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People of African ethnicity, particularly individuals born in sub-Saharan Africa, bear the brunt of the heterosexual HIV epidemic in the UK. Despite accounting for less than 1% of the UK population, black Africans made up almost half of all new HIV diagnoses in the UK in 2006¹.

Although Africans living with HIV in the UK may benefit from access to HIV related healthcare, as a group they also face significant challenges. People living with HIV in the African community often experience stigma and discrimination in relation to their HIV status, compounded by daily hardships connected to migration including issues associated with employment, housing and living conditions.

Why are African communities in the UK disproportionately affected by HIV/AIDS?

Approximately 0.2% of the UK population are infected with HIV². Amongst Africans in the UK HIV prevalence is much higher, at 3%³. Migration from areas of high HIV prevalence largely accounts for this disparity.

Globalisation, HIV/AIDS and African communities in the UK

In this era of globalisation, there is an increasing integration of economies, societies and cultures. It is argued that the rapid spread of HIV/AIDS is linked to globalization, which makes it easier for people to travel and therefore facilitates the spread of HIV from areas of high prevalence.

"Africa bears the heaviest burden of the world's HIV pandemic, with over 25 million people estimated to be infected. The impact of this has been felt across the world and is reflected in the increasing numbers of HIV positive people from African backgrounds in the UK" - Professor Leslie Doyal ⁴

In the UK the heterosexual HIV epidemic is intimately linked to that in sub-Saharan Africa. The vast majority (84%) of Africans living with HIV in the UK were infected in Africa. There were an estimated 24,800 persons born in sub-Saharan Africa who were living with HIV in the UK in 2006, of whom an estimated 36% of men and 23% of women were unaware of their infection⁵.

This is not to say that the HIV/AIDS epidemic in the UK is exclusively bound to the generalised epidemic in sub-Saharan Africa, but it does largely account for the high prevalence of HIV in African communities in the UK relative to the rest of the population.

HIV diagnoses by ethnic group¹, UK

The number of HIV diagnoses among black Africans in the UK is declining. In 2007 there were an estimated 2,690 new HIV infections in Africans in the UK, compared to 3,250 in 2006⁶. Unfortunately, this decline does not reflect a reduction in HIV infections in African countries, but is due to fewer people migrating to the UK from areas of high HIV prevalence.

HIV infections acquired in the UK

The number of Africans living with HIV who were infected in the UK is rising. The number has increased seven-fold from 26 diagnoses in 1997 to 191 in 2006, when 8.1% of newly diagnosed Africans acquired the virus in the UK. Most of these individuals had partners who were probably infected abroad⁷.

The number of infections acquired in the UK is likely to continue to rise as the number of HIV infected Africans grows.

Stigma towards HIV-positive Africans in the UK

HIV-related stigma significantly changes the way people living with HIV are viewed and the way they view themselves. Stigma can lead to discrimination, whereby people are treated less favorably because of their HIV status.

Stigma towards Africans with HIV/AIDS in the UK can come from general society and the African community itself. It can have a huge impact and can lead to social marginalisation, low self-esteem and the breakdown of relationships.

"My wife started calling me names. She took the phone, she rang [names an African country], she rang my mom, she rang her parents and she said that she cannot stay with somebody that is AIDS" - ⁸

Stigma can make people reluctant to access health services. It may make them hesitant to take an HIV test, fearing the reaction to a positive result. If people are unaware of their HIV status they not only risk reducing their life expectancy but may also transmit the virus to others.

Sigma Research looked at stigma and discrimination experienced by people living with HIV in the UK and how it contributes to reduced health and wellbeing. In relation to African migrants the study argues that:

"HIV-related stigma reinforces racist perceptions by [portraying] Black African people as hyper-sexualised, irresponsible and infectious people who pose a threat to the public health and the stability of the health care system in the UK."

The research found that black Africans face particular disincentives to be open about HIV both in society in general, and within African networks. ⁹

"Even now it is very hard to tell somebody I am sick, because like our community they take it as a curse, or like you misbehaved or went out with somebody, like they take you as a prostitute, it is an attitude which is very bad…" - HIV positive African woman living in the UK ¹⁰.

A 2008 study found that black heterosexual men and women were the least likely group to tell other people about their status. The study found that 33% of African heterosexual men had not told anybody of their diagnosis, and 40% of African women had not told their partner that they had HIV¹¹.

HIV related stigma in the African community is strongly influenced by negative experiences of HIV in Africa where medical care is limited¹². There is a strong association between HIV and death.

"Medications are not so available in our country so the moment you are associated with HIV then you're a dead man. People don't like to be associated with dead people, with people that are going to die" - ¹³

It is important that those working in healthcare, who may be treating, testing or counselling Africans in the UK are aware of the high levels of stigma in the African community.

