ≥18 years). MRS received between 35 and 250 migrants per day at the time of data collection in January 2022. In addition, this study focused on Men, n Women, n p-value migrant peoples in transit; there may be different SRH needs at (%) (%) (difference between different stages of migration: predeparture, in transit, interception, genders) and arrival at destination (20). Finally, our self-applied questionnaire allowed participants to skip questions that they did not wish to Lifetime number of n = 46 n = 46 0.14 pregnancies (men: answer, and some items had large proportions of missing data (e.g., number of times you only 7/20 women who reported sexual intercourse in the last impregnated a woman) 4 weeks answered the item on the relationship to that sexual 0 13 (28.3) 7 (15.2) partner). Missing data could bias results if respondents with 1 16 (34.8) 10 (21.7) particular characteristics were less willing to respond. 2 8 (17.4) 11 (23.9) The UN Committee on Economic, Social, and Cultural Rights 3 5 (10.9) 8 (17.4) and the Convention on the Elimination of All Forms of 4 or more 4 (8.7) 10 (21.7%) Discriminations against Women affirm that sexual and Age at first pregnancy n = 31 n = 34 0.42 reproductive health and access to SRH services are basic human (women) rights (21). Indeed, the 2030 Sustainable Development Goals <18 years 4 (12.9) 8 (23.5) include the aim to achieve access to universal SRH services (22). 18–30 years 22 (71.0) 23 (67.6) However, access to SRH services remains limited in many low >30 years 5 (16.3) 3 (8.8) and middle income countries and in humanitarian settings (3), Are you currently n = 39 often due to scarce resources and inadequate infrastructure (7, 23). pregnant? A recent systematic review demonstrated that there are a number No 30 (76.9) of evidence-based interventions to improve HIV and STI prevention Yesa 9 (23.1) knowledge and contraception and condom-use skills for young How many months n=8 people in LMIC and humanitarian settings, and that these require pregnant are you? adaptation “to the context and realities of humanitarian settings First trimester 4 (50.0) (such as high levels of trauma exposure and loss),” (3). The Second trimester 2 (25.0) authors suggest that in such resource-limited and challenging Third trimester 2 (25.0) settings, trauma-informed approaches may be considered a priority a 9 women self-reported that they were currently pregnant; blood testing rather than resource-demanding high intensity interventions. They confirmed pregnancy among 11 women. also suggest that program planners should consider whether SRH Frontiers in Reproductive Health 08 frontiersin.org Erausquin et al. 10.3389/frph.2022.953979 services in LMIC and humanitarian settings could be integrated into Funding existing service systems (3). The Inter-Agency Field Manual on Reproductive Health in This project was supported by funds and donations of supplies Humanitarian Settings provides an outline of minimum from Instituto Conmemorativo Gorgas de Estudios de la Salud, reproductive health interventions that should be implemented when Community Development Network of the Americas, Acino Swiss a humanitarian crisis emerges (4). Of critical importance is the need Farma, Glaxosmithkline Panamá, Ann Knudson, and the for gender-specific care, as women and girls in humanitarian crises Oklahoma University’s Physicians Pharmacy, Sagrav SA, and have distinct needs when engaging with SRH services (24). In the Omega Diagnostics. The National Research System of SENACYT case of migration through the DF in Panamá, the humanitarian provided funding for some of the rapid tests by means of José crisis is not new, nor is an end in sight. To address the SRH needs Suárez and Amanda Gabster. The funders were not involved in the of highly vulnerable migrant peoples who transit the DF en route to study design, collection, analysis, interpretation of data, the writing North America, a minimum standard of integrated sexual and of this article or the decision to submit it for publication. reproductive health interventions is necessary. Furthermore, the design and delivery of SRH services must take a regional approach, with participation from countries across Latin America and Acknowledgments the Caribbean. The authors are immensely grateful to the participants and guardians of underage participants for their involvement in the study. The authors would also like to thank the Center for Data availability statement Research and Diagnosis of Emerging and Infectious Diseases, Metetí, Darién of the Instituto Conmemorativo Gorgas de The raw data supporting the conclusions of this article will Estudios de la Salud, Community Development Network of the be made available by the authors, without undue reservation. Americas, UNICEF, Médecins Sans Frontières, Panamás Ministerio de Salud, Servicio Nacional de Fronteras (SENAFRONT), and Servicio Nacional de Migración for their ongoing support, especially the volunteers: Albin Mendoza, Andy Ethics statement Ledezma, Leyner Salinas, Melanio Marin, Roberto Ramos, and Rosendo Fuentes. We also thank the Panamánian Red Cross The studies involving human participants were reviewed and Darién Chapter, especially the volunteers: Máximo González, approved by Comité de Bioética de la Investigación del Instituto Miliza Peralta, Nelson Cabezón, Yudith Peña, Nayelys Miranda, Conmemorativo Gorgas de Estudios de la Salud. Written Cynthia Degracia, Orlando Pisario, Lizi Lino, María Sánchez, informed consent to participate in this study was provided by Yesica Lino, Loyda Berrio, Ludis Mezua, and Caselina Piraza. participants age 18 and older. For participants 12–17 years, a parent or legal guardian/next of kin provided written consent and the minor participant provided written assent. Conflict of interest The authors declare that the research was conducted in the absence of any commercial or financial relationships that could Author contributions be construed as a potential conflict of interest. JTE, JS, and AG conceived of the presented idea. 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