HIV testing and high risk sexual behaviour among London's migrant African communities: a participatory research study

Factors associated with testing for HIV and hepatitis C among behaviorally vulnerable men in Germany: a cross-sectional analysis upon enrollment into an observational cohort

BACKGROUND

HIV and hepatitis C virus (HCV) have shared routes of transmission among men who have sex with men (MSM). Routine testing facilitates early diagnosis and treatment, thereby preventing morbidity and onward transmission. We evaluated factors associated with HIV and HCV testing in a behaviorally vulnerable cohort of predominantly MSM.

METHODS

From June 2018 through June 2019, the BRAHMS study enrolled adults at ten German outpatient clinics that serve gender and sexual minority populations. Participants completed behavioral questionnaires that captured prior experience with HIV and HCV testing. Multivariable robust Poisson regression was used to evaluate factors potentially associated with testing in the previous 6 months.

RESULTS

Among 1017 participants with median age 33 (interquartile range 28-39) years, 1001 (98.4%) reported any lifetime history of HIV testing and 787 (77.4%) reported any HCV testing, including 16 (1.6%) known to be living with HCV. Testing within the last 6 months was reported by 921 (90.6%) and 513 (50.4%) for HIV and HCV, respectively. Recent HIV testing was more common among participants with higher education level and recent HCV testing. Recent HCV testing was more common among participants with non-cisgender identity, lifetime history of illicit drug use, hepatitis B immunity or infection, and recent HIV testing.

CONCLUSION

Prior testing for HIV was common in this cohort, but interventions are needed to improve HCV risk stratification and access to testing. HIV testing infrastructure can be successfully leveraged to support HCV testing, but differentiated preventive care delivery is needed for some vulnerable populations.

Modes of administering sexual health and blood-borne virus surveys in migrant populations: A scoping review

There has been a growing number of sexual health and blood-borne virus (SHBBV) surveys specifically administered to migrant populations. The purpose of this scoping review is to collate available information about how SHBBV surveys have been administered in migrant populations and the effect that mode of administration has on data quality, reliability and other practical considerations, e.g. response rates (RR) and social desirability bias. A methodological framework for scoping reviews was applied. SHBBV survey studies administered to international migrants published since 2000 were included if they contained some description of mode of administration. Ninety one studies were identified for inclusion from Embase, Medline, Web of Science, Google Scholar and supplementary grey literature. 'Interview only' was the most common mode of administration (n = 48), predominately comprising face-to-face interviews. Thirty six studies reported data from 'self-completed' surveys only, with pen-and-paper being most common (n = 17). Few studies (n = 7) combined interview and self-completed methods of survey administration. Sixty one studies did not report (or only partially reported) RR or the data necessary to calculate RR. Of the studies that reported RR, most were missing other key information including method of recruitment, consent procedures and whether incentives were offered. Strengths and limitations of all administration modes are summarised. Guidelines to inform future SHBBV survey research in migrant populations are presented.

Factors associated with access to HIV testing among international students in Japanese language schools in Tokyo

Japan has been recognized for its excellent universal health coverage system. However, the migrant population faces many barriers in accessing health services in Japan. Japan hosts around 260,000 international students, mostly from developing countries. Among them, language school students tripled from 2011 to 2017, against the backdrop of labor shortage in Japan. Most of these students are also engaged as cheap laborers and are vulnerable populations with poor access to health services. Several socio-economic and behavioral factors may increase their vulnerability to HIV and prevent them from accessing HIV testing in Japan. We examined the factors associated with access to HIV testing among international students in language schools in Tokyo. We conducted a cross-sectional study among international students studying in Japanese language schools in Tokyo. We collected data from 769 Chinese, Vietnamese, and Nepalese students using a self-administered questionnaire. We measured their access to HIV testing through questions on their knowledge of where to receive HIV testing and utilization of HIV testing. Bivariate and multivariable logistic regression models were used to analyze the data. Nepalese students were less likely to know where to receive HIV testing in Japan than Chinese students (AOR = 0.12, 95% CI 0.01–0.96). Students who did not need Japanese language interpreters during visits to health facilities were more likely to know where to receive HIV testing (AOR = 1.93, 95% CI 1.14–3.25). Students who did not have knowledge of free and anonymous HIV testing in Japan were also less likely to know where to receive HIV testing in Japan (AOR = 0.18, 95% CI 0.08–0.42). Students who did not have knowledge of free and anonymous HIV testing (OR = 0.05, 95% CI 0.02–0.10) and who had not utilized HIV testing in their home country (OR = 0.12, 95% CI 0.06–0.27) were less likely to utilize HIV testing in Japan. Factors associated with access to HIV testing among Japanese language school students in Tokyo are nationality, need for Japanese language interpreters, perceived access to doctors/health workers, utilization of HIV testing in the home country, and knowledge of free and anonymous HIV testing. These findings may help to design interventions for improving access to HIV testing among international students in Japan.

Knowledge, information needs and behavior regarding HIV and sexually transmitted infections among migrants from sub-Saharan Africa living in Germany: Results of a participatory health research survey

BACKGROUND

A total of 3,419 new HIV diagnoses were reported in Germany in 2016, with migrants from sub-Saharan Africa (misSA) accounting for 14.1%. To understand the driving factors behind the epidemiological situation, we conducted a quantitative cross-sectional survey on knowledge, attitudes, behavior, and practices regarding HIV and sexually transmitted infections (STIs) among misSA living in six German cities utilizing participatory health research.

METHODS

Participants were recruited by peer researchers. Levels of knowledge, information needs, and preferred methods of information dissemination were analyzed to inform future prevention planning. Additionally, we analyzed sexual behavior and other risk factors for contracting HIV and STIs. The results may facilitate the formulation of targeted prevention messages in the future.