"Like my family situation, and coming to terms with understanding it as a black African... in Africa, it's like ‘oh my God, he's got it' and you're treated like a leper. So you've still got that at the back of your head...but the person who was counseling me, because they didn't come from that background maybe skimmed through that bit…" - ¹⁴

There have been a number of campaigns to address the deep-rooted stigma towards Africans living with HIV in the UK, including the ‘Changing Perspectives' campaign launched by the African HIV Policy Network (AHPN). The AHPN campaign sought to encourage faith communities, the media, HIV positive people and the British government to tackle HIV-related stigma and discrimination.

The most effective way to tackle stigma is to provide people with accurate information about HIV/AIDS. It is also vital that people living with HIV are involved in designing, facilitating and delivering anti-stigma initiatives to ensure that responses are relevant to the specific needs of that group or community.

Government legislation, treatment and immigration

"Every ring of the doorbell, they've come to deport me, that's what it feels like, the sight of a police car, are they looking for me, you know; that's the kind of life you have to live and definitely with the virus you don't need that" - ¹⁵

The difficulties that Africans with HIV in the UK face are often related to, or compounded by, issues of migration.

A significant proportion of African people living with HIV in the UK are (or have been in the past) refugees or asylum seekers. A 2003 study of sixty-two African women with HIV in London found that about a third were asylum seekers at the time of interview. Sixteen had either compassionate or exceptional leave to remain for between one and five years. Twelve had been granted indefinite leave to remain and a further six had British nationality. Two described themselves as illegal and one as a visitor¹⁶.

Immigration status particularly affects HIV treatment:

• In 2004 the Department of Health restricted health services to HIV infected migrants. Following the legislation failed asylum seekers, illegal immigrants and people overstaying tourist visas are not eligible for free NHS treatment¹⁷. This ruling was disputed in the high court in 2008, and may consequently be overturned¹⁸.
• Government policies of asylum seeker dispersal (whereby asylum seekers are ‘dispersed' to relieve pressure on areas such as Dover and London) may interrupt HIV treatment. Asylum seekers with HIV may be sent to areas that do not have specialist HIV healthcare facilities¹⁹.
• HIV positive Africans in the UK who are unsure if they will be given legal residence may be reluctant to start treatment as it is vital that once started, HIV treatment is adhered to (otherwise the virus may become drug resistant). Africans who face being returned to countries where access to HIV/AIDS drugs is not guaranteed have the dilemma of whether to start treatment.
• People wishing to return home also face difficult decisions in relation to HIV treatment. ‘…[I]t's double jeopardy. Because if I go back then there is a chance I might not be able to get the medical treatment I've been getting, then there's a chance I might die. So it's either going back and facing this or staying here and being separated from my family'²⁰

There are certain factors that may put some migrants, particularly asylum seekers, at risk of HIV infection after their arrival in the UK. These factors include poverty (which may lead to risky behaviour) and poor access to safer sex education and healthcare²¹.

HIV testing and African communities

Black Africans in the UK have relatively high rates of HIV testing²². A 2005 study found that approximately 40% of black Africans had ever had an HIV test, compared to 12-13% of the general UK population (once blood donation as the reason for testing is excluded)²³.

Overall 36.4% of black African men and 44% of black African women reported having ever tested. The majority (55%) of men had their last HIV test as part of a general health check up, either at a genitourinary medicine (GUM) clinic (34%) or in a general practitioner (GP) surgery (26%). The majority of women (63%) tested in antenatal clinics because of pregnancy²⁴.

A report found that Africans were likely to test because of suspicion of infection, either because of feeling unwell or because of the infection of a child or family member²⁵.

"I would feel very tired, very weak, and I would feel really completely different from how I was in Africa. I would say ‘what is happening with me?' and I thought is it this type of job…or maybe the weather and the change in this country is affecting me..." - an unidentified African man explaining his reason for testing for HIV ²⁶

Testing only once symptomatic explains why there is a very high level of late diagnosis in this group²⁷.

HIV testing in the UK is generally carried out on a voluntary basis, through voluntary counselling and testing (VCT). Other strategies have also been employed such as opt-out HIV testing for all pregnant women, offering opt-out HIV tests to patients attending sexual health clinics, and offering an HIV test to patients with symptoms suggestive of HIV infection²⁸.

As there is a high HIV prevalence amongst black Africans in the UK, and a high rate of late diagnosis, it has been suggested that a more active form of testing would be effective. This could include making opt-out testing a standard practice in GUM clinics and GP surgeries. A study found that 76.4 percent of black Africans diagnosed as HIV positive in the UK had visited their general practitioner in the year before diagnosis²⁹. Offering routine testing to these people would have meant earlier diagnosis.

Another option would be to make HIV testing more accessible by offering tests in community-based organisations³⁰. Although working within the affected community would have many benefits, there are concerns regarding service uptake including issues of stigma and confidentiality, and questions about procedure such as onward referrals to HIV services and the appropriate training of testing staff³¹.

