Black African men

Up to a fifth of HIV infections among black African men initially classified as ‘heterosexual exposure’ in the UK are likely to have been acquired as a result of sex with other men, a new study suggests.

The researchers used a technique called phylogenetic analysis in order to compare the genetic structure of the virus in 22,500 people diagnosed with HIV. This technique can identify transmission clusters – in other words, groups of people who may have acquired HIV from each other. It is the technique that is sometimes used in evidence during prosecutions of HIV transmission.

The analysis was only of people who had subtype B. This is the strain of HIV that is most prevalent among men who have sex with men in the UK. (In African countries and among people who have moved from Africa to the UK, subtype C is generally more common.)

The researchers wanted to find out why an increasing number of individuals who describe themselves as heterosexual were being diagnosed with subtype B. One possibility is that this is because of more sexual mixing between men who have sex with men and heterosexual people, resulting in subtype B increasingly being passed on between men and women.

Another explanation is that some men are not disclosing that they have sex with other men when they test for HIV. The researchers found some evidence for this. Around a third of individuals (who had been described as heterosexual) were in transmission clusters in which all the other members were men who have sex with men.

This was most often the case for men of black African ethnicity.

Depending on the assumptions used, the researchers estimate that between 1 and 21% of black African men reported as heterosexual actually acquired HIV during sex with other men.

The researchers note that stigma and discrimination can make disclosure of same-sex behaviour more difficult for men in black African communities.

The results point to the need for HIV prevention interventions for black African communities to be inclusive and sensitive to the needs of men who have sex with men. Individuals may not readily disclose their same-sex behaviour or identify as gay, but need to have access to appropriate information and support. There is a further need for highly targeted work which is able to engage African men who have sex with men.

Complex needs of 'high-risk' gay men

A case note review in Scotland has shown that a significant proportion of gay men newly diagnosed with HIV or a rectal sexually transmitted infection (STI) have complex psycho-social needs and overlapping vulnerabilities, alongside their risky sexual behaviour.

The researchers noted factors such as poor emotional wellbeing or a mental health concern that required professional help; problematic alcohol consumption; experience of physical, emotional or sexual abuse; living in an area of social deprivation; homelessness; joblessness or financial worries; and involvement in prostitution.

Men were considered ‘vulnerable’ if they reported two or more of these issues. This was the case for:

  • 24.4% of HIV-negative men who had rectal chlamydia or gonorrhoea.
  • 28.3% of men newly diagnosed with HIV.
  • 50.0% of men who had been diagnosed with HIV for more than a year and were recently diagnosed with a rectal STI.

The researchers say that the risks men are taking with their sexual health may be a symptom of these other issues. However, HIV prevention interventions and sexual health services do not currently provide an adequate response to problems with emotional wellbeing, mental health or alcohol use.

They argue that the diagnosis of a rectal STI (and particularly repeat diagnosis) should trigger an intensive package of HIV prevention support for the individual which must include assessment, to establish whether the individual has problems in any of these areas. One-to-one support may be required.

The Scottish needs assessment has been published at the same time as Public Health England (PHE) have drawn attention to the multiple health inequalities experienced by men who have sex with men – greater use of alcohol, drugs and tobacco; higher rates of depression, anxiety and suicidal thoughts; and poorer sexual health than the general population. These health inequalities frequently co-exist and influence each other, PHE say. They are shaped by the wider socio-economic and cultural context, including the experience of stigma.

Gay men discussing HIV status

The Scottish case note review also highlighted problems to do with the infrequency with which many men test for HIV or discuss HIV status with their sexual partners. Men often made assumptions about both their own HIV status and that of their partners, and based sexual decisions on those beliefs.

These issues were particularly relevant in long-term relationships. Men often stopped using condoms with their partner as a symbol of trust, intimacy and commitment, without necessarily testing or discussing HIV statuses before making this decision. This was especially the case among younger men.

And the case note review found strong evidence of risk behaviour while men were in relationships. Around four-in-ten of the HIV-negative men newly diagnosed with HIV or a rectal STI were in a relationship at the time.

These men often reported concurrent sexual relationships with other men, either in the context of an agreed open relationship, during threesomes along with their partner, or without their partner’s knowledge.

“There is a need to encourage men to question the safety of the assumptions they make about open relationships, and to equip them to find more effective ways of reducing their risks,” they write. In particular, they recommend that couples test together and share their results, before giving up condom use.

More generally, the researchers recommend a continued focus on regular HIV testing and the benefits of knowledge of HIV status in HIV prevention interventions. This is a priority in HIV Prevention England’s programme.

Case study: prevention workshops

In the United States, heterosexual black women have a heavy burden of HIV infection. In Atlanta, Georgia, the community-based organisation SisterLove delivers small group workshops to around 4000 women a year, with a particular focus on women living in the city districts with the highest prevalence of HIV.

Among the issues fuelling the epidemic in black women are poverty, power imbalances between men and women, and women’s limited choice of partners (because so many men are in prison).

The ‘Healthy Love’ workshop is intended to be a culturally appropriate prevention intervention for black women. It is delivered to groups of women who already know each other, such as groups of friends, classmates, church groups or African immigrant organisations. These social connections are thought to encourage more open discussion and increase the chances that the learning is followed up afterwards.

As well as activities providing basic knowledge and safer sex skills, the intervention addresses specific cultural issues. Some activities challenge sexual taboos and social attitudes that denigrate women’s sexuality. Others provide information about the heavy impact of HIV on black women and help participants to assess their individual risks in this context.

The workshop is delivered in a single session that takes about four hours. Compared to a series of workshops, this makes it cheaper to deliver and easier to recruit and retain participants.

A randomised controlled trial found that the intervention had an impact on knowledge, condom use and HIV testing. The American public health body, the Centers for Disease Control and Prevention (CDC) judged the intervention to be effective and has made the materials needed to deliver it freely available online. Of course, some adaptation would be needed for use in the UK.