RESULTS

We included 2,432 participants in the analysis. General knowledge about HIV was adequate, as 86.9% were aware of the presented information. Statements about HIV co-infections were prior knowledge for 53.4% of the participants and about German HIV policies and HIV testing for 54.7%. Knowledge about other STIs differed, ranging from 69.6% who have ever heard of gonorrhea to 23.8% who have ever heard of genital warts. Groups with particular knowledge gaps were i) younger misSA, ii) recent migrants, iii) misSA without regular access to the German health care system, iv) misSA of lower socioeconomic status, and v) misSA with Muslim religious affiliation. The majority of participants reported information needs (72.8%), and 71.3% wanted to obtain this information from health professionals. Male misSA were more likely to report five or more sexual partners compared to females. Less than half of participants reported always using condoms with non-steady sexual partners (46.8%). Reasons for not using condoms differed between males and females. A considerable proportion of females (16.3%) and males (6.8%) experienced sexualized violence. More than one fourth of women (26.9%) were affected by female genital mutilation/cutting.

DISCUSSION

Future prevention planning should focus on sub-groups with particular knowledge gaps, recognizing their preferred methods of information dissemination. Prevention messages for male misSA should focus on their own risk perception and for female misSA on empowerment, e.g. to negotiate condom use.

Factors affecting HIV counselling and testing among Ethiopian women aged 15-49

BACKGROUND

HIV voluntary counseling and testing (VCT) is a crucial gateway to all strategies related to care, prevention and treatment of human immunodeficiency virus (HIV) infection. Nevertheless, utilization of voluntary counselling and testing (VCT) service among adults is very low in Ethiopia. The objective of this study is to identify determinants associated with VCT utilization among adult women aged 15-49 in Ethiopia.

METHODS

A cross-sectional study was conducted based on data taken from the Ethiopian Demographic Health Survey (EDHS) 2016. Using cluster sampling, 14,369 women aged 15-49 years were selected from all the nine administrative regions and two city administrations. Logistic regression was used to analyze factors associated with HIV VCT utilization.

RESULTS

Overall prevalence of ever tested for HIV was 53% (95% CI, 52, 54). Aged 20-44, ever married, being at higher socio economic position (SEP) and having risky sexual behavior were factors which are positively associated with VCT utilization. Being Muslims in urban and protestants in rural were factors significantly and negatively associated with VCT utilization. Those who had stigmatizing attitude both in urban and rural and who had comprehensive knowledge in rural were less likely to utilize VCT service.

CONCLUSION

VCT utilization among women in Ethiopia is demonstrating better improvement in recent years. However, stigmatizing attitude continued to be among the major factors, which are negatively affecting VCT uptake among women in Ethiopia. Concerted efforts should be made by all stakeholders to mitigate stigma, improve socio economic inequities and increase awareness on the benefit of VCT in controlling HIV in the society. In this aspect, the role of religious leader, schools, health extension workers and community leaders should not be undermined.

Co-Designing an Intervention to Increase HIV Testing Uptake with Women from Indonesia At-Risk of HIV: Protocol for a Participatory Action Research Study

Early diagnosis is a critical component of the global response to the human immunodeficiency virus (HIV). In Australia, more than two-thirds of women from Southeast Asia are diagnosed late with HIV. There is limited evidence regarding the barriers to HIV testing and which interventions work to increase an uptake among migrants living in high-income countries. This participatory action research (PAR) project will work with women from Indonesia to co-design an intervention to increase HIV testing uptake in Western Australia. The project will involve trained community researchers, representatives from relevant organizations, and community women born in Indonesia. We will conduct three PAR cycles. Phase one will use focus groups to understand enablers for HIV testing among community members. In phase two, data will be presented back to members of the participating communities who will be invited to co-design an intervention to increase HIV testing. The final cycle will focus on implementing and evaluating the resulting intervention. This project will add to the small body of literature on pathways and enablers to HIV testing, and to new insights regarding interventions that work for women from migrant communities and why.

Impact of HIV knowledge and stigma on the uptake of HIV testing - Results from a community-based participatory research survey among migrants from sub-Saharan Africa in Germany

Background

In 2015, 3,674 new HIV diagnoses were notified in Germany; 16% of those newly diagnosed cases originated from sub-Saharan Africa (sSA). One quarter of the newly diagnosed cases among migrants from sSA (MisSA) are notified as having acquired the HIV infection in Germany. In order to reach MisSA with HIV testing opportunities, we aimed to identify which determinants influence the uptake of HIV testing among MisSA in Germany.

Methods

To identify those determinants, we conducted a quantitative cross-sectional survey among MisSA in Germany. The survey was designed in a participatory process that included MisSA and other stakeholders in HIV-prevention. Peer researchers recruited participants to complete standardized questionnaires on HIV knowledge and testing. We conducted multivariable analyses (MVA) to identify determinants associated with ever having attended voluntary HIV testing; and another MVA to identify determinant associated with having had the last voluntary HIV test in Germany.

Results

Peer researchers recruited 2,782 participants eligible for inclusion in the MVA. Of these participants, 59.9% (1,667/2,782) previously had an HIV test. For each general statement about HIV that participants knew prior to participation in the study, the odds of having been tested increased by 19% (OR 1.19; 95%-CI: 1.11–1.27). Participants reporting that HIV is a topic that is discussed in their community had 92% higher odds of having been tested for HIV (OR 1.92; 95%-CI: 1.60–2.31). Migrants living in Germany for less than a year had the lowest odds of having had their last HIV test in Germany (OR 0.17; 95%-CI: 0.11–0.27). Additionally, MisSA 18 to 25 years (OR 0.55; 95%-CI: 0.42–0.73) and participants with varied sexual partners and inconsistent condom use (OR 0.75; 95%-CI: 0.44–0.97) had significantly lower odds of having had their last HIV test in Germany.

Discussion

Through participatory research, we were able to show that knowledge about HIV and discussing HIV in communities increased the odds of having attended HIV testing among MisSA. However, recent migrants and young sexually active people are among the least reached by testing offers in Germany. Community-based interventions may present opportunities to reach such migrants and improve knowledge and increase discussion about HIV.

