An agenda for future research on HIV and sexual behaviour among African migrant communities in the UK

A One-Size-Fits-All HIV Prevention and Education Approach?: Interpreting Divergent HIV Risk Perceptions Between African American and East African Immigrant Women in Washington, DC Using the Proximate-Determinants Conceptual Framework

BACKGROUND

To date, there are very few comparative US studies and none in DC that distinguish between US-born and foreign-born black women to examine and compare their perceptions of HIV risk. This qualitative study, therefore, analyzes African American and East African women's perceptions of HIV risk in the Washington DC Metropolitan area, which has the highest AIDS rate in the United States.

METHODS

Forty in-depth, semistructured interviews and 10 cognitive interviews were conducted among a sample of 25 African American women and 25 East African born women between October 2012 and March 2013 to examine perceptions regarding HIV risk. The in-depth semistructured interviews were preceded by the cognitive interviews and accompanying survey. Study protocol was reviewed and approved by the American University Institutional Review Board.

RESULTS

Adopting Boerma and Weir's Proximate Determinants conceptual framework to interpret the data, the results of the study demonstrate that African American and East African immigrant women have divergent perceptions of HIV risk. Although African American women ascribe HIV risk to individual-level behaviors and choices such as unprotected sex, East African women attribute HIV risk to conditions of poverty and survival.

CONCLUSIONS

Study findings suggest that addressing HIV prevention and education among black women in DC will require distinct and targeted strategies that are culturally and community-centered to resonate with these different audiences.

TOGETHER Project to Increase Understanding of the HIV Epidemic Among Sub-Saharan African Migrants: Protocol of Community-Based Participatory Mixed-Method Studies

Background

Sub-Saharan African Migrants (SAM) are the second largest group affected by HIV/AIDS in Belgium and the rest of Western Europe. Increasing evidence shows that, more than previously thought, SAM are acquiring HIV in their host countries. This calls for a renewed focus on primary prevention. Yet, knowledge on the magnitude of the HIV epidemic among SAM (HIV prevalence estimates and proportions of undiagnosed HIV infections) and underlying drivers are scarce and limit the development of such interventions.

Objective

By applying a community-based participatory and mixed-methods approach, the TOGETHER project aims to deepen our understanding of HIV transmission dynamics, as well as inform future primary prevention interventions for this target group.

Methods

The TOGETHER project consists of a cross-sectional study to assess HIV prevalence and risk factors among SAM visiting community settings in Antwerp city, Belgium, and links an anonymous electronic self-reported questionnaire to oral fluid samples. Three formative studies informed this method: (1) a social mapping of community settings using an adaptation of the PLACE method; (2) a multiple case study aiming to identify factors that increase risk and vulnerability for HIV infection by triangulating data from life history interviews, lifelines, and patient files; and (3) an acceptability and feasibility study of oral fluid sampling in community settings using participant observations.

Results

Results have been obtained from 4 interlinked studies and will be described in future research.

Conclusions

Combining empirically tested and innovative epidemiological and social science methods, this project provides the first HIV prevalence estimates for a representative sample of SAM residing in a West European city. By triangulating qualitative and quantitative insights, the project will generate an in-depth understanding of the factors that increase risk and vulnerability for HIV infection among SAM. Based on this knowledge, the project will identify priority subgroups within SAM communities and places for HIV prevention. Adopting a community-based participatory approach throughout the full research process should increase community ownership, investment, and mobilization for HIV prevention.

Attitudes, perceptions and behaviours towards HIV testing among African-American and East African immigrant women in Washington, DC: implications for targeted HIV testing promotion and communication strategies

OBJECTIVES

The objective of the study was to examine and compare the HIV testing attitudes, perceptions and behaviours between African-American and East African immigrant women in the Washington, DC metropolitan area.

METHODS

Adopting an inductive, qualitative methodological approach, we conducted a total of 40 in-depth, semistructured interviews between October 2012 and March 2013. Qualitative thematic analysis was used to analyse the data.

RESULTS

Overall, African-American women held more favourable views towards HIV testing than East African immigrant women. Very few East African immigrant women sought HIV testing intentionally. The majority of East African participants were tested inadvertently, while others tested for immigration-related or employment-related purposes. There were many barriers that impede women from seeking an HIV test including negative assumptions (eg, "Getting an HIV test implies that I am HIV positive"), negative emotions (eg, "Fear of being diagnosed with HIV and what this will mean for me") and potential negative reactions from partner or others (eg, "Getting an HIV test can signal distrust, disrespect, or infidelity"). There were nuances in how each group articulated some of these barriers and East African women expressed unique concerns that originated from experiences in their home countries.

CONCLUSIONS

The study shed light into the complexity of factors that constrain women from presenting themselves voluntarily for an HIV test and highlighted the nuances between African-American and East African perceptions. Implications of findings for effective targeted HIV screening promotion and communication strategies among these groups of women are discussed.

