A Review of Research Among Black African Communities affected

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EXEC U T IVE SU MMARY
BACKGROUND
RESULTS
People of sub-Saharan African origin are the
second largest group affected by HIV in Western
Europe after Men who have Sex with Men
(MSM). Two thirds of all heterosexually acquired
HIV infections diagnosed between 1997 and
2002 in Western Europe were among people
from countries with generalised epidemics,
90% of them in sub-Saharan Africa. Similarly,
in the UK, black Africans constitute approximately
0.5% of the UK population, but represent almost
28% of people diagnosed with HIV.
The review included 129 studies, of which
29 were published in peer-reviewed journals.
Twenty-four of these were descriptive quantitative
studies, and five were qualitative studies. A
total of 100 ‘grey literature’ publications (mainly
reports and online publications) encompassing
quantitative and qualitative data were also
included.
There is therefore a critical need to develop
HIV prevention interventions with black African
communities affected by HIV in Europe.
However, information on existing interventions
was available through grey literature, and details
of 31 interventions were thus obtained, 22 in
the UK and nine in other European countries.
REVIEW AIMS AND METHODS
RECOMMENDATIONS
This review aims to describe and summarise
the literature on prevention interventions with
African migrant communities affected by HIV
in the UK and other European countries, and
to make recommendations for future
interventions.
We identified six major areas of need for HIV
prevention interventions with black African
communities:
We conducted a keyword search using Embase,
Medline and PsychInfo, searched existing
reviews, ‘grey literature’, and expert working
group reports.
We then explored six key themes that emerged
from descriptive studies:
1. HIV testing
2. Sexual lifestyles and attitudes
3. Gender
4. Use of HIV services
5. Stigma and disclosure
6. Deprivation and legal status
There were no studies in peer-reviewed journals
describing HIV interventions with people of subSaharan African origin.
1. Promoting Voluntary Counselling and Testing
(VCT)
2. Improving HIV awareness and sexual health
services knowledge
3. Meeting the psychosocial needs of black
African families, adolescents and children
affected by HIV
4. Promoting safer sex and condom use among
black African MSM
5. Improving HIV awareness among black
African adolescents and youth
6. Facilitating access to employment for black
Africans affected by HIV
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CO N T E N T S
Executive Summary
02
1. Introduction: Aims of the Review
03
2. Methods and Results
08
08
09
10
11
12
14
3. Descriptive Studies
3.1 HIV testing
3.2 Sexual lifestyles and attitudes
3.3 Use of HIV services
3.4 Gender
3.5 Stigma and disclosure
3.6 Deprivation and legal status
17
4. Intervention Studies
23
5. Summary & Recommendations
24
References
Tables:
Table 1 Descriptive quantitative and qualitative
studies on black African communities affected by
HIV in the UK and other European countries
Table 2 Surveys on the sexual health attitudes and
needs of black Africans in the UK
Table 3 HIV Prevention Interventions with African
Communities in the UK (n=22, grey literature)
Table 4 HIV Prevention Interventions with African
Communities in other European Countries (n=9,
grey literature)
ACKNOWLEDGEMENTS
We gratefully acknowledge the help of the
following researchers in defining the search
strategy for this review and commenting
on drafts of the report: Prof. Graham Hart
and Dr. Mark Petticrew (MRC Social &
Public Health Sciences Unit), Prof.
Jonathan Elford and Prof. Helen Roberts
(City University), Dr. John Imrie (UCL
Centre for Sexual Health and HIV
Research) and Dr. Jane Anderson
(Homerton University Hospital Foundation
Trust, Hackney).
This study was funded by the Medical
Research Council’s Social and Public
Health Sciences Unit, Glasgow.
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INTRODUCTION
People of sub-Saharan African origin
are the second largest group affected
by HIV in Western Europe after Men
who have Sex with Men (MSM). In
2003, approximately 58% of new HIV
infections in Western Europe were
acquired through heterosexual contact,
and 26% of these were among people
of sub-Saharan African origin [71].
Moreover, two thirds of all
heterosexually acquired HIV infections
diagnosed between 1997 and 2002
were among people from countries
with generalised epidemics, 90% of
them in sub-Saharan Africa. In 2004,
new diagnoses among sub-Saharan
African migrants constituted 30.9% of
all new HIV diagnoses in the UK, 34.1%
in Belgium, 27.4% in France, 14.3% in
Germany, and 13.4% in Portugal [71].
In the UK, HIV prevalence among black
Africans has been increasing constantly
since 1997, and almost doubled
between 2000 and 2002 [88].
Although black African migrants and
their descendents only constitute about
0.5% of the UK population, they
represent nearly 28% of those
diagnosed with HIV [93]. According to
recent research, approximately 37% of
all people diagnosed with HIV between
1995 and 2005 in the UK were black
African [89].
While generalising about the
experience of ‘African communities’
in Western Europe inevitably imposes
a reductionist frame on a vastly
complex issue [84, 85], the literature
highlights a number of traits that
roughly characterise the experiences
of sub-Saharan African migrants living
with HIV across Western Europe:
1. Late testing and diagnosis, often at
the onset of AIDS-related illnesses or,
for women, in the context of antenatal
screening [2, 7, 4, 10-13, 19, 22, 24,
49, 60, 63, 83, 101, 113].
2. Barriers to accessing healthcare
and social services increased by
uncertain immigration status, social
isolation, discrimination, and HIVrelated stigma [25, 28, 29, 61, 64,
72, 91].
3. High levels of unemployment and
poverty, especially among recent
migrants [32-34, 37, 54, 65, 83, 86,
95, 115].
There is therefore a clear need for
specific interventions to encourage
testing and improve access to care
among black African communities in
Western Europe. However, little is
known about the effectiveness of
existing HIV prevention interventions.
This scoping review therefore aims to:
(a) Survey the descriptive quantitative
studies, qualitative studies, and
interventions studies undertaken
among black African communities in
the UK and other European countries.
(b) Record the characteristics of the
interventions and research projects
identified.
(c) Clarify some of the factors which
contribute to increasing the
effectiveness of prevention
interventions with black African
communities in the UK and other
European countries.
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METHODS & RESULTS
We searched the databases Embase,
Medline, and PsychInfo, using
combinations of the following text words:
‘HIV’, ‘migrant’, ‘migration’, ‘subSaharan’, ‘Black African’, ‘Africa’, ‘UK’
and ‘Europe’. We did not use the key
word ‘Black’, however, as this would
have yielded a larger number of
publications related to black African
Americans. A search for studies in
progress was conducted using the
National Research Register and the
Cochrane Library. We also handsearched retrieved articles,
bibliographies of selected papers, ‘grey
literature’, and expert working group
reports from the UK and other European
countries. Individual researchers were
contacted to obtain further unpublished
studies [132, 135, 137].
Studies included:
1. Studies that described an intervention
or the planning phase of an intervention
with HIV positive people of sub-Saharan
African origin living in the UK and other
European countries.
2. Quantitative, descriptive studies
relating to people of sub-Saharan origin
living with HIV in the UK and other
European countries.
3. Qualitative studies relating to social
and economic issues affecting people
of sub-Saharan origin living with HIV in
the UK and other European countries.
Only studies published between 1996
(i.e. post-HAART) and October 2005
were included, with no restriction on
language, study design, or outcome
assessed. However, the high number
of English language ‘grey literature’
publications available on the internet
probably did introduce a language and
country bias. We included literature from
European countries other than the UK
since sub-Saharan African migrants living
with HIV in major European cities are likely
to be affected by similar issues, such as
unequal access to social services and care,
immigration concerns and stigma.
We found 29 descriptive studies published
in peer-reviewed journals concerned with
migrants’ access to, and experience of, HIV
testing and health care, 24 of which were
quantitative, and five qualitative (see Table
1). No studies published in peer-reviewed
publications described interventions with
migrants from sub-Saharan African countries.
However, outlines of 31 interventions were
available through ‘grey literature’ (reports
and online publications, see Tables 3 and
4). Eight of these did not focus specifically
on the needs of sub-Saharan Africans, but
rather on the needs of people living with HIV
at large.
A total of 129 studies met our inclusion
criteria. The majority of these (100) were
‘grey’ publications: reports from
governmental and non-governmental
organisations both in the UK and other
European countries, online materials, and
conference abstracts. Some of the reports
included in this category contained
quantitative and/or qualitative data. Two
descriptive studies were excluded from the
‘descriptive studies’ category on the basis
of quality assessment criteria but included
in the ‘grey literature’ section.
The majority of studies on African
communities conducted in the UK are
primary observational studies, and very few
are intervention studies. As Fenton noted in
a recent presentation on the state of play in
research on African communities in the UK,
‘there are still gaps in behavioural
interventions, evaluations of interventions
and the collation of evidence’ [109].
RESULTS:
Publications reviewed (n= 129):
Peer-reviewed studies (n= 29):
- Quantitative descriptive studies (n= 24)
- Qualitative descriptive studies (n= 5)
‘Grey literature’ publications (n= 100)
Interventions identified through ‘grey literature’ (n=31):
- UK-based interventions (n= 22)
- Interventions in other European countries (n=9)
- Interventions evaluated in Randomised Controlled Trials (n=0)
- Interventions with process evaluation (n=5)
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TABLE 1
DESCRIPTIVE QUANTITATIVE AND QUALITATIVE STUDIES ON BLACK AFRICAN
COMMUNITIES AFFECTED BY HIV IN THE UK AND OTHER EUROPEAN COUNTRIES
AUTHOR(S) DATE FOCUS
1. Anderson 2004 The experiences and
& Doyal
needs of African women
living with HIV in London.
METHODS
2. Arendt & 2003 Characteristics of the
von Giesen
population of HIV-1 positive
female migrants in
Northrhine- Westphalia,
Germany.
Comparison between data concerning 204 HIV1-positive female migrants from Sub-Saharan
Africa, Asia, and European countries other than
Germany, with those of 282 German HIV positive
women.
Female migrants tested at a younger age than non-migrants,
and most were infected through heterosexual intercourse.
Both groups showed the same pattern of AIDS-defining diseases,
with tuberculosis occurring more frequently among migrants.
3. Boyd, 2005 Ethnic differences in stage of
Murad,
pres-entation for adults newly
O’Shea, de
diagnosed with HIV-1 infection
Ruiter,
between 1998 and 2000 in
Watson,
a large ethnically diverse HIVEasterbrook
1-infected clinic population in
south London.
Analysis of demographic and clinical data obtained from
databases and medical records for all persons aged
over 18 attending King's College Hospital who tested
positive between 1998 and 2000, and for a random
sample of patients attending St Thomas' hospital with
a positive test in the same period. Comparisons were
made by ethnic group and over time.
Of the 494 patients surveyed 36.2% were white, 54.7% were
black African and 9.1% were black Caribbean. Among whites,
72.6% were MSM, 3.4% injecting drug users and 21.2%
heterosexuals, compared to 2.2%, 0.4% and 93.3% among
black Africans. Black Africans were more likely to present with
an AIDS diagnosis and a lower CD4 cell count compared to
whites and Caribbeans.
4. Burns, 2001 To assess whether
Fakoya,
Africans present at more
Copas &
advanced stages of
French.
disease than non-Africans
in the UK.
A retrospective review of all adults diagnosed African patients presented with significantly more advanced
HIV positive from January 1998 to December disease than non-Africans, and were more likely to have AIDS
1999 attending two specialist HIV clinics in
at presentation in 1998-1999 than in 1982-1995.
London. Demographic and clinical data were
collected from case notes. Comparison with
data from a retrospective study of all HIVinfected Africans and a comparison group of
non-Africans from 1982 to 1995 attending the
same centres.
5. Connell, 2001 To investigate observed
McKewitt &
ethnic inequalities in
Low
indicators of sexual health
among Black African and
Caribbean youth in
Lambeth, Southwark, and
Lewisham.
Rapid ethnographic assessment methods were used,
including focus group discussions with participants
(n=42) from different ethnic backgrounds about
sexual lifestyles and service use. The authors
conducted two cross-sectional surveys to investigate
sexual behaviours, attitudes and sexual health
service use in samples from the general population
(n=463) and genitourinary clinic attendees (n=298).
RESULTS
Qualitative study using self-complete questionnaires The women described the experience of being a migrant in
and in-depth semi-structured interviews with 62 the UK, and the ways in which stigma impacted on their lives
women from 11 African countries attending HIV and access to HIV services.
specialist clinics in five London hospitals.
6. Coulon 2004 Motherhood in the context Analysis of 20 interviews of women from the
& Feroni
of antiretroviral treatment Manif 2000 cohort.
in France.
The study found high rates of bacterial STIs in the study
population, but reported that these infections were not of great
concern to young people. Authors recommended that
interventions to reduce rates of STIs should engage young
people by using their ‘conceptual frameworks’, i.e. emphasise
relationships and trust instead of focusing solely on personal
health considerations.
The authors concluded that interviews showed a 'normalisation'
of pregnancy with HAART, and that women felt confident about
the pregnancy outcome and their HIV treatment.
7. Creighton, 2004 GUM clinics practitioners’ Analysis of 56 anonymous questionnaires
Doctors surveyed believed that the dispersal of positive asylum
Sethi,
opinions about appropriate- received from GUM clinicians in England in 2003. seekers is disruptive and may compromise HIV care, thereby
Edwards &
ness of refugee dispersal
leading to increased risk of transmission.
Miller
and its impact on HIV care.
1996a Characteristics of AIDS8. Del
Amo, Goh,
defining conditions
Forster
among Africans living in
the UK.