Contextual factors associated with consistent condom use and condom self-efficacy amongst African asylum seekers and refugees in Hong Kong

BACKGROUND

Hong Kong has no systematic domestic policies committed to the rights of asylum-seekers and refugees (ASRs). This study explores the sexual health behaviours and social inequities amongst African ASRs in Hong Kong.

METHODS

A cross-sectional survey of African ASRs was conducted through three local non-governmental organizations in 2013. A logistic model was used to test the interactions and relationship between the respondents' consistent condom use and contextual antecedents, socio-demographic factors, psychosocial factors and condom self-efficacy (CSE) score.

RESULTS

371 adult African ASRs were recruited. In the previous month, 35% and 38% of participants consistently had used condoms with regular and casual sexual partners respectively. However, less than 50% perceived no risk of HIV/STIs and less than 60% reported not knowing how to access sexual health screening. Consistent condom use was less likely among African ASRs who were married (adjusted odds ratio (aOR) = 0.10), used recreational drugs (aOR = 0.11) or were unsure of their sexual orientation (aOR = 0.05) and was positively associated with higher CSE scores (aOR = 1.09) Pre-migration determinants and lifestyle determinants accounted for most of the variance in the model.

CONCLUSION

The inconsistent condom use makes African ASRs vulnerable to HIV/STIs. Tailored interventions are needed to address the associated determinants and inequities amongst African ASRs living in Hong Kong.

Migrants and HIV stigma: findings from the Stigma Index Study (UK)

This paper is based on data collected in 2009 for the international Stigma Index Study which measured the experiences of stigma among participants living with HIV in the UK. Data were collected using a self-completed survey questionnaire and focus group discussions. Quantitative data were analysed using SPSS, while qualitative data were subjected to thematic analysis. The Stigma Index attempts to establish a baseline for documenting the experience of stigma and discrimination by people living with HIV while also acting as an advocacy tool whose power lay in the involvement of people living with HIV in the design of study instruments and data collection. Participants were recruited through collaborations with a broad range of UK HIV support organisations. The ethics protocols used were those described in the Stigma Index guidebook. A total of 867 people living with HIV took part, of whom 276 described themselves as 'immigrants'. Most of this 'migrant' subsample (70%) was women. Nearly, all (91%) identified as heterosexual, while 9% were attracted to someone of the same sex as them. Socioeconomic deprivation was a key theme and they reported other stigmatised chronic conditions in addition to HIV. It is not possible to ascertain from the questionnaire, the migrants' countries of origin and length of stay in the UK. Control of information about HIV was critically managed, with respect to family and partners. Felt stigma increased anxieties about personal safety, particularly among men. Strategies for safeguarding against the negative impact of stigma included avoiding social gatherings, intimacy, and clinical and HIV social care settings. Most participants were unaware of policies and declarations that protected them as persons living with HIV. Specific recommendations include creating awareness about rights as enshrined in various legal frameworks that protect the right of people living with HIV, which has been reconfigured as a 'disability'.

HIV-Risk Index: Development and Validation of a Brief Risk Index for Hispanic Young People

The prevalence of HIV risk behaviors among young people facilitates the spread of HIV, in particular regarding unsafe sex behavior, although this trend is different within this population. For this reason, identifying the riskier young population is required to prevent HIV infection. The main purpose of this study was to develop and validate a risk index to assess the different sexual HIV risk exposure among Hispanic Young people. For this purpose, 9861 Spanish young people were randomly distributed into two groups (derivation and validation group). According to the results, the factor analyses grouped the nine items of the HIV- risk index into two factors (factor 1, direct sexual risk indicators and factor 2, indirect sexual risk indicators) with an equal structure for men and women by a multi-group confirmatory factor analysis. The variance explained was 54.26 %. Moreover, the Cronbach's alpha coefficient revealed high internal reliability (α = .79) and the convergent validity supported its evidence based on different HIV risk indexes. Therefore, the HIV-risk index seem to be a rigorous and valid measure to estimate HIV risk exposure among young people.

Which Psychological Factors are Related to HIV Testing? A Quantitative Systematic Review of Global Studies

Deciding to test for HIV is necessary for receiving HIV treatment and care among those who are HIV-positive. This article presents a systematic review of quantitative studies on relationships between psychological (cognitive and affective) variables and HIV testing. Sixty two studies were included (fifty six cross sectional). Most measured lifetime testing. HIV knowledge, risk perception and stigma were the most commonly measured psychological variables. Meta-analysis was carried out on the relationships between HIV knowledge and testing, and HIV risk perception and testing. Both relationships were positive and significant, representing small effects (HIV knowledge, d = 0.22, 95 % CI 0.14-0.31, p < 0.001; HIV risk perception, OR 1.47, 95 % CI 1.26-1.67, p < 0.001). Other variables with a majority of studies showing a relationship with HIV testing included: perceived testing benefits, testing fear, perceived behavioural control/self-efficacy, knowledge of testing sites, prejudiced attitudes towards people living with HIV, and knowing someone with HIV. Research and practice implications are outlined.

Restricted access to antiretroviral treatment for undocumented migrants: a bottle neck to control the HIV epidemic in the EU/EEA

Background

In the European Union/European Economic Area (EU/EEA), migrants from high-endemic countries are disproportionately affected by HIV. Between 2007 and 2012, migrants represented 39 % of reported HIV cases. There is growing evidence that a significant proportion of HIV acquisition among migrant populations occurs after their arrival in Europe.

Discussion

Migrants are confronted with multiple risk factors that shape patterns of population HIV susceptibility and vulnerability, which simultaneously affect HIV transmission. Undocumented migrants incur additional risks for contracting HIV due to limited access to adequate health care services, protection and justice, alongside insecure housing and employment conditions.

All EU/EEA countries have ratified a number of international and regional human rights instruments that enshrine access to health care as a human right that should be available to everyone without discrimination.