'Migrants from over there' or 'racial minority here'? Sexual networks and prevention practices among sub-Saharan African migrants in France

Migrants from sub-Saharan Africa bear a disproportionate burden of HIV infection in Europe, with an increasing proportion of them acquiring HIV after migration. This transformation in the epidemic pattern has raised concerns about the sexual mixing and preventive behaviours of migrants. This paper aims at exploring how racial boundaries shape sexual networks and structure prevention practices among migrants from sub-Saharan Africa. Analyses are based on a French survey carried out among 1874 individuals born in sub-Saharan Africa, aged 18-49 and living in Paris and its surroundings. Our results provide evidence of the existence of African sexual networks, over and beyond those of national origin. The intra-African segregation of these sexual networks leads to sexual contacts between migrants from low- and high-HIV prevalence countries, which probably contribute to the development of the epidemic amongst these migrants. Moreover, racially-based perceptions of HIV-related risk seem to produce a specific attitude toward prevention practices as shown by higher rates of condom use among migrant women from sub-Saharan Africa with a partner born outside sub-Saharan Africa. As a consequence, community-based approaches to HIV prevention should take into account the identification of migrants from sub-Saharan Africa as a racial minority and not only focus on national borders.

'Experts', 'partners' and 'fools': exploring agency in HIV treatment seeking among African migrants in London

In an attempt to promote patient agency and foster more egalitarian relationships between patients and doctors, discourse concerning health and wellbeing in the UK has increasingly centred around the notion of informed and 'expert' patients who are able to effectively input into the direction and management of their own health care and treatment. While the relationship between a patient and their doctor can play a vital role in influencing the treatment decisions and health-related outcomes of people living with long term illness, little is known about the ways in which people living with HIV actually perceive their relationship with their doctors, nor the implications this may have for the types of treatment they may seek to use and the related information that they share. Drawing on 11 focus group discussions and 20 repeat interviews undertaken in 2008-2009 with HIV-positive adult migrants from Zambia, Zimbabwe and South Africa living in the UK, this paper argues that patient-doctor relationships can be heavily influenced by the perceived legitimacy of different forms of medical knowledge and treatments and by culturally influenced ideas regarding health, wellbeing and agency. Despite a desire amongst some migrants to use 'traditional' medicines from southern Africa as well as other non-biomedical treatments and therapies, the research found that the perceived lack of legitimacy associated with these treatments in the UK rendered their use a largely clandestine activity. At the same time, many patients made clear distinctions concerning issues affecting their immediate health and factors influencing their more general wellbeing, which in turn, impacted upon the information that they chose to share with, or conceal from, their doctors. Such findings challenge assumptions underpinning policy promoting patient agency and have significant and, in cases, potentially adverse implications for the safety and effective administration and management of HIV treatments in African migrant populations and possibly more generally.

African Australians living with HIV: a case series from Victoria

Background: This research aimed to describe the characteristics of African-born Victorians living with HIV, identify associations with delayed HIV diagnosis and describe their response to combination antiretroviral therapy (cART). Methods: A case series of African-born adults living with HIV in Victoria was conducted. Data was collected in interviews and reviews of case notes. Associations with delayed HIV diagnosis (CD4 below 200 cells µL–1 at diagnosis and/or AIDS within 3 months of HIV diagnosis) were explored using univariate regression. AIDS-defining illnesses and response to cART were described. Results: Fourteen males and six females were included. Ten were born in the Horn of Africa (nine in Ethiopia). Sixteen had sexual exposure (12 heterosexual; four male-to-male sex). Seven reported acquiring HIV in Australia. Median CD4 count at diagnosis was 145 cells µL–1. Ten had delayed HIV diagnosis, of whom eight were born in the Horn of Africa. Delayed HIV diagnosis was associated with birth in the Horn of Africa (odds ratio: 11.56). Nine had a diagnosis of AIDS, including three cases of tuberculosis, three of Pneumocystis jiroveci pneumonia and two of cerebral toxoplasmosis. Eighteen had received cART, of which 16 achieved virological suppression and 15 achieved a CD4 count above 200 cells µL–1. Clinical failure and virological failure occurred in seven and five cases, respectively. Conclusions: HIV prevention strategies for Victoria’s African communities should address HIV exposure in Australia. Ethiopian-born Victorians with HIV appear to be at particular risk of delayed diagnosis. Response to cART in this series was comparable to that observed in other industrialised countries.