A retrospective study of 55 HIV-1 seropositive
African patients living in the UK seen between
January 1986 and November 1993 in an East
London HIV clinic.
A total of 26 (47%) patients had AIDS, 31 (56%) had symptomatic
HIV disease at the time of presentation, of whom 19 (34.5%)
had an AIDS defining condition. Tuberculosis was the most
common AIDS defining illness, (in 27% of all initial AIDS
diagnoses).
1996b Spectrum of disease,
9. Del
Amo, Goh,
severity of immune
Forster
deficiency and treatment
prescribed in HIV-infected
African and non-African
patients in London.
Retrospective review of case notes for all HIVinfected Africans and a comparison group of
non-Africans attending 11 specialist HIV/AIDS
Units in London.
A total of 1056 Africans (313 developing AIDS) and 992 nonAfricans (314 developing AIDS) were studied. African patients
presented at lower levels of CD4+ lymphocyte count, at a
more advanced clinical stage, and with different AIDS-indicator
diseases as compared with non-Africans.
10. Dougan, 2005 Epidemiology of HIV
Elford,
among black and ethnic
Rice,
minority MSM in England
Brown,
& Wales
Sinka,
Evans, Gill,
Fenton
Ethnicity data from two national HIV/AIDS surveillance
systems were reviewed (1997–2002 inclusive).
Undiagnosed HIV prevalence among MSM attending
14 genitourinary medicine (GUM) clinics participating
in the Unlinked Anonymous Prevalence Monitoring
Programme was examined by world region of
birth.
Between 1997 and 2002, 1040 Black and Minority Ethnic
(BME) MSM were newly diagnosed with HIV in England &
Wales, representing 12% of all new diagnoses reported among
MSM. In 2002, the proportion of BME MSM living with
diagnosed HIV was significantly higher than white MSM.
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AUTHOR(S) DATE FOCUS
METHODS
RESULTS
11. Dougan,
Patel,
Tosswill,
Sinka
Reports of new HIV diagnoses received at the
Communicable Disease Surveillance Centre were
analysed. The study included individuals probably
infected in west Africa and those infected through
heterosexual intercourse within the United
Kingdom by a heterosexual partner infected in
west Africa were included.
Between 1985 and 2003 inclusive, 1324 individuals diagnosed
and reported with HIV had probably been infected in west Africa,
with 222 diagnoses made in 2003. A further 130 individuals
were probably infected through heterosexual intercourse within
the United Kingdom by a heterosexual partner infected in west
Africa. This suggests that the number of people infected with HIV
in west Africa and diagnosed in E, W & NI has increased in recent
years. There is also evidence of heterosexual transmission within
the United Kingdom from people infected in west Africa.
2005 HIV diagnoses made in
England, Wales, and
Northern Ireland
among those probably
infected in west Africa,
and evidence for
ongoing heterosexual
transmission within the
UK.
12. Doyal & 2005 Experiences of HIV
Semi-structured interviews conducted between The study highlighted the complex ways in which gender,
Anderson
positive African women 2001 and 2002 with 62 women from different experiences of migration and positive status impact on women's
in London.
parts of Africa receiving treatment through the lives.
NHS in London.
13. Erwin & 1999 Treatment issues
Six focus groups were held with 44 participants Salient issues discussed were: fear of discrimination, fear of
Peters
among Africans living from Uganda, Zambia, Ethiopia, Nigeria, Kenya, being ‘experimented’ upon during treatment and distrust of
with HIV in the UK.
Zimbabwe and Tanzania. Nineteen men and 25 the medical profession.
women took part in the focus group discussions
(aged from 22 to 46 years old).
14. Erwin et 2002 Pathways to HIV testing Questionnaire survey of 392 HIV positive patients
al.
and care among black attending a clinic in south London between July
Africans and white
1999 and March 2000.
patients in London.
Sixty four percent of respondents were white, 26% black
African, and 10% from other ethnic groups. Twenty eight per
cent of black Africans suspected they were HIV positive before
diagnosis, compared to 45% of white patients. Before testing,
11% of black Africans had attended a genitourinary medicine
clinic and 80% had consulted a GP. Twenty per cent of black
Africans expressed concern over entitlement to care.
15. Evans,
Bond &
MacRae
The study showed relatively high levels of STIs among Caribbean
men: 18% of the 133 Caribbeans had gonorrhoea compared
with one (2%) of the 47 Africans. 69% of Caribbeans reported
intercourse before the age of 17 compared with 48% of Africans
(P=0.004), but there was no difference in the numbers of sexual
partners, either in the previous year or in total.
1999 Issues around sexual Cross-sectional survey of 180 heterosexual African
behaviour and STIs
and Caribbean men.
among African and
Caribbean men in
London.
16. Fenton, 2001 Risk of HIV
Analysis based on data from 748 respondents
Chinouya,
transmission among collected for the Mayisha study (see Table 4.)
Davidson &
sub-Saharan Africans
Copas
in London travelling to
their country of origin.
Forty-three per cent of men and 46% of women had travelled
to their home countries in the past five years. Current
employment status and highest level of achieved education
were significantly associated with the likelihood of travelling
to one's country of origin. Men were more likely than women
to have acquired a new sexual partner while travelling abroad.
17. Fenton, 2002 Demographic and
Mayisha Questionnaire Survey (see Table 4.)
Chinouya,
behavioural factors
Davidson &
associated with HIV
Copas
testing among migrant
Africans in London.
Thirty four percent of men and 30% of women reported ever having
had an HIV test. HIV testing was significantly associated with age
and previous STI diagnosis among women, as well as with nationality,
education, employment, and self-perceived risk of acquiring HIV
among men. The study suggests that HIV testing remains largely
associated with an individual's STI history or self-perceived risk.
18. Forsyth, 2005 To explore the link
Burns &
between conflicts in
French
African countries,
migration, and HIV
presentation in the UK.
Data was collected retrospectively for HIV-positive
Africans attending an HIV unit in London between
1985 and 2003. Dates of armed conflicts in
Africa were correlated with year of HIV diagnosis
among the clinic population.
A total of 656 African individuals from 34 countries presented
during the study period; 40% were men and 60% were women.
The study shows that the annual presentation patterns of
African patients by country of origin correlates with periods
of social and political unrest.
19. Hickson, 2004 Epidemiology of HIV
Reid,
among black and
Weatherburn,
minority ethnic (BME)
Stephens,
men who have sex with
Nutland &
men (MSM) in England
Boakye
and Wales (E&W).
Ethnicity data from two national HIV/AIDS surveillance
systems were reviewed (1997–2002 inclusive).
Undiagnosed HIV prevalence among MSM attending
14 genitourinary medicine (GUM) clinics participating
in the Unlinked Anonymous Prevalence Monitoring
Programme and having routine syphilis serology
was examined by world region of birth.
Of the 1040 BME MSM diagnosed with HIV between 1997
and 2002, 27% were black Caribbean, 12% black African, 10%
black other, 8% Indian/Pakistani/Bangladeshi, and 44%
other/mixed. Where reported (n = 395), 58% of BME MSM
were probably infected in the United Kingdom. An estimated
7.4% of BME MSM aged 16–44 in E&W were living with
diagnosed HIV in 2002 compared with 3.2% of white MSM.
20. Low,
1996 Differences in progression Retrospective cohort study of 2048 HIV-1-positive
Paine, Clark,
to AIDS between HIV-1- individuals.
Mahalingam
positive Africans and HIV& Pozniak
1-positive non-Africans
in London.
Differences in progression to AIDS and death and CD4+ lymphocyte
decline between HIV-1-infected Africans and non-Africans in London
could not be attributed to ethnicity or different viral subtypes. Age
and the clinical and immunological stage at presentation, or AIDS,
were the major outcome determinants.
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AUTHOR(S) DATE FOCUS
METHODS
RESULTS
21. Lyall et al. 1998
Uptake of interventions
to reduce Mother to
Child Transmission of
HIV by women aware of
their status in the UK.
Review of mother-infant pairs who presented
for infant diagnosis of HIV infection.
Women with a diagnosis of HIV infection acted to reduce
the risk of transmission to their infants. Uptake of antiretroviral
therapy increased significantly over time, and the caesarean
section rate was high.
22. Malanda 2001
et al.
The provision of
psychological care for
HIV-positive black
Africans in London.
The proportion of Black African individuals
looked after in a large centre for the care of
HIV infection in London was compared with
the proportion of such patients referred for
specialist mental health help.
Black Africans were almost three times less likely to be
referred for specialist mental health care. They were more
likely to be suffering from AIDS at the time of referral, be
referred for assessment of possible organic brain disease
and to suffer from major depression or organic brain disease.
23. Manfredi, 2001
Calzo &
Chiodo
Epidemiological
features of HIV
infection among nonEU migrants to Italy.
Comparison of epidemiological, clinical and
therapeutic data for 41 non-EU migrants with
those of 123 Italian and EU patients in a crosssectional age and gender-matched case-control
study.
Approximately 4% of patients surveyed came from outside
the EU (51.2% from sub-Saharan Africa), with a proportional
predominance of females, and heterosexual and perinatal
transmission of HIV disease. Compared with Italian and EU
subjects, patients coming from abroad had a shorter duration
of known HIV infection, but only some were aware of their
HIV disease prior to immigration, or acquired HIV infection
only after coming to Italy (14.6% and 12.2%, respectively).
24. Mayaux, 2003 Characteristics of HIVinfected women who
Teglas &
do not receive ARV
Blanche
treatment in the
French perinatal
cohort.
Observational study conducted as part of the
French Perinatal Cohort of 2167 HIV-infected
women and their children between 1996 and
1999.
Approximately 4% of women in the cohort did not receive
prepartum treatment; reasons for which were refusal (34%),
premature delivery (8%) and unmonitored pregnancy (54%).
Treated and untreated women did not differ in terms of
geographic origin (Europe vs. sub-Saharan Africa).
25. McMunn 1998
et al.
Health service use in
relation to HIV/AIDS
prevention among
Ugandan migrants
living in southeast
London.
Cross-sectional survey with face-to-face
interviews using a semi-structured
questionnaire about knowledge and use of
health services, receipt of health promotion
information and satisfaction with services,
among 118 Ugandan migrants in South London
in 1996.
Ninety seven percent of migrants interviewed were registered
with a local GP and 94% of people reported having been to
the GP, 98% of them in the past year. Ninety nine percent
had had contact with at least one African organization. The
vast majority of health promotion information was received
from GP surgeries. Sixty one percent of respondents desired
further information on HIV/AIDS, while 56% indicated that
the GP surgery was the most convenient place to receive
this information.
26. MRC
1996
collaborative
study of HIV
infection in
women
Ethnic differences in
the socioepidemiological and
clinical characteristics
of a cohort of women
with HIV infection in
Britain and Ireland.
Analysis of baseline data (ethnic group, sexual
history, likely route of HIV infection, reasons
for HIV testing and first AIDS-defining disease)
from 400 women with HIV infection recruited
into a cohort study from 15 genitourinary
medicine/HIV clinics in Britain and Ireland.
Sixty-five per cent of women were white and 29% black
African. Their median number of lifetime sexual partners
was seven and three, respectively. Ninety-three per cent of
black African and 43% of white women were probably infected
through sexual intercourse. Perceived risk (33%) or
investigation of symptoms (26%) were the most common
reasons for HIV testing. Seven per cent of white women and
16% of black African women (p < 0.001) had AIDS when
HIV infection was diagnosed.
2003 Impact of the HIV
epidemic in subSaharan Africa on the
pattern of HIV in the
UK.
Analysis of national surveillance data, routine
voluntary confidential HIV reporting and
unlinked anonymous seroprevalence surveys
in the UK to December 2001.
Twenty percent of all reported HIV infections diagnosed in
the UK by the end of 2001 were probably acquired in Africa,
and 90% of these were heterosexually acquired. Among
those living with diagnosed HIV infection in 2000, 23% (4883
of 21,291) were described as black African, 81% of whom
lived in London.
28. Staehelin 2003 Access to ARV
therapy, disease
et al.
progression and
survival among
migrants from subSaharan Africa in the
Swiss cohort study.
Prospective national cohort study of HIV-1infected adults from seven HIV centres in
Switzerland. Survival analysis methods were
used to compare uptake of antiretroviral
therapy, survival and progression to AIDS in
the 2684 participants from Sub-Saharan Africa
and Northwest Europe enrolled from 19972001.
Among the patients surveyed (n=1331), the number of
patients from sub-Saharan Africa increased from 3 (1.6%)
to 47 (14%). A majority of HIV-positive migrants were most
likely infected prior to arrival in Switzerland. Sub-Saharan
Africans often presented at a more advanced stage of disease.
27. Sinka,
Mortimer,
Evans &
Morgan
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TABLE 2
SURVEYS ON THE SEXUAL HEALTH ATTITUDES AND NEEDS
OF BLACK AFRICANS IN THE UK
NAME OF
RESEARCH FOCUS
SURVEY/PROJECT
DATE GEOGRAPHIC
AL FOCUS
POPULATION
SIZE (• = data
METHODS
(• = data not available)
not available)
Cross-sectional survey of migrants conducted by
748 respondents
recruited in community community-based training interviewers.
settings (social events,
colleges, university,
etc.).
MayishaI
Sexual attitudes & lifestyles of black
2002
African men & women from five subSaharan African communities (Congo,
Kenya, Uganda, Zambia, Zimbabwe).
