Testing and diagnosis

Late diagnosis of HIV infection among Africans living in the UK is a major problem, hindering access to antiretroviral treatment at an appropriate time, adding to the likelihood of serious illness and shortening life expectancy in this population. The challenge is to shorten the time between infection and diagnosis, so that people access care and treatment at an appropriate time.1

Of black Africans diagnosed in 2007, 42% had a CD4 cell count (a key indicator of the health of the immune system) below 200 cells/mm3. Furthermore, the majority of Africans receiving a late diagnosis had been resident in the UK for over two years. This suggests it was not a matter of having been in the country too short a time to have had a chance to be tested, but opportunities to test being missed.2

Late diagnosis is particularly common in black African men.

Late diagnosis has a profound impact on morbidity and mortality. Late diagnosis is a factor in a third of all HIV-related deaths.3 In 2006, more than one-in-ten black African and Caribbean people who received an HIV diagnosis were concurrently diagnosed with AIDS. Between 2002 and 2006 it is estimated that black African and Caribbean people were 13 times more likely to die within a year of a late diagnosis than if they had been diagnosed earlier.4

More frequent HIV testing in black African people would reduce the numbers who are diagnosed late. There are a wide variety of reasons why black Africans do not always come forward for HIV testing, often linked to personal and social circumstances.

Many people who do not get tested frequently simply do not feel that they are at risk of having HIV.5 (In line with this, only a third of BASS Line respondents knew that at least 1 in 20 African people in England have HIV).6 Nonetheless, one study found that even among those individuals who did suspect that they had HIV, a much larger proportion of black African people than white people waited a year or more before being tested.7

Other reasons for not testing may include:6,5,7

  • Having other priorities than health – immigration, housing, employment and childcare.
  • Beliefs that health services are to be used when one is ill; a lack of a tradition of preventive medicine.
  • The stigma of HIV infection – its association with sexual practices outside the norm, it being seen as a death sentence.
  • Worry about the emotional impact of a positive diagnosis on oneself and on loved ones.
  • Fear of adverse reactions from family and friends, including social isolation and violence.
  • Lack of perceived benefit to testing positive, often linked to concerns around access to healthcare.
  • Concerns around the confidentiality of test results, both in relation to individuals in the UK and in Africa, and to the UK immigration authorities.
  • Belief that having HIV could lead to being deported from the UK.
  • Not knowing where to get an HIV test.

The vast majority of HIV testing occurs in GUM (genitourinary medicine) or sexual health clinics and antenatal clinics. There is evidence that some black African people find attending GUM clinics stigmatising and therefore these services may be under-utilised by black African people. In many cases, people are diagnosed with HIV and linked to care following attendance in other health settings including hospital wards and general practice.8,5,7

Current HIV testing strategies encourage a wide range of medical practitioners to consider offering HIV testing. 2008 guidelines recommend that testing should be offered to all patients admitted to hospital and to all patients registering with a GP in areas where the prevalence of diagnosed HIV is higher than 2 in 1000. This would include those areas – including 26 London primary care trusts – where the overwhelming majority of black Africans live.9 However, there are considerable challenges in encouraging non-specialist healthcare workers to offer HIV testing.

Outreach testing clinics may also be offered in African community settings and while such programmes may reach a relatively small number of individuals, the proportion with undiagnosed HIV can be high. Moreover large numbers of those reached have no contact with mainstream health services.10

See also

References

  1. Elam G et al. Approaches to Voluntary Counselling and Testing: Exploring policy and practice in the UK, US, Ghana, Malawi, South Africa and Ethiopia. AHPN, London, 2009
  2. Health Protection Agency Sexually transmitted infections in black African and black Caribbean communities in the UK. See www.hpa.org.uk/web/HPAweb&HPAwebStandard/HPAweb_C/1225441605082, November 2008
  3. Lucas S et al. National review of deaths among HIV-infected adults. Clin Med 8: 250-252, 2008
  4. Health Protection Agency Testing Times: HIV and other Sexually Transmitted Infections in the United Kingdom: 2007. November, 2007
  5. Burns F et al. Why the(y) wait? Key informant understandings of factors contributing to late presentation and poor utilization of HIV health and social care services by African migrants in Britain. AIDS Care, 19: 102-108, 2007
  6. Hickson F et al. Bass Line 2008-09: Assessing the sexual HIV prevention needs of African people in England. Sigma Research, 2009
  7. Erwin J et al. Pathways to HIV testing and care by black African and white patients in London. Sexually Transmitted Infections 78: 37-39, 2002
  8. Prost A et al. Feasibility and acceptability of offering rapid HIV tests to patients registering with primary care in London (UK): a pilot study. Sexually Transmitted Infections; 85(5):326-329, 2009
  9. Health Protection Agency HIV in the United Kingdom: 2010 Report. Health Protection Report 2010 4(47), November 2010
  10. Health Protection Agency Time to test for HIV: Expanded healthcare and community HIV testing in England. HPA, 2010
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