Data from two large, community surveys of African people living in England suggest that the proportion of people who have recently tested for HIV has increased over the last five years. There are also improvements in people’s knowledge about HIV testing and treatment, suggesting that the activities of health services and health promotion organisations may be bearing fruit.
The findings come from the African Health and Sex Survey report, to be published this week by Sigma Research, a unit of the London School of Hygiene and Tropical Medicine. Data collected within the past year are compared with data from a similar cross-sectional survey, conducted in 2008-09. Nonetheless it is important to note that there are methodological problems with making comparisons between separate surveys – the findings should be treated with caution.
Between September 2013 and January 2014, 1026 African people who were living in England completed an online survey that was promoted through targeted Facebook advertising, community-based organisations and additional online advertising. Over half the respondents completed the survey on a smartphone or tablet.
The previous survey (Bass Line 2008-09) relied more on pen-and-paper surveys, distributed by health and community organisations. The new online methods recruited a smaller sample, but one which may have had less contact with organisations focused on HIV prevention and care, and so may be somewhat more representative of the wider African population. So as to try to correct some of the problems associated with comparing samples recruited through different methods, the researchers have adjusted their figures for demographic variables associated with different results – age, education, ethnic group, gender, partner numbers, length of time living in the UK and HIV testing history.
In the most recent sample, more respondents were women (61.7%) than men (38.3%). The sample was normally distributed across the age range and most respondents described themselves as black African (62.1%) or black African British (22.1%). The most common countries of birth were Zimbabwe, England and Nigeria. The average length of time living in the UK was nine years, just under half were London residents and three-quarters had university or college-level education.
Uptake of HIV testing
In the most recent data, two-thirds of respondents (65%) had ever been tested for HIV, including one in ten (10.9%) who had been diagnosed with HIV.
While one third had never tested for HIV, this figure appears to have dropped since the last survey, five years ago (adjusted odds ratio 0.84, 95% confidence interval 0.71-1.01).
Moreover, six in ten of those who had tested negative said they had done so within the past year, with only one in ten having tested more than five years ago. There was a statistically significant improvement in the proportion who had recently tested, compared to the previous survey (adjusted odds ratio 1.50, 95% confidence interval 1.19-1.88).
In general, older people were more likely to have tested for HIV and have been diagnosed with HIV. Respondents with high levels of education were much more likely to have tested for HIV. Those with lower education had the lowest rates of testing (50.0% had never tested) but were also the most likely to have tested HIV positive (33.3%).
Improving the uptake of HIV testing and reducing undiagnosed infection is a key aim of the HIV Prevention England programme.
For the two-thirds who had tested, there were notable differences in their reasons for taking a test, according to whether their last test result was HIV-negative or HIV-positive. While HIV testing as a part of regular health screening is promoted by public health bodies, it was a reason to test for 30.4% of those receiving a negative result, but only 10.9% of those being diagnosed with HIV.
People who were HIV-positive had more commonly been tested because they were ill (33.6%) or because a doctor had suggested it (12.7%).
Overwhelmingly, the reason that non-testers said they had not tested was because they “had no reason to think they had HIV” – suggested by 63.1% of non-testers. Far fewer people said they didn’t know where to test (7.8%) or were too afraid of an HIV-positive result (6.6%).
Moreover, comparison between the recent survey and the one conducted five years earlier suggest that there are statistically significant fewer people who:
- Say it’s not important for them to know their HIV status.
- Are not sure that they could get an HIV test if they wanted one.
- Are too afraid of an HIV-positive result to test.
- Don’t know HIV medications work better if taken early.
- Don’t know HIV medications can help people stay healthy.
But while all of these indicators are moving in the right direction, there is one important knowledge indicator which has worse results than five years ago. In the current survey, 72.7% of respondents did not know that 1 in 20 Africans in the UK have HIV, a statistically significant increase on the previous survey (adjusted odds ratio 1.38, 95% confidence interval 1.15-1.64). The lack of progress in raising awareness of this uncomfortable fact may be linked to the large number of non-testers who say they have no reason to think they have HIV.
Where to test
Just under half of those who had tested had done so at a sexual health clinic. Around one in ten had been tested at an antenatal clinic (11.0%) or GP surgery (10.1%). Fewer people had done so with an HIV or African organisation (4.1%).
But when people were asked where they would prefer to test, the most popular suggestion was at a GP surgery. This was especially the case for people who had never tested for HIV, who generally expressed more interest in innovative settings for HIV testing than people who had previously tested.
Among non-testers, 31.0% would prefer to test with their GP, 20.5% with a home-testing kit (receiving an immediate result), 17.6% at a sexual health clinic, 10.2% at a private healthcare clinic, 9.1% with a home-sampling kit (with results returned from a lab later), and 8.0% at an HIV or African organisation. This indicates that a wider range of settings and options for HIV testing may help to encourage higher rates of testing and reduce undiagnosed infection.
HIV knowledge – priority groups
The survey assessed respondents’ knowledge and awareness of factual information about HIV. The HIV Prevention England programme is attempting to improve people’s understanding of these issues.
While levels of knowledge were high in relation to a number of points, there are considerable gaps in people’s understanding of a number of key facts. Moreover, knowledge was especially poor in some demographic groups.
Just under half the respondents (44.2%) did not know, did not understand or were not sure of this statement: “Effective treatment of HIV, using medication, significantly reduces the risk of HIV being passed on to others”. Similarly, 35.8% did not know that “HIV medication is available free of charge to anyone in the UK who has diagnosed HIV” (with no change in understanding of this point since the last survey).
In relation to the statement, “HIV medicines work better if people with HIV start taking them early (before they start getting ill)”, understanding has significantly improved since the last survey, but still 21.3% did not know it.
And, as already mentioned, 72.7% did not know, did not understand or were not sure of the statement “At least 1-in-20 of all Africans living in England have HIV infection”.
For each of these points, knowledge was poorer among:
- People who have never tested for HIV.
- People with low levels of education.
- People under the age of 30.
- People who have lived in the UK for three years or less.
These are therefore priority groups within African communities for HIV prevention activities.
NAM’s monthly email bulletin HIV prevention news: England will highlight other findings from the African Health and Sex Survey in the coming months. Sign up to receive the bulletin here.
Bourne A et al. African Health & Sex Survey 2013-2014: Headline findings. London: Sigma Research, London School of Hygiene & Tropical Medicine, 2014. (Full text freely available here).