From a clinical and public health perspective, early HIV care and treatment is associated with viral suppression, improved health outcomes and reductions in transmission risks. A current challenge of the HIV epidemic is to reach the highest proportion of overall viral suppression among people living with HIV in order to impact on HIV transmission.

Although the majority of EU/EEA countries regard migrants as an important sub-population for their national responses to HIV, and despite the overwhelming evidence of the individual and public health benefits associated with HIV care and treatment, a significant number of EU/EEA countries do not provide antiretroviral treatment to undocumented migrants.

Summary

HIV transmission dynamics in migrant populations depend on the respective weight of all risk and vulnerability factors to which they are exposed, which act together in a synergistic way. People who are not linked to HIV care will continue to unwillingly contribute to the on-going transmission of HIV. Following the recommendations of the European Union Agency for Fundamental Rights, ensuring access to HIV-care for all sub-populations, including undocumented migrants, would fulfil the human rights of those populations and also strengthen the control of HIV incidence among those not currently able to access HIV care.

Barriers and Facilitators to HIV Testing in Migrants in High-Income Countries: A Systematic Review

Migrants, particularly from low- and middle-income countries, are at a heightened risk of adverse HIV outcomes. HIV testing may improve these outcomes. We reviewed and synthesised studies into migrants and HIV testing (outcome variable), published between January 1997 and April 2014. Papers using quantitative, qualitative and mixed methods designs, and samples with adult (≥18 years) migrants from low- and middle-income countries in high-income countries were included in the paper. Of 3155 papers retrieved, 31 met the inclusion criteria and are included in the review. A large number of barriers and facilitators to HIV testing were identified across the individual, social and structural levels. A number of study design and methodological issues, however, inhibited a comprehensive synthesis. There is no doubt that addressing HIV testing in migrants in high-income countries is complex; however, it has important implications for individual, community and population health, and a strong, empirically based response is warranted.

Barriers to accessing HIV services for Black African communities in Cambridgeshire, the United Kingdom

The majority of new HIV diagnoses in the United Kingdom (UK) occur in people with heterosexually acquired HIV infection, the majority of whom are African communities. Current research shows that despite health promotion efforts and advances in therapy these communities are accessing HIV care late. This study therefore explored barriers to equal access to HIV services by African migrants in the UK. Kleinman's (Patients and healers in the context of culture: an exploration of the borderland between anthropology, medicine, and psychiatry, vol 3. University of California Press, Berkeley, 1980) model of health care systems was applied in this research as a theoretical framework and lens through which the reported findings are viewed as it places health within the broader context of culture. In this research a qualitative approach with focus groups was used. A total of thirty participants were recruited from African migrant community organisations in Cambridgeshire in the East of England strategic health authority in order to study the experiences of African migrants when accessing sexual health services. It was found that barriers to equal access to HIV services exist for African communities in Cambridgeshire. These included language barriers and others bordering on the use of traditional medicine by African migrants, understanding of cultural diversity, awareness of how and where to access HIV services, and getting information about HIV. Findings highlighted the importance of taking the sectors of Kleinman's [1] model into consideration when planning HIV services for African communities.

High HIV Prevalence among Asylum Seekers Who Gave Birth in the Netherlands: A Nationwide Study Based on Antenatal HIV Tests

OBJECTIVES

Asylum seekers are considered to be a particularly vulnerable group with respect to HIV. Data on the HIV prevalence among asylum seekers, however, are scarce. The aim of this study is to map the HIV prevalence among asylum seekers who gave birth in The Netherlands.

METHODS

We used a nationwide electronic medical records database from the community health services for asylum seekers (MOA). The study population consisted of 4,854 women and girls who delivered in asylum reception between 2000 and 2008. A unique electronic health data base was used and case allocation was based on ICPC-codes.

RESULTS

The number of women and girls that was HIV positive during their last pregnancy was 80, of which 79 originated from sub-Saharan Africa. The prevalence for women from this region of origin (3.4%) was high compared to women from all other regions of origin (0.04%; OR = 90.2; 95%CI 12.5-648.8). The highest HIV prevalence rates were found for women from Rwanda (17.0%) and Cameroon (13.2%). HIV prevalence rates were higher among women who arrived in reception without partner (OR = 1.82; 95%CI 0.75-4.44) and unaccompanied minors (OR = 2.59; 95%CI 0.79-8.49), compared to women who arrived in reception with partner.

CONCLUSIONS

We conclude that, among asylum-seeking women from sub-Saharan Africa giving birth in The Netherlands, the HIV prevalence is high compared to the host population. For women from other regions of origin, the prevalence is at the same level as in the host population. The high HIV prevalence underlines the importance of preventive interventions and voluntary HIV testing for sub-Saharan African asylum seekers as from shortly after arrival.

Prevalence and Knowledge Assessment of HIV and Non-Communicable Disease Risk Factors among Formal Sector Employees in Namibia

INTRODUCTION

The burden of non-communicable diseases (NCDs) is growing in sub-Saharan Africa combined with an already high prevalence of infectious disease, like HIV. Engaging the formal employment sector may present a viable strategy for addressing both HIV and NCDs in people of working age. This study assesses the presence of three of the most significant threats to health in Namibia among employees in the formal sector: elevated blood pressure, elevated blood glucose, and HIV and assesses the knowledge and self-perceived risk of employees for these conditions.

METHODS

A health and wellness screening survey of employees working in 13 industries in the formal sector of Namibia was conducted including 11,192 participants in the Bophelo! Project in Namibia, from January 2009 to October 2010. The survey combined a medical screening for HIV, blood glucose and blood pressure with an employee-completed survey on knowledge and risk behaviors for those conditions. We estimated the prevalence of the three conditions and compared to self-reported employee knowledge and risk behaviors and possible determinants.

