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