Social, behavioural, and intervention research among people of Sub-Saharan African origin living with HIV in the UK and Europe: literature review and recommendations for intervention

Africans are the second largest group affected by HIV in Western Europe after men who have sex with men (MSM). This review describes and summarises the literature on social, behavioural, and intervention research among African communities affected by HIV in the UK and other European countries in order to make recommendations for future interventions. We conducted a keyword search using Embase, Medline and PsychInfo, existing reviews, 'grey literature', as well as expert working group reports. A total of 138 studies met our inclusion criteria; 31 were published in peer-reviewed journals, 107 in the grey literature. All peer-reviewed studies were observational or "descriptive," and none of them described HIV interventions with African communities. However, details of 36 interventions were obtained from the grey literature. The review explores six prominent themes in the descriptive literature: (1) HIV testing; (2) sexual lifestyles and attitudes; (3) gender; (4) use of HIV services; (5) stigma and disclosure (6) immigration status, unemployment and poverty. Although some UK and European interventions are addressing the needs of African communities affected by HIV, more resources need to be mobilised to ensure current and future interventions are targeted, sustainable, and rigorously evaluated.

HIV/AIDS and African immigrant women in Philadelphia: Structural and cultural barriers to care

Although African immigration to American cities is increasing, there is little published demographic or epidemiological data on this population. As growing numbers of HIV-positive Africans seek care at public health centres in the city of Philadelphia, medical personnel are confronted with the challenges of serving this population. This qualitative study explores the perspectives of HIV service providers who are treating this new patient group, and it examines the cultural and structural barriers African women face in the area of HIV prevention, testing, and treatment in the city of Philadelphia. These barriers include legal status, linguistic problems, fear of the American health system, misunderstandings about modes of transmission of HIV, and lack of awareness about antiretroviral treatment. Culturally appropriate education about HIV prevention and treatment needs to be developed for African immigrants, and medical personnel need to understand the experiences, fears, and concerns of this population.

Late HIV diagnosis of people from culturally and linguistically diverse backgrounds in Sydney: The role of culture and community

In Australia more than 85% of newly diagnosed HIV infections in 1999-2003 were homosexually acquired. In contrast, among people from culturally and linguistically diverse backgrounds, there is a much higher proportion of heterosexual exposure and many of the heterosexually acquired infections are diagnosed 'late', with people sometimes presenting with symptoms of AIDS. This paper reports on circumstances of late HIV diagnosis, meaning of an HIV-positive diagnosis and perceptions of risk among HIV-positive people from a variety of cultural and ethnic backgrounds in Sydney. The focus was on commonalities across cultures and ethnicities. Data were collected through semi-structured in-depth interviews with clients of the Multicultural HIV/AIDS and Hepatitis C Service and a sexual health clinic. Regular HIV tests were the exception in this group. Testing was usually motivated by a serious health crisis. Participants interpreted their diagnosis in the context of their knowledge and experiences with HIV/AIDS in their country of birth and the perceptions of HIV/AIDS in their ethnic communities in Australia. Many were not aware of the relationship between HIV and AIDS. Risk was perceived in terms of 'risk group' membership not in terms of practices and behaviours. Late diagnosis cannot be explained solely by association with country of birth, race or ethnicity. Rather, it is located within complex sets of social and cultural relations: the values attributed to HIV/AIDS and those infected and the social and cultural relations of ethnic communities in Australia and the dominant culture. These are enacted in healthcare seeking behaviour, perceptions of people with HIV and perceptions of being 'at risk'.

‘My fear is to fall in love again…’ How HIV-positive African women survive in London

Many studies are now documenting the circumstances of people living with HIV/AIDS in different parts of the world. We know an increasing amount about the experiences of women who make up the majority of those infected in countries in sub-Saharan Africa. However, very few researchers have examined the lives of female migrants from the region living with HIV. This article begins to fill that gap by exploring the situation of 62 women from different parts of Africa receiving treatment from the National Health Service in London. It is based on a qualitative study carried out between 2001 and 2002 using semi-structured interviews. The analysis explores the ways in which the women's lives are shaped in complex ways by their sex and gender, by their status as migrants and by their seropositivity. It examines the nature of their survival strategies, focusing mainly on the management of information, the use of health services and the importance of spirituality in their lives. The article concludes by highlighting the paradox whereby these women have access to treatment that would be unavailable in their own countries but their survival depends on them remaining in a country which few regard as 'home'.

The social determinants of oral health: new approaches to conceptualizing and researching complex causal networks

Oral epidemiological research into the social determinants of oral health has been limited by the absence of a theoretical framework which reflects the complexity of real life social processes and the network of causal pathways between social structure and oral health and disease. In the absence of such a framework, social determinants are treated as isolated risk factors, attributable to the individual, having a direct impact on oral health. There is little sense of how such factors interrelate over time and place and the pathways between the factors and oral health. Features of social life which impact on individuals' oral health but are not reducible to the individual remain under-researched. A conceptual framework informing mainstream epidemiological research into the social determinants of health is applied to oral epidemiology. The framework suggests complex causal pathways between social structure and health via interlinking material, psychosocial and behavioural pathways. Methodological implications for oral epidemiological research informed by the framework, such as the use of multilevel modelling, path analysis and structural equation modelling, combining qualitative and quantitative research methods, and collaborative research, are discussed.