RESULTS

25.8% of participants had elevated blood pressure, 8.3% of participants had an elevated random blood glucose measurement, and 8.9% of participants tested positive for HIV. Most participants were not smokers (80%), reported not drinking alcohol regularly (81.2%), and had regular condom use (66%). Most participants could not correctly identify risk factors for hypertension (57.2%), diabetes (57.3%), or high-risk behaviors for HIV infection (59.5%). In multivariate analysis, having insurance (OR:1.15, 95%CI: 1.03 - 1.28) and a managerial position (OR: 1.29, 95%CI: 1.13 - 1.47) were associated with better odds of knowledge of diabetes.

CONCLUSION

The prevalence of elevated blood pressure, elevated blood glucose, and HIV among employees of the Namibian formal sector is high, while risk awareness is low. Attention must be paid to improving the knowledge of health-related risk factors as well as providing care to those with chronic conditions in the formal sector through programs such as workplace wellness.

The 'Antiretrovirals, Sexual Transmission Risk and Attitudes' (ASTRA) study. Design, methods and participant characteristics

Life expectancy for people diagnosed with HIV has improved dramatically however the number of new infections in the UK remains high. Understanding patterns of sexual behaviour among people living with diagnosed HIV, and the factors associated with having condom-less sex, is important for informing HIV prevention strategies and clinical care. In addition, in view of the current interest in a policy of early antiretroviral treatment (ART) for all people diagnosed with HIV in the UK, it is of particular importance to assess whether ART use is associated with increased levels of condom-less sex. In this context the ASTRA study was designed to investigate current sexual activity, and attitudes to HIV transmission risk, in a large unselected sample of HIV-infected patients under care in the UK. The study also gathered background information on demographic, socio-economic, lifestyle and disease-related characteristics, and physical and psychological symptoms, in order to identify other key factors impacting on HIV patients and the behaviours which underpin transmission. In this paper we describe the study rationale, design, methods, response rate and the demographic characteristics of the participants. People diagnosed with HIV infection attending 8 UK HIV out-patient clinics in 2011-2012 were invited to participate in the study. Those who agreed to participate completed a confidential, self-administered pen-and-paper questionnaire, and their latest CD4 count and viral load test results were recorded. During the study period, 5112 eligible patients were invited to take part in the study and 3258 completed questionnaires were obtained, representing a response rate of 64% of eligible patients. The study includes 2248 men who have sex with men (MSM), 373 heterosexual men and 637 women. Future results from ASTRA will be a key resource for understanding HIV transmission within the UK, targeting prevention efforts, and informing clinical care of individuals living with HIV.

Social Determinants of Health Associated with Self-Reported HIV Testing among Women

BACKGROUND

There currently is lack of knowledge about HIV testing practices in Iran. The purpose of this pilot study was to evaluate the prevalence of self-reported HIV testing and its associated factors among women.

METHODS

This cross-sectional study was conducted in Sanandaj City, located in the west of Iran, in 2012. Data were collected using self-administered questionnaire including demographics characteristics and the main outcome variable was self-reported HIV testing. The univariate and multivariate logistic regression models using STATA software was used for data analysis.

RESULTS

A total of 1200 women were interviewed during the study (Response rate=87.5%). The mean age was 29.67 years (SD: 7.01 years), 49% were aged 28 years or younger, 39.2% were single, 16.9% were pregnant and 60% did not have academic education. The proportion of women that were HIV-tested was, 32.1% (CI 95%: 29.2%, 35.0%). HIV testing was associated with younger age, knowledge of HIV/AIDS, household wealth, pregnancy, academic education, occupation and duration time of occupation, rating of quality of health services and substance use history in her husband.

CONCLUSION

The self-reported HIV testing rate among our sample women is 32.1%, lower than the HIV testing rate in other studies. Therefore, interventions to expand HIV testing and increase awareness of HIV risk are urgently needed in Iran.

HIV testing in black Africans living in England

We examined the uptake of HIV testing in black Africans living in England before the introduction of national testing guidelines. Analyses were conducted using data from an anonymous self-completed questionnaire linked to oral fluid samples to establish HIV status in black Africans attending community venues in England in 2004. Of 946 participants, 44% had ever been tested for HIV and 29% had been tested in the previous 24 months. Of those with undiagnosed HIV, 45% had previously had a negative HIV test. Almost a third of people tested in the UK had been at general practice. Uptake of HIV testing was not associated with perceived risk of HIV. These findings highlight the need for the implementation of national HIV testing guidelines in the UK, including the promotion of testing in general practice. Regular testing in black Africans living in the UK should be promoted regardless of their HIV test history.

Hidden yet visible: methodological challenges researching sexual health in Sudanese refugee communities

Research addressing sensitive topics with people from small, minority, ethnic communities can present challenges that are difficult to address using conventional methods. This paper reports on the methodological approach used to explore sexual health knowledge, attitudes and beliefs among the Sudanese community in Queensland, Australia. The multiphase, mixed-method study involved young people 16 to 24 years of age participating in a written survey and semi-structured interview and focus-group discussions with the broader Queensland Sudanese community members. Community collaboration, the key factor to the success of this research, optimised the development of a research environment that built trust and facilitated access and subsequent understanding. Research conducted in partnership with the target community can address methodological challenges and produce meaningful information when researching sensitive topics with small but 'highly-visible' populations.

Factors that affect HIV testing and counseling services among heterosexuals in Canada and the United Kingdom: an integrated review

OBJECTIVE

To examine factors that affect the utilization of HIV testing and counseling (HTC) services among heterosexual populations in Canada and the U.K.

METHODS

We conducted an integrated review of published and unpublished literature (1996-September 2010) using Scopus, OVID-EMBASE, CSA illumina, CINHAL, PROQuest, Web of Science, and Google.

RESULTS

Twenty-seven studies met the inclusion criteria. We identified and categorized the key factors into three broad categories depending on their source. Personal-related factors included socio-demographic characteristics, risk perception, illness, HIV-related stigma, level of HIV and testing knowledge, and culture. Provider-related factors included provider-recommended HIV testing, provision of culturally and linguistically appropriate services, and doctor-patient relationship. System-related factors included integrating HIV testing with other health care services, anonymity of testing services, suitability of testing venues, technical aspects of HIV testing, and funding for immigrant health services.