London
PADARE
Sexual attitudes and practices of HIV
positive Africans accessing services.
2002
London (Camden 214 respondents
& Islington)
recruited in
statutory and
community-based
services.
SHIBAH
Sexual health issues affecting black
Africans living with HIV.
2003
London
(Lambeth,
Southwark and
Lewisham)
Questionnaire delivered by community-based trained
interviewers.
124 respondents Survey and in-depth interviews with 20 of the survey
respondents.
recruited in
organisations
offering support or
treatment for HIV.
Project Nasah Anti-HIV treatments information needs 2003
of African people diagnosed with HIV.
London,
435 respondents
Manchester,
Leeds/Bradford
Twenty minute long interviews conducted by trained
community-based interviewers.
Ubuntu-Hunhu Health and social care needs of black
Africans in Hertfordshire.
2003
Hertforshire
An initial phase comprising a 45 minute-long interview
with 15 positive black Africans living in Herts, and a
second phase consisting of a questionnaire-based
survey and intervention with 322 black Africans
recruited in social venues in Herts.
PacheduZenzele
Assessing the level of HIV awareness
and HIV services awareness among
Zimbabweans in Luton.
2001
Luton
Mayisha II
Sexual attitudes & lifestyles of black
2004
African men & women – evaluation of
the feasibility and acceptability of
unlinked anonymous HIV prevalence
survey.
East London
Project
A study of ethnicity, socio-economic
circumstances and sexual behaviour
among people diagnosed with HIV.
SONHIA
Factors impacting on testing and
Ongoing London
treatment among newly diagnosed black
Africans living with HIV
London, Luton,
West Midlands
323 respondents
recruited in
community
settings.
•
•
1,359 respondents Cross-sectional quantitative survey and nested
qualitative study with 44 respondents.
recruited in
community
settings.
2004- 6 HIV treatment 1700 people with
2006 centres in East diagnosed HIV
including 612
Ongoing London
Black Africans.
•
Cross sectional survey.
Cross-sectional survey and nested qualitative study.
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3 . D ES CR I P T I VE ST U D I E S
KEY POINTS
This section explores six prominent themes
emerging from the descriptive studies
included in the review. The discussion is
primarily focused on studies pertaining to
African communities in the UK. Many of
the findings considered here stem from
nine surveys focusing on the sexual health
attitudes and needs of black Africans in
the UK: Mayisha I & II, Project Nasah,
PADARE, Ubuntu-Hunhu, Pachedu-Zenzele,
SHIBAH, the East London Project, and
SONIAH (see Table 2).
3. 1 HIV TESTING
At the end of 2002, approximately 15,400
African men and women were living with
HIV in the UK, 31% of whom were
undiagnosed [84]. An unlinked and
anonymous seroprevalence survey
undertaken among heterosexual attendees
at seven GUM clinics in London in 1999
and 2000 found that one in 16 women
and one in 33 men born in sub-Saharan
Africa were infected with HIV [87]. Thirty
nine percent of those that were HIV positive
remained undiagnosed after the visit.
Simalarly, Mayisha II found that two-thirds
of black Africans living with HIV in England
were undiagnosed [99]. High levels of
undiagnosed HIV infection and, frequently,
late diagnosis following longstanding HIV
infection [4], make a powerful case for
interventions emphasising the benefits of
early testing.
A number of possible factors may explain
the low levels of HIV testing found among
black Africans in the UK:
• Low self-perceived risk: a study by Erwin
et al. on ‘pathways to HIV testing’ found
that only 28% per cent of black Africans
surveyed thought they might be HIV positive
before diagnosis (versus 41% of white
patients) [10]. This would indicate that black
Africans often do not suspect their status.
• Lack of information regarding available
services: studies show a persistent need
for HIV-related information among black
Africans in the UK [10, 11, 13, 21, 26, 29, 54].
• Socio-economic and legal barriers to
accessing services: uncertain immigration
status is one of the main concerns of black
African migrants living with HIV, and can
be a powerful deterrent to testing and
accessing services [72, 25, 28].
Encouraging innovative approaches to VCT
promotion is a priority for primary and
secondary HIV prevention interventions
with black African communities. African
adults residing in the UK often present
with a different clinical spectrum to nonAfricans [7]: co-infection with Tuberculosis
and late presentation to HIV services, often
at the onset of symptoms from AIDS-related
illnesses, are frequent. Moreover, African
adults often discover their status at a more
advanced stage of disease progression
and with lower CD4 counts at diagnosis.
These factors put considerable incentive
on developing interventions encouraging
early testing.
Research shows that poor access to
services and strained relationships with
healthcare providers are factors which lead
many Africans in the UK to present late
for HIV care [10, 54, 75, 114, 125]. While
many positive Africans are diagnosed in
Genitourinary Medicine (GUM) clinics, a
sizeable proportion also learn their status
as hospital in-patients following an AIDSrelated illness: Project Nasah [128], a
survey of 435 HIV positive Africans showed
that, while the majority of respondents had
been diagnosed in GUM clinics, 38% were
diagnosed as hospital in-patients, and 5%
through general practice. A study by
McMunn, Mwanje, Paine & Pozniak [21]
suggests that black African patients see
general practitioners as an important source
• Poor access to health services
and poor relationships with
healthcare providers lead many
Africans in the UK to present
late for HIV care.
• Studies suggest that mandatory
HIV testing would hinder
prevention.
• Promoting innovative paths to
VCT therefore remains the most
important goal of prevention
interventions for African
communities in Europe.
of information on HIV/AIDS, highlighting the
potential for making information about VCT
or VCT services themselves more readily
available through primary care [102].
Some researchers and clinicians have grown
impatient with the VCT approach and
advocate routinised HIV testing during
hospital visits as a remedy to the problem
of late diagnosis. Manavi & Welsby [134],
for example, argue that HIV testing ‘should
be widely accepted, without conventional
voluntary counselling and testing’. Conversely,
other researchers feel that the routinisation
of testing would lower quality standards for
VCT by side-stepping appropriate counselling.
Migrants’ groups and HIV specialists, in
particular, have argued that mandatory
testing would entrench the existing
stigmatisation of HIV positive people and
act as a further deterrent to accessing
services. These views against mandatory
testing were collated in a report from the All
Party Parliamentary Group on AIDS (UK)
[35]. The report concluded that the
government should foster policies that
encourage VCT.
Interventions should therefore focus on:
1. Devising innovative methods to promote VCT.
2. Developing training and information
resources for practitioners in primary care
settings (e.g. VCT training packs).
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KEY POINTS
Studies report:
• low levels of self-perceived risk
among black Africans in the UK
A review of the literature therefore indicates
that regular voluntary counselling and
testing remains the most effective method
for controlling HIV. Promoting innovative
paths to VCT is consequently considered
one of the most important goals of
prevention interventions for African
communities in Europe.
CHALLENGES TO EFFECTIVE VCT
PLANNING
The favoured approach to VCT encourages
same-day rapid testing and counselling
with an appropriate carer, conducted in
an environment which protects anonymity
and confidentiality. However, interventions
focusing on the promotion of VCT, either
through primary care or in specialist
settings, must take into account the findings
of recent qualitative studies examining
experiences of testing and treatment. In
these studies, the moment of diagnosis is
depicted as one where concerns about
health, stigma, and socio-economic needs
coalesce, generating tremendous mental
and physical strain. A recent study by
Flowers et al. for example, describes black
Africans’ impressions of pre and post-VCT
counselling [74]:
‘Much as I think I may have come
across to the GUM clinic as an
articulate, informed young woman,
I still feel the pros and cons of testing
should have been offered to me. I
still feel I should have received pretest counselling and given the time
to go home and think about it. (…)
If you take an HIV test within ten
minutes of you being asked to have
the test, I don’t think it’s on.’
Future interventions with black Africans
affected by HIV must therefore focus on
the needs of the newly diagnosed and on
improving VCT provision. Some authors
have also raised questions about the
cultural appropriateness of HIV counselling
practices for black Africans using services
in the UK [74], as the uptake of counselling
and psychological support services by
African patients is low [18, 110]. This could
be because talking to a stranger about
family issues may not be culturally
appropriate, but also because of
practitioners’ lack of cultural competency.
In some studies black Africans talked about
not ‘being able to listen’ to what was being
said about HIV care during post-diagnosis
counselling because of the impact of grief
[74, 86]. Thus, the timing and content of
pre- and post-test counselling are factors
which should be carefully considered in
future interventions encouraging VCT.
3.2 SEXUAL LIFESTYLES AND
ATTITUDES
Condom use
Elam et al.’s [70] study on sexual behaviour
among ethnic minority groups in the UK
found that many black Africans had low
self-perceived risk, and, consequently, low
condom use. Similarly, in the SHIBAH
survey [86], 56% of black Africans living
with HIV (n=124) ‘always’ used condoms,
33% ‘sometimes’, and 10% ‘never’.
PADARE, SHIBAH, and Mayisha I found
relatively low levels of sexual health
knowledge among black Africans surveyed
in London. The PADARE study, in particular,
revealed important knowledge gaps: 16%
of the participants (n= 214) felt they could
be cured of HIV in the UK, while 8% thought
an undetectable viral load meant they
could not pass on the infection to anyone
else [52].
In Mayisha I, over 90% of the men and
women surveyed (n=748) strongly agreed
with the statement ‘I think I could convince
a new sexual partner to use a condom,
even if they did not want to use one’. In
both Mayisha I [13] and PADARE, a majority
• low condom use
• condom use associated with
partner distrust
• the persistence of HIV-related
stigma
• an emphasis on traditional
values, monogamous
relationships, and fidelity
of participants reported the intention to
use condoms with new partners, but few
actually did: while the majority of 214
positive black African respondents in
PADARE had had sex in the last four weeks,
40% reported using a condom only on
some or on no occasions, and 29% had
had unprotected sex. In Mayisha II, only
49.2% of men and 38.7% of women who
answered the question about condom use
(n= 1123) reported using a condom the
last time they had sex. These findings
concur in indicating relatively low condom
use.
This problem is related to the acceptability
of condoms and their conflicting
associations with both protection and
promiscuity. Chinouya & Reynolds [54],
drawing on findings from Mayisha I, have
argued that the condom is seen as a
symbol of protection among black Africans
in the UK. Yet there is evidence that the
use of condoms is still perceived by many
as indicating a lack of trust between
partners. In Mayisha II for example, the
majority of respondents felt that condom
use was not appropriate or necessary in
long-term relationships, and implied partner
distrust.
Levels of condom use and confidence in
communicating with partners about sexual
health must be understood within the
broader context of relationships, and as
linked to issues of trust, fidelity, and the
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desire for children. Elam et al. [70]
highlighted that serial monogamy is ‘the
expected pattern among Africans and
Caribbean women’, who view multiple
partnering as ‘physically and emotionally
risky’. The majority of black African and
black Caribbean respondents in the study
thought that sexual relationships should
be based on fidelity, trust, and stable
partnerships. Trust and faithfulness are
also seen as key values by the respondents
of Mayisha II, views which are often
underpinned by strong religious beliefs.
Relationships and safer sex
The PADARE study showed that casual
relationships are frequent among young
black Africans in the UK, with 22% of both
men and women reporting that their most
recent partner was a casual one. PADARE
also found that black Africans had partners
among people of Caribbean origin, whites,
and other black British people. This has
led Bhatt et al. [39] to conclude that while
most HIV infections in African communities
in England are likely to have been
contracted abroad, new adult infections
are occurring as a result of exposure in
the UK. However, as Chinouya & Reynolds
[52] point out, both McMunn’s and Bhatt’s
studies were conducted prior to the arrival
of more recent African refugees in the late
1990s. Recent evidence shows that
heterosexual HIV transmission is occurring
within the UK among people infected in
West Africa [9]. However, more research
needs to be carried out in order to better
understand patterns of sexual mixing and
the potential risk of HIV transmission, both
within black African groups and between
different ethnic groups.
Several interventions in the UK have sought
to empower black African men and women
to negotiate safer sex with their partners.
However, HIV-related stigma remains a
major barrier to open discussions about
sexual health. As noted in PADARE and
Mayisha II, emotions and the desire to
seem ‘trustworthy’ play an important role
in sexual decision-making, and sometimes
override concerns about health. In some
contexts, the ‘imperatives’ of relationships
take precedence over awareness of the
benefits of HIV testing, as explained by
one of the female respondents in Mayisha
II: ‘I never even, you know, said, [before
we married] oh, you should go and take
an HIV test, and yet we used to be told
things like that. I think it’s, you know when
you’re, sometimes when you’re in love with
somebody you forget all the proper logistics
I suppose’ [98].
and raise issues of secrecy around sex or
particular sexual practices. The ways in
which people learn about sex are culturally
mediated: Chinouya and O’Brien [50]
argue that, in many African families, sexual
matters are seldom discussed between
parents and children, and that, instead,
other relatives or peers may be more active
in giving information about sex and sexual
health. Interventions with people of subSaharan African origin living with HIV
therefore need to take into account
culturally defined attitudes towards sexual
behaviour and sex education.
There were also fears that questioning a
partner’s HIV status in the context of a
new relationship might be interpreted as
distrust. Respondents often assumed that
a partner’s potential risk was easily
identified, and that risk could be avoided
by carefully choosing one’s partners. This
was linked to notions of ‘safe’ and ‘unsafe’
identities: for respondents in Elam et al.
[70] and Mayisha II, a partner’s potential
risk could be ‘weighed up’ by considering
their previous sexual history, marital status,
and cultural or educational background.