"African communities stand to benefit tremendously from increased awareness and uptake of HIV testing… When individuals test regularly and know their HIV status, they can make an informed choice about their behaviours, get treatments more quickly if needed, and help prevent the onwards spread of the disease" - Dr Burns, Centre for Sexual Health and HIV Research

Go to our UK help and advice page for information about where to go for an HIV test.

Late presentation and onward transmission

Late presentation means that some people living with HIV are not diagnosed until their infection has significantly progressed and their CD4 count is below the recommended threshold for starting treatment.³² African men and women are typically diagnosed with HIV later than white British people, with 42% of new diagnoses among Africans in the UK in 2007 being late.³³

Many late diagnoses among Africans in the UK can be explained by poor levels of testing in the countries where they were infected. However, most late diagnoses occur amongst those who have been in the country for more than two years, indicating a lack of engagement between testing services and this population.³⁴ High levels of HIV-related stigma in African communities could also partly explain why people are not tested until they are seriously unwell. In 2006, 11% of black Africans and black Caribbean persons had an AIDS-defining event at fist HIV diagnosis, and these groups accounted for 59% of all persons diagnosed with concurrent HIV and AIDS diagnoses.³⁵.

Late diagnosis contributes to short-term mortality. In 2006, late presenting Africans were 13 times more likely to die within a year of their HIV diagnosis than all black African adults first diagnosed at higher CD4 counts³⁶.

Delayed presentation has major personal, epidemiological and health economic impacts.

On a personal level late presentation denies individuals and their partners the opportunity to access effective therapies and support. On a public health level late diagnosis means that those affected may have been infected with HIV for some time, and therefore may have unknowingly transmitted the infection to others^{37 38}. Late diagnosis may lead to high economic costs to the health service, as emergency care and treatment for AIDS-defining illnesses are often needed in addition to antiretroviral therapy³⁹.

HIV/AIDS treatment for African communities

The HPA reports that 69% of HIV-infected Africans were receiving antiretroviral drugs (ARVs) in the UK in 2006. 92% of those not on ARVs were in the earlier stages of HIV infection and therefore did not yet require treatment⁴⁰.

Many Africans in the UK have witnessed the catastrophic consequences of HIV within their communities and families in countries where HIV treatment has not been readily available or has only just started to be rolled out.

"Because I've been to Africa where HIV is rife and people are struggling to get bloods taken, let alone be given medication, I'm just glad to get tablets …" - ⁴¹

A study by the Terrence Higgins Trust found that for this reason the majority of Africans with HIV in the UK are satisfied with the level of care and treatment that they receive from the NHS.

"…the health services are very powerful, very helpful, very supportive, very sign-posting" - ⁴²

"They treat me good and normal. Some doctors don't use gloves. Some nurses don't use gloves. They know I'm HIV positive but they don't care" - ⁴³

Africans in the UK have also experienced first hand the consequences of not taking HIV treatment and therefore realise its importance.

"At the end of the day I've lost four brothers [from] HIV so I know how it is. Out of the boys I'm the only one alive, so basically I know that it's very vital that I hang onto this last straw that I have which is the combination therapy and that is why I have to follow it religiously" - ⁴⁴

However, healthcare professionals treating HIV-infected Africans must be sensitive to the very different cultural backgrounds from which they have come. The ideas and practices of Western biomedicine, and the availability of antiretroviral medication in the UK may be unfamiliar, and the choices that have to be made are complex and demanding⁴⁵.

Read more about HIV/AIDS treatment in the UK.

HIV prevention in African communities

Although the vast majority of HIV infections in the African community in the UK were acquired abroad, there is considerable risk of onward transmission in the UK. Raising awareness and educating people about HIV/AIDS and offering testing are all ways of preventing HIV transmission.

Prevention efforts targeted at African communities in the UK must take into consideration the diversity within this large community including cultural, religious, economic and political differences⁴⁶.

Read more about HIV prevention in African communities.

The way forward

British HIV/AIDS organizations need to adapt to the changing demographic of the AIDS epidemic in the UK. As black Africans accounted for almost half of all new HIV diagnoses in the UK in 2006, prevention and educational efforts need to focus on this key group. It is vital that organizations working within African communities to prevent the spread of HIV work with the community and make sure that their strategies are culturally appropriate. Stigma and discrimination and late diagnosis are two major issues that must be addressed in order to stop the number of black Africans living with HIV in the UK rising further.

The majority of HIV infections among black Africans occur in individuals newly arrived in the UK. The asylum and refugee process offer a number of opportunities to engage with new arrivals and offer them information about HIV and how to access related services, such as testing sites. Informing people of the healthcare resources available to them early in the asylum process can reduce late diagnosis and therefore decrease the number of HIV related deaths amongst the African communities in the UK.

The 2008 High Court judgement that decreed that withholding treatment from failed asylum seekers is unlawful is likely to have positive consequences for HIV-positive Africans who did not qualify for refugee status. Making sure that Africans living with HIV in the UK are able to access treatment not only complies with human rights legislation but also protects public health in the UK.

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