CONCLUSION

The findings from our review indicate that HTC behaviors of heterosexuals in the Canada and the U.K. are likely influenced by several unchangeable (socio-demographic characteristics) and amenable factors. There is need to step-up research to confirm whether these associations are causal using stronger research designs. PRACTICAL IMPLICATION: We have made several recommendations that could be used to improve existing services in Canada.

Women from Africa living with HIV in London: a descriptive study

There are no studies that have examined the particular needs and experiences of African women living with HIV in the UK at a time when they represent an increasingly large proportion of the UK HIV epidemic. This study explores the illness biographies and daily lives of HIV-positive African women receiving treatment in London. Sixty-two women from 11 African countries attending HIV specialist clinics in five London hospitals participated in self-completion questionnaires and in depth semi-structured interviews. Using a narrative approach, women were asked to talk about their HIV status in the broader context of their life history. Important differences exist within this group based mainly on nationality, income, education level and legal status in the UK. However, marked similarities also emerged which were related in part to their situation as migrants and were compounded by their illness. Stigma, both actual and perceived, had a profound impact on women's lives, making control of information about their situation a matter of acute concern. This had an effect on how women accessed health services and voluntary sector agencies. The resilience of women in dealing with difficulties in their lives was strengthened by religious belief. Such similarities and differences need to be properly understood by health and social care professionals if they are to offer the most appropriate care for this growing population of patients.

Interviewing Sub-Saharan migrants in Switzerland about HIV/AIDS: critical reflections on the interview process

Although research underpinnings for the interview process are often discussed in the scholarly community, reports of explicit experiences about this step are often insufficient or lacking in research publications on migrant health and in the context of HIV/AIDS. The authors highlight the challenges they encountered in conducting qualitative interviews in a multilingual, transcultural setting with Sub-Saharan migrants on HIV prevention and care. The authors discuss challenges and solutions during the conduct of interviews. They particularly highlight strategies on interview conduct, participant focus, and interviewer's behavior, which supported good quality in their research interviews. The main aim of the article is to critically reflect experiences and to suggest successful methods during interview phases with regard to the migrant setting and the sensitivity of the research topic.

Experiences of and responses to HIV among African and Caribbean communities in Toronto, Canada

African and Caribbean communities in Canada and other developed countries are disproportionately affected by HIV/AIDS. This qualitative study of African and Caribbean communities in Toronto sought to understand HIV-related stigma, discrimination, denial and fear, and the effects of multiple intersecting factors that influence responses to the disease, prevention practices and access to treatment and support services. Semi-structured interviews were conducted with 30 HIV-positive men and women and focus groups were conducted with 74 men and women whose HIV status was negative or unknown. We identified a range of issues faced by African and Caribbean people that may increase the risk for HIV infection, create obstacles to testing and treatment and lead to isolation of HIV-positive people. Our findings suggest the need for greater sensitivity and knowledge on the part of healthcare providers; more culturally specific support services; community development; greater community awareness; and expanded efforts to tackle housing, poverty, racism and settlement issues.

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.

Missed opportunities for earlier HIV diagnosis within primary and secondary healthcare settings in the UK

OBJECTIVE

To identify opportunities for earlier HIV diagnosis within primary and secondary care settings in the UK in Africans with newly diagnosed HIV infection.

METHODS

A survey of newly diagnosed HIV-positive Africans attending 15 HIV treatment centres across London was conducted between April 2004 and February 2006. The survey consisted of a confidential self-completed questionnaire linked to clinician-completed clinical records.

RESULTS

A total of 263 questionnaires were completed, representing an uptake rate of 79.5% of patients approached and 49.8% (131/263) of participants presented with advanced HIV disease (CD4 cell count < 200 cells/mul at diagnosis). In the year prior to HIV diagnosis 76.4% (181/237) had seen their GP, 38.3% (98/256) had attended outpatient services, and 15.2% (39/257) inpatient services, representing missed opportunities for earlier HIV diagnosis. Of those attending GP services the issue of HIV and/or HIV testing was raised for 17.6% (31/176) and 37.1% (78/210) had a previous negative HIV test, 32.5% of these within the UK. Medical attention was sought for wide ranging reasons, often not obviously connected to underlying HIV status. Despite the population predominantly coming from countries of high HIV prevalence personal appreciation of risk was comparatively low and knowledge of benefits of testing lacking.

CONCLUSION

Africans are accessing health services but clinicians are failing to use these opportunities effectively for preventive and diagnostic purposes with regards to HIV infection. Comparatively low appreciation of personal risk and lack of perceived ill health within this community means clinicians need to be more proactive in addressing HIV.

Sexual behaviour and HIV infection in black-Africans in England: results from the Mayisha II survey of sexual attitudes and lifestyles

OBJECTIVES

To estimate HIV prevalence and the distribution of high risk sexual behaviours, sexual health service use, and HIV testing among black Africans aged 16 years or over in England. To determine demographic, behavioural and service use factors associated with HIV prevalence.

METHODS

A cross-sectional community-based survey (Mayisha II) in London, Luton and the West Midlands. A short (24-item) anonymous self-completion questionnaire with linked voluntary anonymous oral fluid sampling, using an Orasure device for HIV testing.

RESULTS

A total of 1359 eligible black African men (51.9%) and women (48.1%) were recruited, of whom 74% (1006) provided a sufficient oral fluid sample for HIV testing. 42.9% of men and 50.9% of women reported ever having had an HIV test. Overall, 14.0% (141, 95% CI 11.9 to 16.3) of respondents tested HIV positive (13.1% of men and 15.0% of women); 9.2% (93) had undiagnosed HIV infection, while 4.8% (48) had a diagnosed HIV infection. HIV prevalence was significantly higher in men: born in East Africa; who had had a previous STI diagnosis; or who were recruited in bars and clubs; and in women: born in East or Southern Africa; aged 25 years and over; who had had two new sexual partners in the past 12 months; or who had had a previous STI diagnosis.

