Friday, 12 March 2010

The complex challenge of HIV prevention among black Africans in England

Black African communities in England experience the highest reported and undiagnosed heterosexually acquired HIV prevalence;

The majority of black Africans in England are tested for HIV very late; most cases, particularly in men, have a high viral load (i.e. a high level of HIV virus in their body) and are thus unable to benefit fully from available treatment and care;

There are more same-sex relationships than reported among black Africans in England;

The sexual health of the black African communities is dependent on diverse socio-economic factors;

There are many unmet sexual health and social needs among black African communities in England, making them vulnerable to HIV

Although black Africans make up only about 1% of the UK population, they account for almost half of all new HIV diagnoses in the UK. Apart from high HIV prevalence, their potential to benefit from available treatment and care is limited by many factors, such as late diagnosis, stigma and discrimination, unemployment, poor living conditions and uncertain immigration status for some.

HIV prevalence among black Africans in England

HIV prevalence in the UK is low compared to other parts of the world, but is one of the highest in western and central Europe. HIV therefore remains a significant infectious disease with profound implications for morbidity and the cost of treatment and care. However, the impact of HIV on mortality in the UK has significantly reduced since the introduction of combination therapy in the mid 1990s. This applies only to those who are diagnosed and take up treatment in good time to benefit from therapy.

Black Africans are the heterosexual group most affected by HIV in the UK. Although most of the infections among this group were acquired outside the UK (mainly in Sub-Saharan Africa), an increasing number are becoming infected while in the UK. In 2008, 38% of the new HIV diagnoses in the UK were among black Africans. The majority of black Africans living with diagnosed HIV in the UK are aged between 20 and 49 years. Overall, more women than men have been tested for HIV, possibly through antenatal care to prevent mother-to-child transmission. This suggests the need for testing interventions that target men.

Late Diagnosis

Late HIV diagnosis remains a major problem among black Africans in England. In 2007, about 42 per cent of black Africans diagnosed with HIV were diagnosed late. This compromises their survival chances because evidence indicates that starting treatment with a CD4 cell count below 200 copies/mm3 increases the risk of disease progression and death. The reasons for late diagnosis among black Africans are not clear-cut, but include persistent HIV-related stigma and discrimination. Cultural, social and structural barriers, such as access to testing and care, fear of death and disease, lack of political will, restrictive immigration policies and lack of African representation in decision-making processes have been identified as contributory factors.

A 2007 survey found that many Africans did not test for HIV because they "had no reason to believe they might have HIV". Other reasons given by the respondents for not testing for HIV included: misconception that testing positive would lead to deportation; fear of testing positive; fear of relationships breaking up after testing positive; not knowing where to get tested, which was reported by one in ten respondents; fear of changes in life and work or business patterns as a result of a positive diagnosis.

HIV-related stigma also affects HIV status disclosure among black Africans. It has been found that, compared to white or minority ethnic gay men, heterosexual black Africans were the least likely to disclose their HIV status to their partners, family, employers or friends. By not disclosing their HIV status to their employers, such individuals, paradoxically, deny themselves their entitlements under the Disability Discrimination Act (DDA) of 2005. Non-disclosure, especially to partners, can also have legal implications in the light of criminal prosecutions for reckless transmission, which have occurred in England.

Some Africans have come from settings where HIV is thought to be a sex workers disease, making some people feel less vulnerable. In some resource-limited settings, treatment and care are not universally available and people have seen loved ones die from HIV in the most traumatic circumstances. To such people, positive diagnosis means a death sentence, hence their reluctance to test.

Sexual orientation

The needs of homosexual and bisexual Africans are largely unknown or even overlooked. Most black Africans in England came from countries where same-sex relationship behaviour is highly discriminated against, stigmatised and in some cases criminalised. Consequently, there are more same-sex relationships among African populations than is officially acknowledged. Cultural and religious diversity among African communities makes it hard for men who have sex with men (MSM) to pursue their sexual desires openly. Individuals brought up in such discriminatory environments might find it very difficult to disclose their sexuality even if they achieve 'sexual freedom' by moving to Europe or North America, because they still rely on communal networks for social support. When such individuals end up with a positive HIV diagnosis, there is a potential for multiple stigma (HIV, black African, gay/bisexual).

The black African man who has sex with men in England also faces ‘high, but undisclosed, rates of racism among gays and homophobia among Africans’. This leaves them with limited support options and some end up living a double life (Positive Nation, 2007). Evidence suggests a discord between stated sexuality and actual sexual behaviour, with a significant number of Africans saying that they are heterosexual when they are involved in same-sex relationships. In cases where such individuals are asylum seekers, they not only worry about their sexual identities but also fear deportation and lack of treatment in their home countries if they are living with HIV.

It has been found that gay and bisexual Africans were more likely to engage in behaviours that increased their risk of contracting sexually transmitted infections, indicating the need for targeted health promotion interventions. Black African MSM test for HIV so late and likewise present for treatment so late, increasing their risk of HIV-related morbidity and mortality. It has been cautioned that although black African MSM in England may come from the same continent, their needs (which are not yet well understood) differ because they migrated for different reasons and from different countries and backgrounds.

Sexual health outcomes: The impact of socio-economic factors

Many HIV positive black Africans face numerous social and economic challenges, making HIV just one of the problems, and of least importance. Black Africans in England comprise individuals who identify with numerous nationalities and ethnic roots, and those identities affect their sexual health attitudes, behaviours and outcomes. HIV prevalence among black Africans in England mirrors the prevalence in their native countries. In addition, a person's country of birth can influence the number of their sexual partners, possibly due to cultural practices in some settings, such as polygamy and wife inheritance.

Many black Africans in England have insecure residency status (those without indefinite leave to remain). This affects their employment possibilities, income, housing and mental health. Immigration cases take a long time to be processed by the Home Office. During such prolonged periods of uncertainty, some Africans are forced into sexual risks, such as prostitution, by their circumstances, thus increasing their risk of HIV infection.
In 2004, legislation was passed in England to stop 'health tourism'. Many of the targets of such legislation include failed black African asylum seekers. Such a policy, and the misconception that people are deported for testing positive for HIV, increases not only stigma and discrimination, but also apathy towards HIV testing and health care.

Lastly, studies from the USA have shown that spirituality is important to the psychological health of people living with HIV. However, links between religion and HIV-related attitudes are not yet fully understood. Many black Africans in England hold ‘strong religious beliefs’. Christianity and Islam, both of which have a large following among Africans, denounce homosexuality in their teachings. For example, important issues in HIV prevention such as ‘sex, homosexuality and drug use are taboo topics in [the] Islamic world’ and may lead to a reluctance to test for HIV.

The full Briefing Paper of the Race Equality Foundation by John Owuor is to be found here.

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