However sex in relationships often preceded
discussions about previous sexual history,
and partners tended to reduce their use
of condoms as the duration and intimacy
of relationships increased.
There remains a persistent need for HIV
information among black Africans in the
UK. Project Nasah (2003) found that
Africans were eight times more likely to
report a need for information about antiHIV treatments than other people living
with HIV. The most widely used treatment
information interventions were talking with
HIV doctors and nurses (96%) as well as
reading treatment information materials
from the GUM clinic (83%) or from support
groups and HIV organisations (80%). Other
studies focusing on access to health
services have argued that, among African
communities, recourse to health services
is often delayed through a system of ‘lay
referrals’ where friends and kin are
consulted and one turns to a medical
expert as a ‘last resort’, when the illness
becomes unbearable [54]. Interventions
might therefore focus on harnessing the
power of ‘lay referral’ networks for
prevention interventions, for example in
increasing knowledge of local services
through peer interventions.
A joint report from the National AIDS Trust,
NAHIP, and the Department of Health [58]
highlights the ‘predominance of traditional
attitudes towards sexual relationships and
behaviours’ among African communities
in the UK. Culturally patterned attitudes
towards sexual behaviour may create
gender role prescriptions that limit women’s
agency in negotiating safer sex, foster
expectations of monogamy and fidelity,
3.3 USE OF HIV SERVICES
Information needs
The need for information about the
availability of HIV services is particularly
great among recent migrants from sub-
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KEY POINTS
• There remains a persistent
need for information about HIV
services among black Africans
living in Western Europe.
Saharan Africa who seek asylum in the
UK, as in the rest of Europe. Recent
migrants suffer as a result of a lack of
clarity regarding entitlements to healthcare,
and difficulty in making use of services
due to language problems. Poverty,
isolation, and sickness act as further
barriers to accessing services.
Related to this, studies have identified
potential problems with the cultural
appropriateness of HIV services accessed
by black African communities in London.
Respondents in Flowers et al.’s study [75],
in particular, talked about language barriers
and communication difficulties with health
providers. Future interventions might
therefore encourage ‘cultural competence’
among medical practitioners caring for
African patients with HIV and enlist
community-based organisations in
providing information about local health
services.
Treatment Issues
Erwin & Peters [29] examined issues
relating to treatment among black Africans
living with HIV in London. Many reported
feeling disempowered and distrustful of
the medical profession, and the majority
said that their main source of treatment
information was word of mouth. Some
made use of alternative treatments such
as ‘traditional’ African remedies to
supplement HAART. McMunn et al. [21]
investigated health service utilisation
among Ugandan migrants in southeast
London, with a view to finding the most
appropriate method of delivering
information about HIV/AIDS. Their study
showed that Ugandan migrants felt GP
surgeries were the most appropriate place
to receive information. Similarly, 80% of
black Africans surveyed (n= 392) in Erwin
et al.’s study [10] had consulted a GP
before testing. Eighty one percent of the
respondents in SHIBAH were registered
with a GP, and about three quarters had
disclosed their serostatus to their GP. This
indicates, again, that important HIV
information interventions should be
developed for use in the context of primary
care.
Few studies to date have taken examined
African patients’ experience of HAART. This
remains an important area of investigation
to inform future secondary prevention
interventions. Flowers et al. [75] highlight
that the side-effects associated with HAART
regimes are an important part of people’s
experience of HIV treatments. Taking HAART
disrupts daily life and can potentially reveal
one’s HIV status to others: ‘people don’t
understand the full implications of what it
is to live on drugs. I mean, it’s a relationship,
it’s a marriage you know’ [75]. A number
of studies on the impact of HAART on
black Africans’ lives show that treatment
may often prevent men and women from
finding or returning to work [29, 54, 75].
Side-effects linked to treatment, in particular
lipodystrophy, often cause loss of selfconfidence and anxieties related to
disclosure. Though more research is
needed to understand patients’ experiences
of HAART, future interventions might focus
on empowering patients to ‘appropriate’
treatments and integrate them into their
daily lives, for example through peerfacilitated discussions on managing
treatment in relation to disclosure, work,
and family.
3.4 GENDER
Positive parenting
Women born in sub-Saharan Africa have
the highest HIV prevalence among pregnant
women in the UK [87]. In recent years,
however, there has been a swift uptake of
voluntary confidential antenatal HIV testing
among black African women in the UK,
• In the UK, GPs play a key role
in delivering HIV-related
information.
• Future interventions must take
into account the cultural
appropriateness of HIV
counselling practices for black
Africans.
• There is a need for secondary
prevention interventions to help
patients manage the side-effects
of treatment and negotiate
disclosure.
resulting in a significant reduction in the
number of children infected with HIV
through Mother to Child Transmission [79,
80]. Nevertheless, there remains a critical
lack of interventions focusing on the needs
of children and youths whose lives are
affected by HIV, either by being positive
themselves, or through having positive
parents [52, 30].
The desire to have children is a strong
factor in sexual decision-making for African
women living with HIV [27, 72]. According
to an in-depth qualitative study by Doyal
& Anderson [28], HIV positive African
women in London are highly concerned
about their capacity to become pregnant,
and consider motherhood to be an
important ‘source of identity and legitimacy’.
According to MacLeish [97] however,
poverty, poor housing, and racism
characterise the day-to-day lives of migrant
mothers. Furthermore, the parenting needs
of positive Africans remain relatively
unexplored. For example, we know little
about the support needs of positive African
parents who choose to disclose to their
children, and about the psychosocial impact
of positive parenting.
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Lack of childcare is also a considerable
burden for women living with HIV, and can
constitute an important barrier for parents
to access healthcare, social services, and
employment. One the respondents in
Flowers et al. [74] explains: ‘here you don’t
have anybody to help you with the children,
with me I have two children, you don’t
have someone to help you out with the
kids, and when you talk to the social
services it’s like you are insisting, you
know’. HIV prevention strategies must
include childcare facilities so as to create
an enabling environment for women to
access services.
Putting men back in the picture
African men are less likely than women to
access HIV prevention services. Chinouya
& Reynolds [54] assert that, while men
are more often present in venues such as
bars and clubs, they are ‘less visible in
settings where HIV prevention was likely
to be discussed’. They also remark that
some men perceive HIV prevention
gatherings as being primarily focused on
women’s needs, children, relationships
and contraception.
Researchers have suggested that gender
roles tend to change upon migration: while
men may be the ‘traditional’ decisionmakers regarding children and the family,
the socio-economic difficulties they face
as a result of migration often leads to a
renegotiation of their roles as husbands,
fathers and brothers [54]. This affects
sexual decision-making among couples,
but also responsibility-sharing within
families, as well as individual men’s sexual
risk behaviour. HIV prevention interventions
must take into account the changing roles
and needs of African men, particularly
younger men, and involve them in the
design of interventions [36, 47].
Furthermore, while there is a considerable
amount of research on the sexual health
needs of MSM throughout Europe, relatively
little is known about the sexual health and
HIV prevention needs of black MSM [73].
Twenty percent of African men interviewed
for the PADARE Project said they had had
sex with other men in the year prior to
interview, which would indicate that black
MSM constitute a small but significant
portion of the African community in the
UK. Moreover, recent evidence suggests
that black and ethnic minority MSM are
highly affected by HIV/AIDS: a recent study
using UK National HIV prevalence data
estimates that 7% of black and ethnic
minority MSM living in the UK were
diagnosed with HIV, compared with 3% of
white MSM in 2002 [8]. Furthermore, a
study by Hickson et al. using self-reported
data showed that 18% of black MSM were
living with diagnosed HIV in the UK in
2004, compared with 10% of white MSM
[15].
HIV prevention is hampered by the fact
that black MSM shoulder stigma both from
the black African community and the gay
community at large [73]. Some
interventions have sought to involve black
MSM as peer educators in raising HIV
awareness [123, 124, 126], and dedicated
support groups do exist in the UK and in
other European countries. However more
research is critically required to understand
the sexual needs of black MSM and the
best ways to reach them with prevention
interventions.
HIV prevention interventions therefore need
to take into account the needs of African
men and encourage them to manage
interventions.
3.5 STIGMA AND DISCLOSURE
In the UK as in other European countries,
there remains overwhelming evidence of
discrimination against HIV-positive people.
Stigma and discrimination impede
disclosure and deter people from accessing
healthcare, social care, or applying for
work, thereby contributing to the social
exclusion of people living with HIV [100,
121, 122]. The impact of HIV-related stigma
on the lives of African people living with
HIV is multi-faceted: African respondents
interviewed by Sigma research [114]
reported numerous experiences of racism
and discrimination while living in the UK;
they also talked about stigmatising attitudes
from doctors and healthcare staff, and
about HIV-related stigma within black
African communities.
Fear of stigma may cause persons living
with HIV to refrain from disclosing their
status to sexual partners, children, friends,
and to the broader community. It may also
lead people to conceal their needs for
social and emotional support, and delaying
access to medical treatments [54, 114].
Stigma in the broader community is
compounded by stigma in more immediate
social networks and within the family.
Flowers et al. note that many HIV positive
people feel unable to access community
and social support groups because of the
fear of disclosing their HIV status [74].
Positive Africans may find it difficult to
manage disclosure on their own terms,
especially if they live in very close-knit
communities, and may feel that they lack
control over ‘who knows’ their HIV status
[10, 13, 114]. Storing antiretroviral
medications at home and taking them at
fixed times, for example, can easily lead
to forced disclosure [75]. Stigma may thus
lead some persons to isolate themselves
from potential support networks for fear of
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unintentional disclosure. Indeed, black
Africans testing for HIV at a London
hospital were found to be twice more likely
than white people to be worried about
future discrimination if they tested positive,
and four times more likely to be worried
about meeting someone they knew at the
clinic [10]. Concern with stigma and
discrimination explains why many positive
African respondents in McMunn et al.’s
study [21] resolved to keep their serostatus
secret.
Stigma within the community can also
precipitate the worsening of economic
problems. French social workers report
that many newly arrived African migrants
find themselves having to move out of
relatives’ homes, either because the latter
are in a precarious financial situation, or
because they have found ARVs and
suspect their guest is HIV positive [37].
According to Erwin et al. [10], black Africans
are significantly less likely than white
patients to disclose their HIV status to
family and friends. Africans in Chinouya
et al. [52] speak of the ‘social cost’ of
knowing one’s status: ‘I don’t know if I can
psychologically cope with the information,
I don’t know if I can cope with the burden
of understanding how I came to be positive
and I am really terrified of the impact this
is going to have on my social status’.
Flowers et al. assert that ‘the cost of
disclosure, whether intentional or not, can
be larger because of the potential loss of
inclusion from both the majority population
and from the smaller ethnic communities’
[74]. Some studies in the UK have noted
that positive Africans are more likely to
disclose their status to close friends and
to their GPs than to family [21, 54].
Interventions with peers may therefore be
the best way to harness the resource of
informal support networks in African
communities. Furthermore, as we will argue
in the following section, interventions
focusing on the wider problems of social
exclusion and underemployment will also
have an important impact on reducing
stigma. One woman living with HIV cited
in Elam explains [66]:
‘If I was asked today what would help me
be confident or comfortable about telling
my family, it’s the independence of getting
my life back to normal, of being able what
I’ve always tried to do: finish my studies
and get a job. Once I’m comfortable or
confident in what I’m doing I don’t think
I would really think or care what other
people thought of me because I have
achieved my inner goals, I’m doing the
things I want to do’.
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KEY POINTS
• Black Africans living with HIV
in the UK are 10 times more
likely to experience problems
getting enough money to live
on than white British people
with HIV.
• Facilitating access or return to
employment must be a priority
for secondary interventions with
positive black Africans.
3.6 DEPRIVATION AND LEGAL STATUS
Immigration concerns
Black Africans living with HIV across Europe
are afflicted by unequal access to care,
poverty, unemployment, and stigma. While
poverty and underemployment are the two
main factors which contribute to social
isolation and poor health outcomes among
migrants, ways of addressing this vary
considerably between countries. In the UK,
applying for asylum and appealing a
rejection can be a lengthy process. During
this time, migrants usually have no access
to resources other than the benefits
administered by the National Asylum
Support Service (NASS). Asylum seekers
are assessed for access to support by
NASS, which involves the reporting of
‘declared’ HIV status. However, no data
are currently collected about the legal
status of people living with HIV in the UK.
An increasing number of applicants are
denied refugee status or exceptional leave
to remain. Some have to stay in the UK
illegally, making it highly difficult for service
providers to involve them in HIV prevention.
This situation heightens the risk of driving
the epidemic underground. Sanvi-Noel
Ahebla from the French NGO ‘African
Positive Association’ puts it starkly: ‘this
refusal to regularise the situation of people
with HIV is a form of discrimination and
stigmatisation. It brings serious and indeed
tragic consequences, cutting these people
off from access to treatment, services and
support. It also hinders access to
prevention, and makes it more difficult to
set up systems of prevention’ [34].
Uncertainty linked to pending decisions
about immigration status, in particular,
has a strong impact on migrants’ lives and
on the way they prioritise needs. One of
the respondents in Flowers et al.’s study
explains: ‘firstly if your social problems are
dealt with then you become …aware and
start thinking of your health’ [74]. Indeed,
African migrants may be more concerned
about immigration and socio-economic
issues than about their HIV status: ‘I’m
not worried about the virus – my worry is
whether I will be allowed to remain here
in this country’ [74].