CONCLUSIONS

Despite about half the sample having had an HIV test at some time in the past, 9.2% of respondents had an undiagnosed HIV infection. This study supports current policy efforts to further promote HIV testing and serostatus awareness.

Demographic, clinical, and virologic characteristics of African-born persons with HIV/AIDS in a Minnesota hospital

Minnesota is currently home to the tenth largest African population and the second largest East African population in the United States. HIV is increasingly being diagnosed in African-born persons in Minnesota. A retrospective survey was conducted on all African-born patients in our HIV clinic between January 1994 and June 2005. We identified 237 patients who were African-born and HIV-positive. They constituted 12% of patients attending the clinic within the study timeframe. There was no significant difference in the ages of the African-born and non-African patients in the HIV clinic. African-born patients were more likely to be women compared with non-African patients (p < 0.001). Forty-three percent of the African-born patients presented with AIDS as defined by CD4(+) T cell counts less than 200 cells per milliliter compared to 33% of antiretroviral naïve non-African HIV patients in the clinic (p < 0.001). Most patients were infected through heterosexual contact and only 4% were diagnosed as a result of routine testing. Seven known HIV subtypes and four unique recombinant forms were identified. The most common opportunistic infection was pulmonary tuberculosis. African immigrants with HIV appear to: (1) access care at later stages of HIV disease than other patients in our clinic; (2) are often infected with non-B subtypes; (3) do not routinely get tested for HIV. Increased awareness to this growing trend is needed for health care providers and public health officials to tailor educational programs and prevention efforts for African immigrants in the United States.

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.

Mayisha II: Pilot of a community-based survey of sexual attitudes and lifestyles and anonymous HIV testing within African communities in London

The pilot aim was to assess the feasibility and acceptability of undertaking anonymous HIV testing using oral fluid samples as part of a community-based survey of sexual attitudes and lifestyles of black African communities in London. The three components of the study were administered in various venues across London: (1) a cross-sectional self-completion anonymous questionnaire survey, (2) an optional oral fluid sample for anonymous HIV testing and (3) a nested in-depth interview study in a sub-set of respondents. A total of 114 black African men and women were recruited. A large number of African countries were represented among respondents from newly-migrant and well-established communities. The response rate to the oral fluid sample was high at 82% and all samples collected were of sufficient quality to be tested for HIV. In-depth interviews with respondents revealed positive views and experiences about participating in the study whilst understanding of the questionnaire was good. We therefore conclude that anonymous HIV testing as part of a community-based survey is feasible and acceptable, whilst a set of recommendations was produced to refine the survey methodology and questionnaire. Participatory research methods are essential for achieving successful community-based surveys among black Africans in Britain.

The late diagnosis and consequent short-term mortality of HIV-infected heterosexuals (England and Wales, 2000-2004)

OBJECTIVES

To describe the proportion of HIV-infected heterosexual individuals diagnosed late and estimate how much mortality could have been prevented by earlier diagnosis.

DESIGN

A population-based study using surveillance reports from England and Wales.

METHODS

Calculation of proportions diagnosed late (CD4 cell count < 200 cells/mul) and short-term mortality (death within a year of diagnosis).

RESULTS

A total of 16 375 heterosexual individuals were diagnosed with HIV (2000-2004): 10 503 with CD4 cell counts available at that time; 42% (4425) were diagnosed late. Late diagnosis increased with age (P < 0.01). One fifth of women diagnosed antenatally were diagnosed late compared with 42% of other women and 49% of men; 70% of all heterosexuals diagnosed were black Africans, born and infected in Africa. Of those, at least 40% were recent arrivals to the UK, and twice as many were diagnosed late as black-African heterosexuals infected in the UK. Short-term mortality was 3.2% (491/15 523); 6.1% among those diagnosed late and 0.7% among others (P < 0.01). Short-term mortality was lower among black-African compared with white heterosexuals (3.1 versus 4.5%; P < 0.01) because of diagnosis at a younger age. Earlier diagnosis would have reduced short-term mortality by 56% (249 fewer deaths) and all mortality by 32% between 2000 and 2004.

CONCLUSION

Groups at high risk of late diagnosis should be targeted for health promotion activities, opportunistic screening, and removal of any barriers to testing. HIV testing in a variety of settings would reduce missed diagnoses and costs. New patient checks in primary care may provide the earliest opportunity to diagnose HIV infection among recent arrivals to the UK.

Access to HIV care among migrant Africans in Britain. What are the issues?

In the UK, substantial numbers of new HIV diagnoses are within migrant communities, especially African communities. Current surveillance shows that despite health promotion efforts and advances in therapy these communities are accessing HIV care late. This paper explores the issues influencing the access and uptake of HIV care by migrant Africans in Britain. Using Kleinman's model of health care systems (Kleinman, 1980) as a theoretical framework, we highlight the importance of placing health within its broader context if we are to make significant improvement to the health of HIV-infected Africans in Britain.

Factors associated with HIV testing among black Africans in Britain

OBJECTIVE

To describe the factors associated with HIV testing among heterosexual black Africans aged 16-44 years living in Britain.

DESIGN

We analysed data from the second British National Survey of Sexual Attitudes and Lifestyles (Natsal 2000)-a stratified national probability sample survey conducted between 1999-2001. Data from Natsal's main and ethnic minority boost (EMB) samples were analysed. Multivariate analysis was performed using complex survey functions to account for the clustered, stratified, and differential selection probabilities inherent within the survey.

RESULTS

A total of 385 (216 women and 169 men) black African respondents were included in the study. 44.0% women and 36.4% men reported ever having had an HIV test. In univariate analysis, HIV testing was associated with being born abroad (OR 3.63), having a new partner(s) from abroad in past 5 years (OR 2.88), and attending a GUM clinic (OR 3.27) among men; and educational attainment (OR 3.50), perception of "not very much" personal risk of HIV (OR 2.75), and attending a GUM clinic (OR 2.91) among women. After adjusting for potential confounders, an increased likelihood of HIV testing was associated with being in the United Kingdom less than 5 years relative to being UK born (adjusted OR 9.49), and ever attending a GUM clinic (adj OR 5.53), for men; and educational attainment (adj OR 4.13), and low perception of HIV risk (adj OR 2.77) for women.

