NAT (National AIDS Trust) argues in a recent report that although black African communities in the UK are disproportionately affected by HIV, “the HIV-related needs of black African communities receive neither the attention nor the resources they should from policy-makers, decision-makers and funders.” In particular, NAT believes that appropriate HIV prevention needs to be scaled up, but in a way which avoids black African people feeling “targeted” or “singled out” as a risk group for HIV infection.
NAT’s report also criticises the failure of primary care and other NHS services to implement guidelines on HIV testing. As a result, rates of late diagnosis remain considerably higher in African people than in other communities.
The report – reviewing a wide range of issues relevant to HIV and black African communities – begins by noting one of the starkest health inequalities in the country. Whilst black African men and women constitute 1.8% of the UK resident population, they account for 34% of all people diagnosed with HIV.
Moreover, around half of African people newly diagnosed with HIV probably acquired their infection in the UK (rather than in an African country) highlighting the need for prevention activities in this country. But stakeholders consulted by NAT said that there were not enough community workers for effective outreach work, there was inadequate coverage of health promotion interventions and inconsistent implementation of programmes, characterised as "stop-start".
“Greater resourcing and staffing need to be provided for direct prevention interventions, health promotion and outreach work amongst black African men and women,” recommends NAT. “Local authorities should work in a longer-term, engaged and sustained way with appropriate providers to ensure HIV prevention amongst African communities delivers impact over time.”
In particular, awareness of prevention options such as post-exposure prophylaxis (PEP) and treatment as prevention is relatively low in African communities – prevention interventions need to address this.
There is also a lack of robust and independent evaluation of prevention work, which hinders the development of a shared knowledge-base of which interventions work and of the ways in which they work. For example, different styles of interventions with faith groups should be trialed and evaluated. Similarly, we don’t have an evidence-based description of the most effective ways to deliver HIV testing in community settings and how best to integrate such projects into the wider local HIV testing ‘economy’.
NAT also says that a recurring theme among the stakeholders they consulted was the dislike of many people of “HIV prevention activity which singles black Africans out as the one ethnic group amongst heterosexuals who are at risk of HIV”.
They stress that a prioritisation of black African communities in HIV prevention activities and funding must continue (because of the disproportionate burden of HIV in these communities), but that the question of “targeting” must be sensitively handled.
“For black African communities already dealing with an immigration system, politics and UK media which appear consistently hostile to their arrival and presence in the UK, and who wish simply to be accepted and respected by UK society, HIV prevention activity which publicly identifies black Africans as a group with HIV is threatening and distressing,” they argue.
NAT has long argued for more prevention work for the general population. In this report, they suggest that interventions which reach black African people should be integrated with wider work for the sexually active heterosexual population. Rather than having a focus on ethnicity, communications should identify risk more specifically, for example around multiple concurrent partners, unprotected sex with new and casual partners, and sex in countries of high prevalence, they recommend.
They note that around 25% of HIV infections acquired in the UK concern neither gay men nor black African communities. Moreover, the ‘second generation’ of people of black African ethnicity who are born in the UK are likely to have different sexual health needs to their parents, especially if they are more likely to have sexual partners from other ethnic groups.
The report also notes that there are considerable inequalities in terms of late diagnosis of HIV infection. While 34% of gay men were diagnosed with a CD4 cell count below 350 cells/mm3 in 2012, 66% of black African men and 61% of black African women were diagnosed late. There is evidence that the number of people who have ever tested for HIV in increasing, but that the frequency of testing still needs to be improved.
Although GPs and other primary care services are seen by many African men and women as appropriate health services in which to be offered an HIV test, guidance from NICE (National Institute for Health and Care Excellence) and BHIVA (British HIV Association) on testing in these settings has not been widely implemented. “The failure of the NHS to implement UK guidance on HIV testing profoundly harms black African communities in the UK and must be addressed urgently,” comments NAT. The report makes several recommendations for commissioners in local authorities and clinical commissioning groups to achieve better implementation.
Their report does not limit itself to HIV prevention and testing, but reviews a wide range of issues affecting HIV and black African communities – including HIV treatment and care, poverty, housing, immigration, social care, mental health, tuberculosis, stigma, discrimination and the specific needs of women, men who have sex with men and young people living with HIV. In each area, the report reviews relevant research, the views of stakeholders and policy implications, before making detailed recommendations.