In the UK, the debate around mandatory
HIV testing has fuelled fears of increased
discrimination among community-based
African organisations. In March 2004,
Trevor Philips, chair for the commission
for Racial Equality (CRE), stressed that the
government should commit to ‘treating
HIV as a public health problem, not an
immigration one’ [109].
In a recent report to the All Parliamentary
Group on AIDS [35] Fortier concluded that
‘the current immigration system does not
adequately provide for individuals with HIV
and in many cases exacerbates poor
health’. Adding credence to her argument,
a recent study by Gazzard et al. states that
‘providing treatment and preventing onward
transmission of HIV from the estimated
899 asylum seekers living with HIV who
entered the UK between October 2003 to
September 2004, would save between
£500 million and £1 billion over an average
lifetime’ [78].
Treatment tourism?
There is little evidence that migrants come
to the UK specifically to seek treatment
for HIV/AIDS, what some have called
‘treatment tourism’. The Terrence Higgins
Trust examined the records of 60 recent
service users from three agencies in South
London, Manchester and the West
Midlands, and noted that only 13 of 60
migrants had sought asylum, while 12 had
come to study. The most common timespan between entry and diagnosis was ten
to twelve months, and 75% of migrants
waited more than 9 months after entry to
test. The most common reason given for
testing was the onset of symptomatic HIV,
with many falling severely ill before
diagnosis.
As many migrants do not suspect their
status, it appears extremely unlikely that
they arrive in Europe with a view to seek
medical treatment for HIV/AIDS. Lot et
al.’s French study reaches similar
conclusions: the majority of African
migrants in Parisian hospitals are diagnosed
at a late stage of disease [96]. Furthermore,
only 6% of them applied to remain in
France on medical grounds in 2001; the
majority had come to join family or to
study. Forsyth et al. [14] have recently
demonstrated a correlation between HIV
presentation in the UK, migration, and
political upheaval in African countries: an
increase in the number of persons
presenting with HIV during or following
periods of political conflict was
demonstrable for Ugandans, Congolese,
Rwandans, Somalians, and Ethiopians.
On the other hand, few people from
countries with high HIV prevalence and
low levels of conflict, such as Botswana,
presented in the UK. This confirms the link
between political conflict, migration and
HIV. It also goes some way to show that
‘health tourism’, i.e. relocation for the
purpose of gaining access to HIV services,
is not the driving force behind recent African
migration to the UK.
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15
MIGRANTS AND HIV
• There is no evidence of ‘health
tourism: the majority of African
people diagnosed with HIV in
Europe are unaware of their
status when they emigrate.
• Data from the Health Protection
Agency [84] shows that HIV
spending in the UK represents
less than 1% of the total NHS
budget. In France, HIV-related
spending has been maintained
at about 65 million since 2002,
less than 2% of the total
expenditure on health.
Current UK policies such as the use of
removal centres and relatively low benefits
entitlements are deemed to have negative
consequences on asylum seekers’ health
and to ‘increase the risk to public health
of HIV transmission’ [5, 34]. The high
HIV prevalence (8% or 79/388) found
among sub-Saharan African migrants living
outside London may suggest that
dispersed migrants are more socially
vulnerable because they have recently
migrated, and may also have had greater
exposure to HIV infection outside the UK
[53, 87]. More careful attention must
therefore be given to the impact of
dispersal policies on the treatment and
psychosocial health of African migrants.
Deprivation
Green & Smith [82] assert that poverty
and social exclusion have a more profound
impact on migrants’ lives than HIV. Socioeconomic deprivation is rife among positive
urban migrants: SHIBAH, a study on the
sexual health of residents in Lambeth,
Southwark and Lewisham found a
staggering 230% increase in HIV/AIDS
cases between 1996 and 2000, the
majority of which were among African
asylum seekers living on a statutory
stipend of £38.96 a week [86]. Black
Africans living with HIV in the UK are 10
times more likely to experience problems
getting enough money to live on than
white British people with HIV [101]. Both
the Nasah and PADARE projects clearly
conveyed that the main problem for
Africans living with HIV was ‘getting enough
money to live on’. Similarly, Project Nasah’s
second briefing sheet on the needs of
African people living with HIV reports that
‘poverty dominates the lives of Africans
living with HIV in England’: having enough
money to live on was cited as a major
concern by 77% of respondents [112].
In the light of these findings, increasing
access to employment must be a high
priority area for interventions with Africans
living with HIV. However, according to
Chinouya & Reynolds, several barriers to
employment need to be taken into
consideration [54]:
• fear of losing health and disability
benefits if employment is lost
• concern about medical needs (e.g.
timing of medication) in the workplace
• concern about disclosure
• fear of discrimination when re-entering
the labour market after a long absence
• lack of assistance or incentives to return
to work
The majority of surveys conducted among
African communities in the UK concur that
the African population is relatively well
qualified: according to the 2001 census,
27% of Africans had ‘higher level
qualifications’ compared to just 14% in the
whole population [131]. However, it is also
often noted that, despite this,
‘unemployment among Africans is more
than double the rate in the whole
population’ [58, 111]. Many HIV-positive
migrants may be of working age and well
educated but unable to find work because
of their immigration status [81]. In London,
the NASAH and PADARE studies have
demonstrated that less than 20% of black
Africans living with HIV are employed,
despite being well qualified. Similarly, only
one fifth of the 124 respondents in the
SHIBAH study were in paid employment.
Since July 2002, asylum seekers are not
allowed to work until they are granted either
refugee or humanitarian status. When
destitute, they are entirely dependent on
NASS for financial support. However, nongovernmental organizations argue that
African migrants would prefer to support
themselves and use their skills rather than
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16
being supported. Bhatt et al.’s study [40]
suggests that there is a large pool of underemployed people of African origin, which
Chinouya & Rheynolds [54] argue could
be a valuable resource in the development
of community-led HIV prevention initiatives.
One third of the 435 respondents in the
NASAH survey said were unhappy about
their labour market opportunities: nearly
40% expressed an interest in training and
acquiring new skills. Indeed, the benefits
of finding or returning to work have been
highlighted in a number of studies. Workers
from Ikambere (France), for example,
recalled the reaction of a positive African
woman after being granted a residence
permit and starting work: ‘Look at that
(…), I’m already starting to put on weight
again’ [90].
One intervention focusing on facilitating
access to employment for HIV positive
people in London has met with
encouraging, though somewhat mixed
results. ‘Routes into Work’, from Positive
Futures, enabled 29% of its clients to find
employment [81, 111]. However, despite
constituting half of the client population,
ethnic minorities benefited less from the
intervention than non-minority groups. For
example, only 6% of African men found
employment as a result of the intervention.
Interviews with 48 intervention participants
revealed that African respondents valued
services that would boost their chances of
getting a new career, such as learning ‘new
skills’ (computing, etc.) and advice on
‘further education’. These were more
popular that more focused services on CV
writing and interview skills; staff from
Positive Futures surmised that African
clients did not see themselves immediately
benefiting from such services because of
immigration problems and institutionalised
racism in the job market. Despite these
shortcomings, the intervention highlights
the existing demand for such schemes.
Encouraging access to employment by
means of skills training and volunteering
schemes should therefore be a priority
area for future interventions with black
Africans living with HIV.
The next section of the review focuses on
interventions with African communities in
the UK and in other European countries.
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17
4 . I N T E R V E N T I O N ST U D I E S
In 1997, the Department of Health
commissioned the first national prevention
projects for Africans in England through
Enfield and Haringey Health Authority.
The programme encompassed media
awareness raising campaigns, resource
development, and community-based
prevention work. A significant landmark
was reached in 2002, when the African
HIV Policy Network (AHPN) was entrusted
with the national prevention programme
for African communities, a testimony to
the network’s achievements in terms of
research and advocacy. The national HIV
prevention initiative for African
communities in the UK is now known as
the National African HIV Prevention
Programme (NAHIP) [31]. It is supported
by the African HIV Research Forum, a
community-based body promoting
research in the area of HIV. In 2005 NAHIP
published ‘Doing It Well: a Good Practice
Handbook for Community-Based
Interventions with African Communities’,
which audited community-based
interventions conducted with African
communities in the UK, and offered
feasibility and evaluation guidelines for
future work [108].
A wide range of specialist HIV services,
agencies and community-based
organisations offer support to black
Africans affected by HIV in London. In
addition, the African Foundation for
Development estimates that there are 217
African informal organisations currently
working in the area of HIV/AIDS in the
UK [130]. Many of these are ‘identitybased’: membership is on the basis of
origin, either a country or a specific
regional/ethnic affiliation (e.g. ‘Mende’
for the Mende group from southern Sierra
Leone).
The short scoping survey of prevention
interventions with African communities
found below is by no means systematic,
and reflects the search strategy used (see
section 2), with the possible implications
of language and publication bias. The
majority of these interventions were
described in reports, and in online or ‘grey’
literature.
We found details of 31 interventions
addressing the needs of African
communities affected by HIV in the grey
literature: 22 were UK-based, 9 were
developed in other European countries. In
the UK, eight interventions out of 20 were
funded by local health authorities. Some
of these were local, community-based
initiatives (e.g. Club Afreaka). The majority
of interventions in the UK were information
interventions aimed at raising awareness
of HIV/AIDS. Only four initiatives were
secondary prevention interventions focusing
on the needs of people living with HIV, all
of them using support groups. Two
interventions specifically targeted black
MSM and a further two encouraged black
Africans to develop skills and gain
employment.
In other European countries, interventions
ranged from broad pan-European efforts
raise awareness of HIV (e.g. TAMPEP) to
programmes generated through national
prevention strategies (e.g. AIDES and
SidaInfo Service in France) and local
community-based initiatives (e.g. Afrikaherz
in Germany). We found a similar emphasis
on information interventions (6) aimed at
raising awareness of HIV/AIDS and
increasing knowledge of available services.
Three interventions were secondary
prevention interventions, again through the
means of support groups.
The present review has identified several
areas of need for prevention interventions
with African communities: (a) promoting
VCT among black African communities;
(b) improving HIV awareness and sexual
health services knowledge; (c) devising
‘family-oriented’ interventions to meet the
psychosocial needs of black African
families, adolescents and children affected
by HIV; (d) improving HIV awareness among
black African adolescents and youth; (e)
promoting safer sex and condom use
among black African MSM; (f) facilitating
access or return to employment among
black Africans affected by HIV.
Although current interventions do meet
some of these needs, more serious
commitment to HIV prevention with black
African communities is required. For
example, while a number of interventions
in the UK focus on raising HIV awareness
among black African youth (e.g. ‘Young
troopers and motivators’, and ‘Targeting
African youth’), these remain small-scale
and one-off projects. Similarly, while there
is a commitment to generate research
capacity within the African community itself
(as in Mayisha I & II, Ubuntu-Hunhu and
Pachedu-Zenzele), no interventions to date
have directly sought to facilitate access to
employment for positive black Africans.
Interventions must be specifically designed
with black African communities to be
effective; the intervention ‘Routes into
Work’, which aimed to encourage positive
people to find employment, enabled 29%
of its clients to obtain work, but only of
these 6% were African men [111].
Progress remains hampered by a lack of
evaluation, which means that service
providers and funders are unable to assess
the effectiveness of individual interventions.
Few interventions have been critically
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assessed for their impact, and none have
been subject to rigorous evaluation such
as randomised controlled trials.
Furthermore, many of these interventions
have been ‘one-offs’, and few were
sustainable through more than one funding
cycle.
To remedy this situation, current and future
interventions must follow the guidelines
set by the National African HIV Prevention
Programme (Pulle, Lubega, Davidson &
Chinouya, 2005). Comprehensive
preparatory research, community
involvement, and the use of findings from
sexual health ‘needs and attitudes’ surveys
such as Mayisha II and PADARE can help
develop, pilot, and evaluate interventions
to ensure their sustainability. Involving
community-based organisations and
informal African networks remains the key
to designing effective interventions for
people of sub-Saharan African origin living
with HIV in the UK: ‘African community
organisations, leaders, and community
members believe African providers to be
the most effective at delivering HIV/AIDS
services, especially if delivered from a
common cultural tradition’ [77].
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NAME
AIMS
SOURCE OF LOCATION
INFORMATION
1. Enfield &
Haringey
Health
Authority
(1997-1999)
1st African
National HIV
Prevention
Programme
To increase
awareness of
HIV/AIDS and
available healthcare
resources.
Bhatt et al.
(2000)
London,
Enfield &
Haringey
METHODS
OUTCOME MEASURE EVALUATION
( • = none found) ( • = none found)
Number of
print resources
distributed;
hours of
broadcast;
2. Print and media prevention campaign callers to the
telephone
designed by Focus Consultancy in
partnership with African organisations and information
line.
health educators
1. Design and distribution of pamphlets
and posters on primary and secondary
prevention areas in healthcare and
community sites;
3. Community radio programme broadcast
over six months targeting African
communities in London
4. Telephone information line.
2. Camden &
Islington
Health
Authority
African
Prevention
Programme
To increase HIV/AIDS Camden &
awareness and
Islington
condom use.
(1997, 2000)
•
The multi-level intervention
programmes which
constituted the original
1998 National African HIV
Prevention Projects in
Enfield & Haringey Health
were evaluated in Bhatt et
al. (2000). Although
substantial
recommendations were
made for future
programmes, the lack of
outcome measures
rendered in-depth
evaluation difficult.