CONCLUSIONS

Black Africans appear to have relatively high rates of HIV testing reflecting, at least partially, awareness of risk behaviours and potential exposure to HIV. Nevertheless, there remains substantial potential for health gain and innovative approaches are required to further increase timely HIV testing.

Ethnic differences in stage of presentation of adults newly diagnosed with HIV-1 infection in south London

OBJECTIVES

To establish whether there were ethnic differences in demographic characteristics, the stage at HIV diagnosis and reasons for and location of HIV testing between 1998 and 2000 in a large ethnically diverse HIV-1-infected clinic population in south London in the era of highly active antiretroviral therapy.

METHODS

A retrospective review was carried out of all persons >18 years old attending King's College Hospital with a first positive HIV-1 test between 1 January 1998 and 31 October 2000, and of a random sample of patients attending St Thomas' hospital with a first positive HIV-1 test in the same period. Demographic data, details of reasons for and site of HIV test, clinical stage, CD4 lymphocyte count and HIV-1 viral load at HIV diagnosis were abstracted from the local database and medical records. Comparisons were made according to ethnic group (white, black African and black Caribbean) and over time (1998, 1999 and 2000).

RESULTS

Of the 494 patients with new HIV-1 diagnoses between January 1998 and December 2000, 179 (36.2%) were white, 270 (54.7%) were black African and 45 (9.1%) were black Caribbean. There were significant differences across the ethnic groups in HIV risk group, reasons for and site of HIV testing, and clinical and CD4 stage at diagnosis. Among whites, 72.6% were men who had sex with men, 3.4% injecting drug users and 21.2% heterosexuals, compared to 2.2%, 0.4% and 93.3% among black Africans, and 28.9%, 0% and 68.9% among black Caribbeans (P<0.001). Black Africans were more likely to present with an AIDS diagnosis (21.3%) and a lower CD4 cell count [223 cells/microL; interquartile range (IQR) 88-348] compared to both whites (9.9%; 358 cells/microL; IQR 151-508) and black Caribbeans (17.9%; 294 cells/microL; IQR 113-380), who were intermediate between whites and black Africans in their stage of presentation. There was a statistically nonsignificant trend with time, between 1998 and 2000, towards earlier diagnosis based on the CD4 cell count in whites (323 and 403 cells/microL) and black Caribbeans (232 and 333 cells/microL), but a later diagnosis in black Africans (233 and 175 cells/microL). The majority of black Africans were HIV-tested as a result of suggestive symptoms or antenatal screening (58.4%) rather than because of perceived risk (40.5%), in contrast to the situation in whites (24.1% vs. 71.7%, respectively) or black Caribbeans (34.5% vs. 65.5%, respectively) (P<0.001). We found no significant differences across ethnic groups in age, HIV-1 viral load or year of HIV diagnosis.

CONCLUSIONS

Black Africans continue to present with more advanced HIV disease than whites or black Caribbeans, with no evidence of any trend towards earlier diagnosis. Future educational campaigns designed to promote the uptake of HIV testing among black Africans and black Caribbeans will need to address the multiple barriers to testing, including misperception of risk, stigma and ready access to testing.

Investigating the relationship between HIV testing and risk behaviour in Britain: National Survey of Sexual Attitudes and Lifestyles 2000

OBJECTIVES

To estimate the prevalence of, and identify factors associated with, HIV testing in Britain.

DESIGN

A large, stratified probability sample survey of sexual attitudes and lifestyles.

METHODS

A total of 12,110 16-44 year olds completed a computer-assisted face-to-face interview and self-interview. Self-reports of HIV testing, i.e. the timing, reasons for and location of testing, were included.

RESULTS

A total of 32.4% of men and 31.7% of women reported ever having had an HIV test, the majority of whom were tested through blood donation. When screening for blood donation and pregnancy were excluded, 9.0% of men and 4.6% of women had had a voluntary confidential HIV test (VCT) in the past 5 years. However, one third of injecting drug users and men who have sex with men had a VCT in the past 5 years. VCT in the past 5 years was significantly associated with age, residence, ethnicity, self-perceived HIV risk, reporting greater numbers of sexual partners, new sexual partners from abroad, previous sexually transmitted infection diagnosis, and injecting non-prescribed drugs for men and women, and same-sex partners (men only). Whereas sexually transmitted disease clinics were important sites for VCT, general practice accounted for almost a quarter of VCT.

CONCLUSION

HIV testing is relatively common in Britain; however, it remains largely associated with population-based blood donation and antenatal screening programmes. In contrast, VCT remains highly associated with high-risk (sexual or drug-injecting) behaviours or population sub-groups at high risk. Strategies to reduce undiagnosed prevalent HIV infection will require further normalization and wider uptake of HIV testing.

Researching sensitive issues and ethnicity: lessons from sexual health

Researchers are generally familiar with the need to adapt their research methods in order to minimise the impact of sensitivity. However, are different considerations required for studies of ethnicity or with ethnic minority respondents? This paper provides insight into strategies used by the authors to tackle sensitivity in qualitative and quantitative research studies of sexual health and ethnicity. Drawing on examples from these studies, the paper demonstrates the relevance of Lee's model of sensitivity, and examines ways in which ethnicity may add further dimensions to our ability to understand, identify and limit sensitivity in the research process. The paper identifies techniques available to researchers for handling sensitivity in general, as well as those that may be useful for researching sensitive topics among ethnic minority populations. The paper concludes that, given the transitional and contextual nature of ethnicity and sensitivity, formulaic approaches for tackling the latter are inappropriate. Instead, strategies are best developed in collaboration with the study communities.