Sexual attitudes, knowledge and behaviour of HIV-positive Africans

To date there are no estimates of HIV prevalence linked to sexual behaviour in a community sample of Africans in the UK. What we know primarily comes from four reports including the Padare study and the Shibah report, and the largest sample from Mayisha I and II.

The PADARE study surveyed 214 black Africans with HIV in London, the majority of who were born in Zimbabwe, Uganda, Zambia and Congo. Only 3% were born in the UK.

The Sexual Health Issues of black Africans with HIV (SHIBAH) Project consisted of a survey of 124 HIV-positive black Africans in Lambeth, Southwark and Lewisham (LSL) and in-depth interviews with 20 survey respondents.

Mayisha I and II: Mayisha I surveyed 748 migrants from five sub-Saharan African communities (Congo, Kenya, Uganda, Zambia, Zimbabwe) resident in London. The information collected included data on demographic characteristics, utilisation of sexual health services, HIV testing history, sexual behaviour, and attitudes. Mayisha II included a survey of sexual attitudes and lifestyles of 1,500 black African men and women aged 16 years and over recruited from social and commercial venues in London, Luton and the West Midlands using a brief, validated, self-completion questionnaire.

The Shibah study showed that there were gaps in HIV knowledge: 16% felt they could be cured of HIV in the UK and 10% did not know; 8% thought an undetectable viral load meant they could not pass the infection on to anyone else. The PADARE study also reported variable condom use. Of those having sex in the last 4 weeks (the majority of the sample), 40% reported using a condom only on some or on no occasions. Twenty-seven per cent of men and 35% of women reported no condom use when they last had sex. The SHIBAH report found 56% of respondents used condoms ‘always’, 33% ‘sometimes’, and 10% ‘never’. The exact rate of unprotected sex is thus unclear. However, 27% of respondents reported problems using condoms. The PADARE study reported that casual relationships were frequent, with 22% of both men and women reporting that their most recent sexual partner was a casual relationship.

The SHIBAH report, whose sample contained a greater number of older respondents than the overall population of black Africans living in LSL, showed fewer respondents engaging in casual relationships. The PADARE study also found evidence of sexual mixing with other ethnic groups. Over half of both men and women reported that their most recent sexual partners were black Africans. Other sexual partners included people of Caribbean origin and white and other black British people. The authors of PADARE conclude that ‘The data suggests significant levels of sexual behaviour that places both the individual living with HIV and their sexual partners at risk of transmitting HIV and other STIs’. However, the rates of unprotected sexual intercourse with the most recent partner were lower than those reported in the 1999 MAYISHA survey sample of people of unknown HIV status from African communities (men 27 vs. 56%; women 35 vs. 58%). This demonstrates a degree of risk reduction behaviour among the HIV-positive sample. The SHIBAH findings also indicate changes in sexual behaviour with age. The rate of unprotected sex in the last four weeks (29%) reported in the PADARE study was slightly higher than the 21% found in 1999 in a sample of HIV-positive gay men in London.

Mayisha II had 1608 participants originating from 38 different African countries. The study revealed a number of important findings, such as the importance of marriage and fertility to respondents, a third of who were married. Respondents also raised issues around the impact of migration on relationships, with a quarter of married men and women having a partner that lived abroad. Diverse sexual lifestyles were present, for example 8% of respondents reported same sex relationships and 20% of men and 8% of women reported two or more partners in the last year.

Sexual health was seen by respondents as an important issue, with around two-fifths of men and women having ever attended a sexual health clinic. Half of female respondents and 43% of the men reported that they had ever had a voluntary confidential HIV test – the majority of which were within the past five years. Respondents’ accounts indicated the importance of community outreach work and HIV awareness raising events as key factors in motivating them to take a voluntary HIV test, but fear of stigmatisation or deportation and expectations of HIV as a ‘death sentence’ continue to deter others from taking the test. Feelings about condom use were mixed. Around half of those that responded had used a condom the last time they had sex, but respondents tended to agree that condom use was not appropriate or necessary in long term relationships – condom use implying lack of trust in such situations.