Programmes in Camden
& Islington were outlined
in two strategy
documents (1997,
2000); no subsequent
evaluations were found
Camden &
Islington
Area,
London
One-to-one health promotion interventions;
peer education and single sex workshops
for different African cultural and linguistic
groups.
3. Wazazi na To increase HIV/AIDS Camden &
Watoto
awareness and
Islington
(African Culture condom use.
(2000)
Promotions,
1998)
London,
Croydon
Health
Authority.
Number of
Trained African health facilitators were
sent to people’s homes to deliver health homes visited
prevention messages to individuals and
families.
4. Targeting
To increase HIV/AIDS The King’s
African Youth awareness and
Fund
(African Culture condom use.
Promotions,
2001)
London
Delivering HIV information to youth of
African origin. One to one support,
workshop sessions and leisure-based
information sharing.
Number of
workshop
attendees
•
5. Men
empowering
men in HIV
prevention
Enfield and
Haringey
Health
Authority
London
Number of
Peer-education; workshops for newly
diagnosed African men to receive support workshop
and sexual health information from other attendees
African men living with HIV; support groups
for 30-40 African men diagnosed with HIV
in the London boroughs of Barking &
Dagenham, Enfield, Haringey and Newham.
•
Takura &
Power, 2002
London
A monthly club night where African MSM Number of
attendees
are mobilised with the aim of offering
prevention interventions e.g. condom
distribution.
•
To increase social
support for African
men; increase
knowledge of specific
sexual health needs
and HIV treatments.
6. Club
To increase condom
Afreaka (2002 use among African
- ongoing)
MSM, contribute to
community
empowerment and
combat stigma.
Number of
women
attending
support groups.
100 homes visited in the
initial project in 1998,
increased to 225 homes
in 2000.
•
7. Peer support
for black
African women
living with HIV
To increase social
The King’s
support for black
Fund
African women living
with HIV.
Birmingham
Peer support groups and workshops.
8. Peer
education for
HIV-positive
young people
from African
communities
To offer advice on
The King’s
sexual health and
Fund
teenage pregnancies.
London,
Camden
Peer-support groups; training in
communication, assertiveness and
confidence-building young HIV-positive
Africans refugees and asylum seekers.
•
•
London
boroughs of
Hackney,
Islington and
Newham
Video
Twelve students took part in a drama
project on HIV/AIDS. The students videoed
the drama for use in community
organisations that provide HIV/AIDS
education.
•
9. AIDS is real To increase
awareness of
HIV/AIDS among
students.
The King’s
Fund
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AIMS
SOURCE OF LOCATION
INFORMATION
METHODS
OUTCOME MEASURE EVALUATION
( • = none found) ( • = none found)
10. Increasing
awareness of
sexually
transmitted
diseases
amongst
Congolese
young people.
To increase
awareness of STIs
among Congolese
young people in
Enfield.
The King’s
Fund
London,
Enfield.
Three health awareness workshops
•
•
11. Young
troupers and
motivators
To increase
awareness of sexual
health
The King’s
Fund
London,
Haringey
Unspecified sexual health awareness
intervention with 60 children and their
families from refugee communities —
particularly from Uganda, Nigeria and Ghana.
•
•
To reduce unwanted
12. Swahilisexual health
speaking
positive action outcomes
The King’s
Fund
London,
Islington
Two seminars were held for 40 people,
with four follow-up workshops, offering
information and advice on HIV/AIDS
and sexual health to Swahili-speaking
young people in Islington.
To support families The King’s
13. Pullisa
living with HIV and AIDS Fund
Outreach
Support Group by offering child care
and health advice.
London,
Newham
Childcare and HIV prevention seminars
•
•
London
boroughs of
Hackney,
Haringey,
Islington and
Newham
Traditional cultural dance, outreach work
and three HIV prevention seminars.
•
•
15. Swahili and Raising awareness of The King’s
HIV/AIDS
Luganda
Fund
evening
lessons about
HIV and the
use of drugs
Among African
communities
in Barking,
Dagenham,
Newham and
Redbridge
Offering advice and information sessions
on HIV/AIDS and drugs by reading
literature and translating it from English
to African languages.
•
•
16. Pachedu- To collect data on
Zenzele (2001) people’s sexual
behaviour & increase
awareness of HIV/AIDS
among Zimbabweans
in Luton
Luton
Collected evidence of people’s sexual
behaviour through a questionnaire and
delivered a prevention intervention in
people’s homes.
•
•
14. 'Gwok Kwo'
(Save Life)
HIV/AIDS
project
17. ‘Routes Into
Work’ from
Positive
Futures (2004)
Raising awareness of The King’s
HIV/AIDS among
Fund
members of the
Acholi community
from Uganda.
To increase the
number of people
living with HIV/AIDS
finding work or
returning to work.
Gordon et al. London
2005
Needs assessment, skills training (e.g.
computer skills), job interview training,
employer training in HIV/AIDS
awareness, work placements & volunteer
opportunities. Programme ran over 18
months and was accessed by 112 clients,
46% of which were of African origin.
Reduction in the
number of
unwanted sexual
health outcomes
(unwanted pregnancies and STIs)
Number of
participants
finding or
returning to
work.
•
Report available (Gordon et
al., 2005): 29% of clients
found work. However ethnic
minorities, particularly
African men (who achieved
a 6% success rate into jobs),
were seen to benefit less
from the intervention.
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AIMS
SOURCE OF LOCATION
INFORMATION
18.
To reduce HIV stigma Elam 2004a, London,
Awaredressers
2004b
Barnet area.
project (Barnet
PCT and the
Terrence
Higgins Trust)
(2002)
METHODS
OUTCOME MEASURE EVALUATION
( • = none found) ( • = none found)
Posters campaign; local African
businesses in Barnet PCT worked with
an outreach team to raise awareness of
HIV by giving out information and
distributing condoms to the African
community.
Local business
participation;
acceptability of
intervention.
A qualitative study of ‘Barnet’s
residents, businesses and their
customers on the
Awaredressers Project’ (Elam,
2004a, 2004b), commissioned
by Barnet PCT and the Terrence
Higgins Trust, involving in-depth
interviews with 30 Awaredresser
volunteers and local residents.
The study documented high
levels of participation and
commitment among local
African businesses.
Respondents thought that HIVrelated posters should depict
different groups of people and
not only black Africans in order
to avoid stigmatisation. They
also felt that HIV prevention
should be targeted at young
people and that trade areas
were appropriate venues for
prevention activities.
19. HIV
Prejudice &
Discrimination
Poster
Campaign
(Barnet PCT
and the
Terrence
Higgins Trust)
(2001)
To reduce HIV-related Elam, 2004a London
stigma and
discrimination and
increase awareness of
HIV/AIDS
Mass poster campaign
•
20. Health
Advice for
Africans
(2005)
King’s Fund London,
To improve sexual
health knowledge
Barnet
among black Africans
living in Barnet
Materials were produced and weekly
sessions held at a community hall in
Barnet, involving health care
professionals.
•
•
21. UbuntuHunhu
To raise awareness of
HIV and improve
knowledge of sexual
health services
among black Africans
in Hertfordshire
Action research – trained African health
promoters conducted a demographic
and sexual health attitudes survey while
delivering information interventions:
distribution of materials on HIV,
condoms, and information about local
sexual health services.
•
•
22. Peer
education for
HIV-positive
young people
from African
communities
(2005)
Secondary prevention King’s Fund London,
Camden
intervention to reduce
unwanted sexual health
outcomes among
young people from
African communities in
Camden
Held courses offering advice on sexual
health and teenage pregnancies with
training in communication, assertiveness
and confidence building. A peer-support
group was also set up.
•
•
Chinouya,
Musoro &
O’Keefe,
2003
Hertfordshire
Qualitative study with in-depth
interviews of 30 local residents’
impressions of the posters
(Elam, 2004b). The study
showed that: respondents were
concerned about the
transmission of HIV through
social contact (especially saliva
sharing); there was marked
discontent over the campaign’s
focus on black Africans, linked
to fears of stigmatisation.
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LOCATION METHODS
NAME
AIMS
REFERENCE
1. African
Positive
Association
To increase social support for
people of African origin living
with HIV and raise awareness
of HIV/AIDS.
France
Ministère de la
Sante et de la
Protection Sociale,
2004
2. AEDES
(Médecins
Sans
Frontières)
To provide training & information Sasse et al., 2002 Belgium
on HIV/AIDS, testing and
healthcare facilities.
Training workshops for healthcare
professionals in Belgium and
developing countries; media interventions (production of a prevention
film about people living with HIV
3. AfrikaHerz
(AIDS-hilfe)
Prevention information and
Germany
Website:
support for migrants of African http://www.patien (Berlin)
origin living with HIV.
teninfo-berlin.de
OUTCOME
MEASURE
EVALUATION
•
•
•
•
Support groups
•
•
4. Club Social To offer support to people of
Castilla & Del Amo, Spain
KIE-TIEM
African origin living with HIV/AIDS 2000
Support groups
•
•
5. AIDES
To improve knowledge of, and
access to, health services for
people living with HIV.
Training course for community- Number of
facilitators
based health facilitators to
improve access to health services, trained
accommodation, and social care
for people of African origin.
A total of 150 facilitators
have been trained since
2001; a process evaluation
is planned for 2005.
6. SIDA Info
Service
To increase HIV/AIDS
awareness and testing.
•
France
Nationwide telephone helpline
in foreign languages to
supplement French helpline.
Number of
telephone
conversations
with persons
of foreign
origin.
The number of telephone
conversations with persons
of foreign origin increased
by 80% between 2001 and
2002.
7. TAMPEP
(Transnational
AIDS/STD
Prevention
among migrant
prostitutes in
Europe Project,
1993-ongoing)
To produce health promotion
materials for women and
transsexuals from Eastern
Europe, Latin America, Africa
and South-east Asia working in
the prostitution industries of
Western, Northern and Southern
Europe
•
PanEuropean,
Netherlan
ds-based.
Print literature and outreach work.
The outreach team is composed
of a cultural mediator from the
migrant community targeted and
a sex worker / peer educator
trained to pass on information
and increase empowerment
among her peers.
Number of Over 50,000 sex workers
have been reached between
migrant
1993 and 1999.
sex
workers
contacted
8. TAWFA (The
African Women
Friendship
Association,
1999-ongoing)
Increase awareness of HIV/AIDS Edubio &
among African communities in Sabanadesan,
Germany, increase social
2001.
support for women and children
living with HIV
Germany,
Berlin
Support groups and drop-in;
community events.
9. Ikambere
(The
welcoming
house)
To increase social support for Ikambere, 2004
African women living with HIV,
increase knowledge of
treatments, facilitate access to
healthcare, social services and
employment
France,
Paris
A ‘safe space’ for African women;
workshops where women meet
doctors and discuss treatment
options confidentially; send female
mediators with women to hospital
consultations; hospital support groups
in a dozen hospitals in the Paris
region); skills literacy, social activities;
regular visits by social workers
to provide general support with social
problems (accommodation, finances,
immigration).
France
Ministère de la
Sante et de la
Protection Sociale,
2004
Group seminars for positive
people of African origin.
•
Number of
women
using
services
•
The service was used by over
300 women, the majority of
them francophone African
countries (52.6 % from Ivory
Coast and Cameroon), often
living in precarious conditions
and with immigration difficulties.
Workshops on access to
treatment, advances in HIV
research, pregnancy and
the desire for children were
particularly well attended.
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This review identified 129 studies relevant
to the planning of HIV prevention
interventions with African communities in
the UK and other European countries.
Twenty nine of these were published in
peer-reviewed journals, 100 in grey
literature. Thirty one intervention studies
were identified from the grey literature, but
only five of those had been evaluated.
By considering six key themes in the
descriptive studies and grey literature, the
review highlighted important current
research and intervention needs. First, as
levels of undiagnosed HIV remain high
among African communities in Europe,
VCT remains the most effective method
for reducing the levels of undiagnosed HIV
infection. There is consequently a critical
need for interventions promoting VCT
among black African communities.
Secondly, sexual health and attitudes
surveys reveal that black Africans have low
self-perceived HIV risk and that culturallydefined attitudes to relationships have a
high impact on sexual risk behaviour and
condom use. Interventions must therefore
work in culturally acceptable ways to
promote safer sex and knowledge of
available sexual health services; in this
respect, peer-based interventions have
been recognized as one of the most
effective methods for communicating HIV
prevention messages.
and also points to the potential benefits of
involving primary care practitioners in
disseminating HIV prevention materials.
Finally, the most readily identifiable issue
affecting black Africans living with HIV
remains poverty, and interventions that
encourage access or return to employment
are a priority.
Thirdly, HIV prevention interventions should
focus on groups which have previously
received little attention. Because HIV also
affects children and families, secondary
prevention programmes must work towards
understanding and meeting the
psychosocial needs of black African parents,
adolescents, and children affected by HIV.
The interventions identified by this review
have begun to meet some of those needs.
For example, a number of interventions in
the UK focus on raising HIV awareness
among young black Africans through peer
exchanges (e.g. African Young People’s
Project). Other interventions seek to
empower black Africans to gain skills and
employment [111, 90]. However, there is
a critical lack of evaluation.
Fourthly, as more British black and ethnic
minority MSM are now living with HIV than
white MSM, attention must urgently be
given to interventions combating stigma
and emphasizing the benefits of safer sex
and testing among this group.
Fifthly, research on health services use
indicates a persistent need for HIV
information among black African youths
SUMMARY:
Six recommendations:
1. Promote Voluntary Counselling and Testing (VCT)
2. Improve HIV awareness and sexual health services knowledge among
black African communities
3. Research and plan for the psychosocial needs of black African families,
adolescents, and children affected by HIV
4. Promote safer sex and condom use among black African MSM
5. Improve HIV awareness among black African adolescents and youth
6. Facilitate access to employment for black Africans affected by HIV
As new evidence confirms the
disproportionate burden of HIV shouldered
by black African communities in the UK
and other European countries, urgent action
is needed to design and evaluate innovative
primary and secondary prevention
interventions.
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24
R E F ER E N C E S
I. DESCRIPTIVE QUANTITATIVE STUDIES IN PEER-REVIEWED JOURNALS
1. The study group for the MRC collaborative study of HIV infection in women. (1996). Ethnic differences in women with HIV infection in
Britain and Ireland. AIDS 10(1): 89-93
2. Arendt, G., von Giesen, H-J. (2003). HIV-1- positive female migrants in Northrhine-Westphalia - relevant but unfocused problem? European
Journal of Medical Research 8(4): 137-41.
3. Boyd, A.E., Murad, S., O'Shea, S., de Ruiter, A., Watson, C., Easterbrook, P.J. (2005). Ethnic differences in stage of presentation of
adults newly diagnosed with HIV-1 infection in south London HIV Medicine 6 (2): 59
4. Burns, F. M., Fakoya, A.O., Copas, A.J., French, P.D. (2001). Africans in London continue to present with advanced HIV disease in the
era of highly active antiretroviral therapy. AIDS 15(18): 2453-5.
5. Creighton, S., Sethi, G., Edwards, S.G., Miller, R. (2004). Dispersal of HIV positive asylum seekers: national survey of UK healthcare
providers. British Medical Journal 329:322-323.
6. Del Amo, J., Goh, B.T., Forster, G.E. (1996a). AIDS defining conditions in Africans resident in the United Kingdom. International Journal
of STD & AIDS 7(1): 44-7.
7. Del Amo, J. et al. (1996b). Spectrum of disease in Africans with AIDS in London. AIDS 10(13): 1563-9.
8. Dougan, S., Elford, J. Rice, B., Brown, A.E., Sinka, K., Evans. B.G., Gill, O.N., Fenton, K. (2005). Epidemiology of HIV among black
and ethnic minority ethnic men who have sex with men in England and Wales. Sexually Transmitted Infections 81: 345-350.
9. Dougan, S., Patel, B., Tosswill, J.H., Sinka, K. (2005). Diagnoses of HIV-1 and HIV-2 in England, Wales, and Northern Ireland associated
with West Africa. Sexually Transmitted Infections 81: 338-341.
10. Erwin, J., Morgan, M., Britten, N., Gray, K., Peters, B. (2002). Pathways to HIV testing and care by black African and white patients in
London. Sexually Transmitted Infections 78(1): 37-9.
11. Evans, B. A. Bond, R. A., MacRae, K. D. (1999). Sexual Behaviour and Sexually Transmitted infection among African and Caribbean
Men in London. International
Journal of STD/AIDS 10 (11): 744-748(5).
12. Fenton, K., Chinouya, M., Davidson, O. and Copas, A., (2001). HIV Transmission Risk Among Sub-Saharan Africans in London Travelling
to their Country of origin. AIDS 15: 1442-4.
13. Fenton, K. A., Chinouya M, Davidson, O., Copas .A., MAYISHA study team. (2002). HIV testing and high risk sexual behaviour among
London's migrant African communities: a participatory research study. Sexually Transmitted Infections 78: 241-245.
14. Forsyth, S., Burns, F., French, P. (2005). Conflict and changing patterms of migration from Africa: the impact on HIV services in London,
UK. AIDS 19: 635-637.
15. Hickson, F., Reid, D., Weatherburn, P., Nutland, W., Boakye, P. (2004). HIV, sexual risk and ethnicity among men in England who have
sex with men. Sexually Transmitted Infections 80: 443-450.
16. Low, N., Paine, K., Clark, R., Mahalingam, M., Pozniak, A. (1996). AIDS survival and progression in black Africans living in south London,
1986-1994. Genitourinary Medicine 72(1), 12-16.
17. Lyall, E.G.H et al. (1998). Review of uptake of interventions to reduce mother to child transmission of HIV by women aware of their HIV
status. British Medical Journal 316: 268-270.
18. Malanda, S, Meadows, J., Catalan, J. (2001) Are we meeting the psychological needs of Black African HIV-positive individuals in London?
Controlled Study of referrals to a psychological medicine unit. AIDS Care 13 (4): 413-9.
19. Manfredi, R. Calza, L., Chiodo, F. (2001). HIV disease among immigrants coming to Italy from outside of the European Union: a casecontrol study of epidemiological and clinical features. Epidemiology of Infectious Diseases 127(3):527-33.
Project1
2/12/05
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Page 25
25
20. Mayaux, M-J., Teglas, J-P., Blanche, S. (2003). Characteristics of HIV-infected women who do not receive preventive antiretroviral therapy
in the French Perinatal Cohort. Journal of Acquired Immune Deficiency Syndrome 34(3): 338-43.
21. McMunn, A, Mwanje, R., Paine K, Pozniak, A.L. (1998). Health service utilization in London's African migrant communities: implications
for HIV prevention.AIDS Care 10(4): 453-462.
22. Sinka, K., Mortimer, J., Evans, B., Morgan, D. (2003). Impact of the HIV epidemic in sub-saharan Africa on the pattern of HIV in the
UK. AIDS 17: 1683-1690.
23. Smacchia, C., Di Perri,G., Boschini, A., Parolin, A., Concia, E. (2000). Immigration, HIV infection, and sexually transmitted diseases in
Europe. AIDS Patient Care Sexually Transmitted Diseases 14(5): 233-7.
24. Staehelin, C., Rickenback, M., Low, N., Egger, M., Lederberger, B., Hirschel, B., d’Acremont, V., Battegay, M., Wagels, T., Bernasconi,
E., Kopp, C., Furrer, H. (2003). Migrants for sub-Saharan Africa in the Swiss HIV Cohort Study: access to antiretroviral therapy, disease
progression and survival. AIDS 17(15): 2237-44.
II. DESCRIPTIVE QUALITATIVE STUDIES IN PEER-REVIEWED JOURNALS
25. Anderson, J., Doyal, L. (2004). Women from Africa living with HIV in London; a descriptive study. AIDS Care 16 (1): 95-105.
26. Connell, M. (2001). Sexually transmitted infections Among Black Young People in South East London: Results of a Rapid Ethnographic
Assessment. Culture Health and Sexuality 3: 311-327.
27. Coulon, M., Feroni, I. (2004). Genre et santé: Devenir mère dans le contexte des multithérapies antirétrovirales. Sciences Sociales et
Santé 22 (3): 13-40.
28. Doyal, L., Anderson, J, (2005). ‘My fear is to fall in love again...' How HIV-positive African women survive in London. Social Science &
Medicine 60(8): 1729-1738.
29. Erwin J, P. & Peters, B. (1999). Treatment issues for HIV positive Africans in London. Social Science & Medicine 49: 1519-28.
III. REPORTS, POLICY DOCUMENTS AND GREY LITERATURE
30. African Issues Group (1999). Tell us the Truth. Working with African Youth on HIV and Sexual Health Issues. World AIDS Day
Conference, 1998. Barkingside: Barnados.
31. African HIV Policy Network (2002). Annual General Report 2001-2. London.
32. Agence National de Recherches sur le SIDA. (2002). Sida, immigration et inégalités, nouvelles réalités, nouveaux enjeux. Collection
Sciences Sociales et SIDA. Juillet 2002.
33. AIDS & Mobility (2004). Activity Report 2001-2003, Plan of Action 2004-2006. Netherlands Institute for Health Promotion and Disease
Prevention.
34. AIDS & Mobility (2003). Access to Care: Privilege or Right? Migration and Vulnerability in Europe. Woerden: European Project Health &
Mobility, October 2003.
35. All Party Parliamentary Group on AIDS (2003). Migration and HIV: Improving Lives in Britain. An Inquiry into the Impact of the UK
Nationality and Immigration System on People Living with HIV.
36. Amamoo, N. A. (1996). Working with men for change: Gender and HIV prevention in the African community in the UK. London, Akina
Mama wa Afrika.
37. Arcat. (2005). Des malades en grande précarité. Le Journal du Sida, n°173: 16-21. Février 2005.
Project1
2/12/05
15:38
Page 26
38. Bitel, M. (1999). African prevention projects: Innovative HIV prevention projects commissioned in 1997/1998 by the South London Voluntary
Sector HIV Consortium: a report on consultancy evaluation of the projects. London, Merton, Sutton and Wandsworth Health Authority.
39. Bhatt, C., Phellas, C., Pozniak, A. (2000). National African HIV Prevention Projects: Evaluation Report. London, Enfield and Haringey Health.
40. Bhatt, C. (1997). Positive Responses: A Local HIV Action Strategy for African Communities. London, Enfield and Haringey.
41. Bingham, J. (2002). The sins of the fathers--Africans with HIV infection in London; lessons for others? International Journal of STD &
AIDS 13 (2): 42-44.
42. Blair, T. (1996). Pan-London Health Promotion Work with African Communities Affected by HIV strategic Development Day. London,
Lambeth, Lewisham, and Southwark.
43. Brown, P., 2000. Rate of HIV transmission among Africans in UK ‘underestimated’ British Medical Journal 320 (7237), 735.
44. Burns, F. (2001) Study of newly diagnosed HIV infection amongst Africans in London (SONHIA). Transfer Report MPhil to PhD. Centre
for Sexual Health & HIV Research, Department of Primary Care and Population Sciences, University College London.
45. Camden & Islington Health Authority (1997). HIV Prevention Strategy 1997-2000, Working with African Communities in Camden &
Islington. London, Camden and Islington Health Authority.
46. Camden & Islington Health Authority (1998). HIV Prevention Strategy 1998-2001. London, Camden and Islington Health Authority.
47. Camden and Islington Health Authority (2000). African Men's Seminar: How can men make a difference in HIV prevention? Seminar
report and key recommendations. London, Camden and Islington Community NHS Trust.
48. Camden and Islington Health Authority (2000). The 1st National African Communities HIV Primary Prevention Conference, Proceedings.
Camden & Islington Community Health Services NHS Trust.
49. Castilla, J., Del Amo, J. (2000). Epidemiología de la infección por VIH/SIDA en immigrantes y minorías étnicas en Espana. Secretaría
des Plan Nacional sobre el SIDA.
50. Chinouya Mudari, M., O'Brien, M. (2005). AIDS and African Childhood in London. The Paradox of African Traditions and Modern
concerns on Childhood. London. Online paper, accessed 09/02/05 at: ttp://www.cindi.org.za/papers/paper2.htm
51. Chinouya, M., Musoro, L.& O’Keefe, E. (2003). Ubuntu-Hunhu in Hertfordshire. Black Africans in Herts: Health & Social Care Issues:
A Report on the Action Research Intervention in the County. The Crescent Support Group.
52. Chinouya, M. and Davidson, O. (2003).The PADARE project: Assessing the health related knowledge, attitudes and behaviours of HIV
Positive African Accessing Services In North Central London. African HIV Policy Network: London.
53. Chinouya, M. (2002). HIV Prevention and African Communities living in England: A study of challenges in service provision. London,
National AIDS Trust and African HIV Policy Network.
54. Chinouya, M., Reynolds, R. (2001). HIV Prevention and African Communities Living in England: A Framework for Action. National AIDS
Trust: London.
55. Chinouya, M., Davidson, O., Fenton, K. (2000). The Mayisha Study: Sexual Attitudes and Lifestyles of migrant Africans in Inner London.
Horsham, Avert.
56. Chinouya, M., Fenton, K., and Davidson, O. (1999). The Mayisha Study: The Social Mapping Phase. Horsham, Avert.
57. Darbes, L., Kennedy, G., Peersman, G., Rutherford, G., Zohrabyan, L. (2005). Behavioral interventions for decreasing HIV infection in
racial and ethnic minorities in high-income economies (Protocol). The Cochrane Library 2005, Issue 1.
58. Department of Health, African HIV Policy Network, National AIDS Trust. (2004). HIV and AIDS in African Communities: A Framework
for Better Prevention and Care. London.
Project1
2/12/05
15:38
Page 27
59. De Cock, K.M., Low, N. (1997). HIV and AIDS, other sexually transmitted diseases and Tuberculosis in ethnic minorities in the United
Kingdom: is surveillance serving its purpose? British Medical Journal 314: 1747.
60. Del Amo, J, Bröring G, Hamers F, Infuso A, Fenton K. (2004). Monitoring HIV/AIDS in Europe’s migrant communities and ethnic
minorities. AIDS 18:1867–1873.
61. Del Amo J, Bröring, G., Fenton K. (2003). HIV health experiences among migrant Africans in Europe: how are we doing? AIDS 17(15): 2261-3.
62. Del Amo, J., Fenton, K., Gray, K., Erwin, J. and Broring, G. (2002). AIDS Surveillance in migrants and ethnic minorities in the European
Union. What are we measuring and what is it telling us? International AIDS Society Conference 2002, Abstract 6401.
63. Delpech, V., Antoine, D., Forde, J., Story, A., Watson, J., Evans, B. (2004). HIV and Tuberculosis (TB) co-infections in the United Kingdom
(UK): Quantifying the problem. International AIDS Society Conference 2004, Abstract 2169174.