Trust in the monogamous nature of their relationships and in being faithful to one partner were highlighted as fundamental by respondents, but men and women’s accounts also provided evidence of concurrent relationships.

HIV positivity in the community samples was also explored. The level of positivity reported is that of the recruited sample and does not necessarily reflect true HIV positivity in the black African population in the UK, but this data will help further understanding of issues associated with HIV infection. Overall, of those respondents providing an oral fluid sample, 14% (141/1006) were HIV positive. Positivity from the community samples was higher among older respondents and those who were widowed, separated or divorced as well as respondents who had ever had a sexually transmitted infection diagnosed. Further analysis is being carried out to explore factors associated with diagnosed and undiagnosed infection and will be published later in the year.

Criminalisation of HIV transmission

Over the past year three men have been convicted of committing Grievous Bodily Harm (GBH) in England for transmitting HIV to female sexual partners. Those convicted were all of Black African origin, and were either seeking asylum or had refugee status. These cases raise a range of issues for African people living with HIV in the UK.

In October 2003, a London judge disallowed evidence about two complainants’ knowledge of Mohammed Dica’s diagnosis, because he deemed their consent irrelevant. Mr Dica was convicted and given an eight-year prison sentence, but the conviction was quashed in March by the Appeal Court. At his third retrial in March 2005, Mr Dica was convicted on one count of recklessly inflicting grievous bodily harm contrary to Section 20 of the OAPA 1861. He was ordered to serve out the remainder of his four and a half year sentence on that conviction.

In January 2004, Kouassi Adaye pled guilty to charges including GBH relating to the transmission of HIV to a woman in Liverpool. Despite not being tested at the time of transmission, the judge said Mr Adaye should have known his status as, one week before he had sex with the complainant, his wife telephoned from South Africa to say that she was positive.

Most recently, in May, Feston Konzani was convicted of three counts of GBH in Middlesbrough and was sentenced to ten years in prison.

These men have been variously described in local and national press coverage as ‘terrorists’, ‘assassins’, and ‘monsters’. While many of us may not dispute that the actions attributed to them are immoral, there are important questions to be raised about the purpose of using the criminal law in such instances. If criminalisation contributes to the environment of fear and blame that drives the epidemic, is it an effective means of addressing HIV transmission?

African people with diagnosed HIV have strong opinions regarding the issue of criminalisation, as noted in Outsider Status (2004). Many questioned why responsibility for transmission was not considered to be shared between both partners. A large proportion were also upset by sensational press coverage that spread misinformation about HIV, while appearing to indict all HIV positive Black African migrants in the UK. Some challenged the criminal justice system’s exclusive selection of Black African male migrants for the development of this case law, while also raising questions about the strength of evidence for and against the defendants. A small proportion of African research participants argued that non-disclosure of positive status before unprotected sex should result in prosecution, but the majority of respondents argued that the negative impacts far outweighed any possible good that could come from such convictions.

Criminalisation of HIV transmission is of key importance to all African people living with HIV in the UK. The African HIV community is already discussing the issues raised by these cases.

Prevention for African communities nationally

In 1997, the Department of Health (DoH), through Enfield & Haringey Health Authority, commissioned several HIV primary prevention interventions in England and Wales to address known and undiagnosed HIV infection in relatively recently arrived African populations. In October 2001, the DoH entrusted the African HIV Policy Network, an African led organisation, with the management of the project (http://www.ahpn.org/). The National African HIV Prevention Programme, or NAHIP as it has come to be known, commenced formally with the appointment of a Project Manager. An advisory group made up of professionals from health promotion, research, policy, community groups, epidemiology, behavioural science and the DoH assists in the strategic management of the programme.

In June 2003 NAHIP began developing a multi-agency collaborative health promotion network to deliver national HIV interventions. Voluntary organisations with experience in HIV prevention and health promotion with African communities were asked to submit statements of interest in order to form a working partnership with NAHIP. Ten organisations were recruited through a selection process overseen by the NAHIP Advisory group and have since been working together to produce a range of resources to be used in HIV prevention campaigns. For further information and to download resources visit the NAHIP website: www.nahip.org.uk