64. Edubio, A., Narimani, P., Ihekweazu, C.A., Broring, G. (2002). Care and development of HIV/AIDS in non-documented migrants in Berlin,
Germany: A dilemma between public health and legal priorities. International AIDS Society Conference 2002, Abstract 2770.
65. Edubio, A. & Sabanadesan, R. (2001). African Communities in Northern Europe and HIV/AIDS. Report of Two Qualitative Studies in
Germany and Finland on the Perception of the AIDS Epidemic in Selected African Minorities. Available online, accessed 09/02/05 at:
www.map-tampere.fi/dokumentit/report_african_communities.pdf
66. Elam, G. (2004a). Perspectives on Terrence Higgins Trust’s HIV Prejudice and Discrimination Poster Campaign: Views of Barnet Residents,
African Business Owners and Their Customers. Report for Barnet PCT and Terrence Higgins Trust.
67. Elam, G. (2004b). Stoping Stigma with Awaredressers: Views of Barnet’s residents, businesses and their customers on the Awaredressers
Project. Report for Barnet Primary Care Trust and the Terrence Higgins Trust, March 2004.
68. Elam, G., McMunn, A. B., and Nazroo, J. (2001). Feasibility Study for Health Surveys in Black African People living in England. Final
report: Implications for the Health Survey for England 2003 . London, Joint Surveys Unit. National Centre For Social Research and
the Department of Epidemiology and Public Health, University College London.
69. Elam, G. & Chinouya, M. (2000). Feasibility Study for Health Surveys among Black African Populations living in the UK: Stage 2: Diversity
Among Black African Communities. London, Qualitative Research Unit. National Centre for Social Research.
70. Elam, G., Fenton, K., Johnson, A., Nazroo, J., & Ritchie, J. (1999). Exploring ethnicity and sexual health: A qualitative study of sexual
attitudes and lifestyles of five ethnic minority communities in Camden & Islington. London: University College London.
71. EuroHIV. HIV/AIDS Surveillance in Europe. End-Year Report 2003. Saint-Maurice: Institut de Veille Sanitaire, 2004. No. 70.
72. Fassin, D. (2000). Constructions et experiences de la maladie: une étude anthropologique et sociologique du sida des migrants d’origine
africaine dans la région parisienne. Available from: www.inserm.fr/cresp
73. Fenton, K., White, B., Weatherburn, P. and Cadette, M. (1999). What are you like? Assessing the sexual health needs of Black gay and
bisexual men. London: Big Up.
74. (forthcoming) Flowers, P., Davis, M., Hart, G., Rosengarten, M., Frankis, J. and Imrie, J. (2005a) Diagnosis, Stigma and Identity among
HIV positive Black African living in the UK.
75. (forthcoming) Flowers, P., Rosengarten, M., Davis, M., Hart, G. and Imrie, J. (2005b). The experiences of HIV positive black Africans
living in the UK: working paper.
76. Focus Consultancy (2000). Social Mapping and Needs Assessment of HIV Prevention Among West African Communities in Inner London
(South) region. London.
77. Focus Consultancy (1997). Social Mapping of African communities for targeting HIV prevention: final report. London.
Project1
2/12/05
15:38
Page 28
78. Gazzard, B., Anderson, J., Ainsworth, J., Wood, C. (2005). Treat with Respect: Treat with respect: HIV, public health and immigration.
Information Centre for Asylum and Refugees in the UK. Available online at: http://www.icar.org.uk/res/drp/drps/drp186.html
79. Gibb et al. (2004) Decline in mortality in Children with HIV in the UK and Ireland. British Medical Journal 328: 524.
80. Gibb et al. (1998). Factors affecting uptake of antenatal HIV testing in London: results of a multi-centre study. British Medical Journal
316: 259-261.
81. Gordon, B., Hudson, M., Mansour, J. (2005).Getting the Message Out: An Evaluation of Equal 1 Action 3: Mainstreaming. Centre for
Economic & Social Inclusion, January 2005. Available from the Positives Futures Partnership.
82. Green, G., Smith, R. (2004). The psychosocial and health care needs of HIV-positive people in the United Kingdom following HAART: a
review. HIV Medicine 5 (Suppl.1), 5-46.
83. Guiard-Schmid, J-B. et al. (2004). Prospective cohort study to compare HIV care for French and foreign patients treated in France.
International AIDS Society Conference, Abstract 2169074.
84. Hamers, F.F., Downs, A.M. (2004). The changing face of the HIV epidemic in western Europe: What are the implications for public health
policies? The Lancet 364: 83-94.
85. Haour-Knipe, M. Migration and HIV/AIDS in Europe. AIDS Infotheque 2000: 4-14.
86. Health First: Chinouya, M., Ssanyu-Sseruma, W., Kwok, A. (2005). The SHIBAH Report: A Study of Sexual Health Issues Affecting Black
Africans Living with HIV in Lambeth, Southwark, and Lewisham. Health First: London.
87. Health Protection Agency (2003). Focus on Prevention: HIV and Other Sexually Transmitted Infections in the United Kingdom in 2003.
An Update: November 2004. London: Health Protection Agency, Centre for Infections.
88. Health Protection Agency (2004). Populations at Risk of HIV and STIs – Black and Ethnic Minority Populations, Updated November
2004. Available online:http://www.hpa.org.uk/infections/topics_az/hiv_and_sti/populationsatrisk/groups/ethnicminorities.htm
89. Health Protection Agency Centre for Infections, Communicable Diseases Surveillance Centre (HIV & STI Department), Scottish Centre
for Infections & Environmental Health. (2005). Unpublished Quarterly Surveillance Tables No.67, 05/2 Table 12b.
90. Ikambere (2004). Rapport 2004. Paris.
91. Institut de Veille Sanitaire (INVS). (2005). ‘Migrants et VIH’. Available online:
http://www.lecrips.net/webpaca/Publications/migrantsetvih/migrantsetvih.htm
92. Institut National de Prévention et d’éducation pour la Santé. Communiqué de Press, 24 Juin 2002: Des outils et une étude pour mieux
aborder la prévention du sida aupres des personnes d’origine étrangere vivant en France. INPES, Paris.
93. Kesby, M., Fenton, K., Boyle, P., Power, R. (2003). An agenda for future research on HIV and sexual behaviour among African migrant
communities in the UK. Social Science & Medicine 57(9): 1573-1592.
94. Lefranc, M L. et al. (2004). The approach taken by SIDA Info Service to HIV/AIDS prevention amongst immigrant groups. International
AIDS Society Conference, Abstract 2174727.
95. Lert, F., Obadia, Y., et al. (2004). Comment vit-on en France avec le VIH/SIDA? Populations et Santé, Numéro 406, Novembre 2004.
96. Lot, F., Larsen. C., Valin, N., Gouezel, P., Blanchon, T., Laporte, A. (2004) ‘Parcours Sociomédical des personnes originaires d’Afrique
subsahararienne atteintes par le VIH, prises en charge dans les hopitaux d’Ile-de-France, 2002’. Bulletin études n. 5, 2004, p.17. Institut
de Veille Sanitaire.
97. MacLeish, J. (2002). Mothers in Exile. London, Maternity Alliance.
98. Maharaj, K., Warwick, I. and Whitty, G. (1996) An assessment of HIV prevention interventions with refugees and asylum seekers, with
particular reference to refugees from the African continent. London: Health and Education Research Unit.
Project1
2/12/05
15:38
Page 29
99. MAYISHA II Collaborative Group (2005). Mayisha II Main Study Report: Assessing the feasibility and acceptability of community based
prevalence surveys of HIV among black Africans in England. Health Protection Agency Centre for Infections: London.
100. Marie Stopes International and Interact Worldwide (2004). Public Attitudes to HIV and AIDS. London.
101. McMunn A., Mwanje, R., Pozniak, A.L. (1997). Issues facing Africans in London with HIV infection. Genitourinary Medicine 73(3): 157-8.
102. Medical Foundation for AIDS & Sexual Health. (2005). ‘Recommended Standards for Health Services’. Available online at:
http://www.medfash.org.uk/publications/documents/Recommended_standards_for_sexual_health_services.pdf. Accessed 12/05/05.
103. Ministère de la Santé, et de la protection sociale. (2004). Programme National de lutte contre le VIH/SIDA en direction des
étrangers/migrants vivant en France (2004/2006). Paris.
104. National AIDS Trust (2004). Annual Report 2003-4. London.
105. National AIDS Trust: Bonnel, C. (2001). Towards a HIV London Prevention Strategy. London.
106. National AIDS Trust (2001). The needs of people with HIV in the UK. London.
107. National AIDS Trust (2001). African HIV Prevention Framework. London.
108. National African HIV Prevention Programme: Pulle, S., Lubega, J., Davidson, O. & Chinouya, M. (2005). Doing It Well: A good practice
guide for choosing and implementing community-based HIV prevention interventions with African communities in England. London.
109. National African HIV Prevention Programme (2004). 3rd National African HIV Prevention Conference Report. What Next? The Future
of HIV Prevention with African Communities. London 11-12 March 2004.
110. Ohen, L., Hunte, S. and Wallace, C. (2004). Who provides Social Advice to HIV positive clients. Lambeth Primary Care Trust, London.
111. Positive Futures. (2002). Access All Areas: A Study of the Accessibility of Positive Futures Services for people from Black and Ethnic
Minorities. London.
112. Project Nasah. Briefing sheet 1 & 2. Available Online: http://www.sigmaresearch.org.uk/downloads/nasahbriefing.pdf
113. Sasse, A., Vincent, A., Galand, M. (2002). High HIV prevalence among patients choosing anonymous testing. International AIDS Society
Conference, Abstract, 9092.
114. Sigma Research and NAT (2004). Outsider status - Stigma and discrimination experienced by Gay men and African people with HIV.
London, Sigma – NAT.
115. Sigma Research (2002). National Survey of People living with HIV. London.
116. Sigma Research: Ndofor-Tah, C., Hickson, F., Weatherburn, P., Amamoo, N.A., Majekodunmi, Y., Reid, D., Robinson, F., Sanyu-Sseruma,
W., Zulu, A. (2000). Capital Assets. London.
117. Takura, D., Power, L. (2002). Establishing initial peer support and services for migrant African women in Birmingham, UK. International
AIDS Society Conference, Abstract Number WePeF6823.
118. Terrence Higgins Trust, Doyal, L. & Anderson, J. (2003). My heart is loaded. African women with HIV surviving in London, a research
report. London.
119. Terrence Higgins Trust (2003). African men and combination therapies: A guide for African men with HIV. London.
120. Terrence Higgins Trust (2003). African women and combination therapies: A guide for African women with HIV. London.
121. Terrence Higgins Trust (2001a). Prejudice, Discrimination and HIV. London.
122. Terrence Higgins Trust (2001b). Social Exclusion and HIV. London.
123. Terrence Higgins Trust (2000). Taking Control: Developing a health promotion strategy for African men. London.
Project1
2/12/05
15:38
Page 30
124. Traore, C. (2000). “African men, HIV risk and responsibilities; Report of an expert seminar’ published by Terrence Higgins Trust,
November 2000.
125. Traore, C. (2002). Promoting knowledge of HIV Status amongst Africans in the UK. International AIDS Society Conference, Abstract 9597.
126. Traore, C. (2004). Promoting VCT for HIV with African and Caribbean men who have sex with men in London. International AIDS
Society Conference, Abstract 2171765.
127. Wasson-Simon, A., Sall, H., Maguet, O., Giaquinto, C. (2002). Generational differences in knowledge of HIV/AIDS among immigrants
from sub-Saharan African immigrants in France: comparing two focus groups of women. International AIDS Society Conference, Abstract 8306.
128. Weatherburn, P., Ssanyu-Seruma, W. & Hickson, F. (2003) Project NASAH: An investigation into the HIV treatment, information and
other needs of African people with HIV resident in England. Sigma Research, NAM Publications, National AIDS Trust and African HIV
Policy Network.
129. Weatherburn, P., Anderson, W., Reid, D. and Henderson, L. (2002) What do you need? Findings from a national survey of people with
HIV. London, Sigma Research.
IV. BACKGROUND
130. African Foundation for Development (AFFORD). Database of African organisations, available online at:
http://www.afford.uk.org/resources/database/
131. Office for National Statistics. Census, April 2001.
132. Centre for Research Dissemination. Finding studies for systematic reviews: a checklist for researcher. Available online at:
http://www.york.ac.uk/inst/crd/revs.htm. Accessed 09/04/05
133. Fenton,K., Mercer, C.H., McManus, S., Erens, B., Wellings, K., Macdowall, W., Byron, C.L., Copas, A.J., Nanchabal, K., Field, J. &
Johnson, A. (2005). Ethnic variations in sexual behaviour in Great Britain and risk of sexually transmitted infections: a probability
survey. The Lancet 356: 1246-1255.
134. Manavi, K., Welsby, P. (2005). HIV Testing no longer needs special status. British Medical Journal 13:133-176.
135. Popay, J. Rogers, A. Williams, G. (1998). Rationale and Standards for the Systematic Review of Qualitative Literature in Health Services
Research. Qualitative Health Research, 8,3, 341-351.
136. UNAIDS (2004). AIDS Epidemic Update 2004. Available Online at: http://www.unaids.org/wad2004/report_pdf.html. Accessed 10/04/05.
137. West Midlands Development and Evaluation Service Handbook. 2000. Available online: http://www.wmpho.org.uk/observatory/des.htm.
Accessed 10/04/0
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