An investigation into newly diagnosed HIV infection among Africans living in London

371 Pages·2009·2.06 MB·English

An investigation into newly diagnosed
HIV infection among Africans
living in London

Thesis submitted in accordance with the requirements of University College London for
the degree of Doctor of Philosophy in Epidemiology

Fiona Margaret Burns

2009
I, Fiona Margaret Burns, confirm that the work presented in this thesis is my own.
Where information has been derived from other sources, I confirm that this has been
indicated in the thesis.
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ABSTRACT

In the UK substantial numbers of new HIV diagnoses are within migrant African
communities. A continuing feature of HIV in this population is the late presentation to HIV
services. This dissertation sets out to explore HIV testing among Africans in the UK, the
factors associated with late presentation to HIV services, and the extent of HIV
acquisition within the UK in African communities. The main focus of the thesis is the
‘study of newly diagnosed HIV among Africans in London’ (the SONHIA study),
which combined qualitative and quantitative methods in a multi-centre study.
The thesis begins with the work undertaken in preparation for SONHIA. It presents a
literature review to provide epidemiological, cultural and historical background. Next is
an analysis of the 2nd National Survey of Sexual Attitudes and Lifestyles to explore the
factors associated with HIV testing among black Africans in Britain. Finally, the
findings from in-depth interviews with key informants to identify the issues affecting
utilisation of HIV services for Africans in Britain are presented.
The SONHIA study consisted of survey of 269 Africans newly diagnosed with HIV. All
respondents self-completed a questionnaire linked to clinical records, and 26 in-depth
interviews with a purposively selected sub-sample were performed. The findings show
that Africans are accessing services but clinicians are failing to use these opportunities
for preventive and diagnostic purposes with regards to HIV infection. HIV presentation
patterns appear governed by factors linked to the characteristics of, and response to, the
HIV epidemic operating within people’s sociocultural networks. UK acquisition of HIV
in this population appears substantially higher than acknowledged by national
surveillance data, with a quarter to a third of HIV possibly acquired in the UK.
The qualitative findings provide contextual understanding of the factors contributing to
late presentation. They highlight the central role of HIV-related stigma and
discrimination in influencing HIV testing behaviours. Failings within the health care
system offer insight as how clinicians can better address HIV in the future.
The key findings are summarized and contextualised with the literature and the current
socio-political climate. The study’s limitations are addressed, and the thesis concludes
with the public health and policy implications of the study.
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Table of contents
Page
Title page 1
Abstract 3
Table of contents 4
List of tables 7
List of figures 10
Glossary 11
List of publications arising from this work 13
Acknowledgements 14
Chapter
1.0 Introduction, Aims and Study Outline 15
1.1 The emergence of an epidemic 15
1.2 The origin of HIV 20
1.3 Epidemiology of HIV 27
1.4 Aces to care 34
1.5 Rationale for interest 43
1.6 Aims and objectives 4
1.7 Study outline 46
2.0 Background 48
2.1 Migration & the population of Great Britain 49
2.2 Migration and HIV infection 56
2.3 Access to care 57
2.4 Ethnicity, inequality and health 58
2.5 African communities & HIV testing 69
2.6 Conclusion 7
3.0 HIV testing among Africans in Britain 79
3.1 Methods 80
3.2 Results 87
3.3 Discussion 96
4.0 Key informant understandings of factors
contributing to late presentation 101
4.1 Methods 103
4.2 Results 105
4.3 Discusion 18
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5.0 Study of newly diagnosed HIV infection
in Africans in London: Methodology 122
5.1 SONHIA 123
5.2 Validation 132
5.3 Study seting 135
5.4 Study population 135
5.5 Ethical aproval 138
5.6 Timetable 138
5.7 The challenges of implementation 138
5.8 Further work 141
6.0 Survey of newly diagnosed HIV positive
Africans in London: Results 143
6.1 Methods 14
6.2 Results 145
6.3 Discusion 169
7.0 Late presentation of HIV in Africans
in London 175
7.1 Methods 176
7.2 Results 181
7.3 Discusion 194
8.0 Acquisition of HIV infection in Africans
resident in England 199
8.1 Methods 202
8.2 Results 206
8.3 Discusion 212
9.0 Qualitative study with purposively selected
respondents 220
9.1 Methods 21
9.2 Results 26
9.3 Discusion 258
10.0 Discussion of findings and future work 262
10.1 Key findings 262
10.2 Limitations 267
10.3 Policy, practice, and research implications 268
10.4 Conclusions 285

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References 288
Appendices
1. Disemination of findings to date 327
2. Topic Guide for key informant interviews 329
3. SONHIA Questionaire 31
4. SONHIA Clinical Data Form 356
5. Information shets 358
6. Consent forms 364
7. Quota matrix for in-depth interviews 366
8. Topic Guide for in-depth interviews 368
9. Colaborators & key workers 370

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List of tables
Table Title Page
1.1. Summary of the 1993 classification of the clinical
manifestations of HIV 23
2.1 Ethnicity of English and Welsh residents born in Africa 53
3.1 Country of origin of study respondents 87
3.2 Characteristics of study respondents 90
3.3 Where and why had last HIV test; proportions by gender 91
3.4 The frequency and odds ratios of factors associated with
HIV testing in black African men & women 93
4.1 Sampling frame used for identifying key informants 103
5.1 Study sites recruitment taly 139
5.2 Sample size and relative risk 140
6.1 Characteristics of those approached and not approached
regarding study participation 147
6.2 Characteristics of those accepting to participate and those
not aproached 148
6.3 Questionaire item non-response 149
6.4 Country of birth of study participants 150
6.5 Socio-demographic profile of study participants 152
6.6 Sexual health and risk of study participants 155
6.7 Health & social service use prior to HIV diagnosis of
study participants 158
6.8 Summary of medical care prior to HIV diagnosis 159
6.9 HIV awareness prior to HIV diagnosis of study participants 160
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6.10 Experiences of testing HIV positive for study participants 162
6.11 Factors influencing study participants timing of HIV test 163
6.12 Clinical characteristics of study population 164
6.13 Post HIV diagnosis 16
6.14 Pros and cons of knowing HIV positive status 167
6.15 Study participants’ beliefs around HIV and HIV services 168
6.16 Participants perceptions of people’s reactions and attitudes to HIV 169
7.1 Univariate analysis of socio-demographic factors associated with
late presentation (CD4 <200 cells/µL at diagnosis) 182
7.2 Univariate analysis of sexual health factors associated with late
presentation (CD4 <200 cells/µL at diagnosis) 184
7.3 Univariate analysis of health & social service use prior to HIV
diagnosis asociated with late presentation 186
7.4 Univariate analysis of HIV awareness factors associated with late
presentation (CD4 <200 cells/µL at diagnosis) 188
7.5 Univariate analysis of factors associated with testing HIV positive
and late presentation (CD4 <200 cells/µL at diagnosis) 189
7.6 Univariate analysis of reactions and attitudes to HIV associated
with late presentation (CD4 <200 cells/µL at diagnosis) 190
7.7 Univariate analysis of beliefs around HIV and HIV services to late
presentation (CD4 <200 cells/µL at diagnosis) 191
7.8 Multivariate analysis of factors associated with late presentation
(CD4 <200 cells/µL at diagnosis) using hierarchal selection 192
7.9 Multivariate analysis of factors associated with late presentation
- non hierarchal selection 193
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8.1 Estimated time of seroconversion based on CD4 205
8.2 Agreement of CD4/Time in UK with assessors rating 207
8.3 Classification of region of acquisition by Assessors and CD4/time
in UK criteria 207
8.4 Major influences of factors in assessing country of acquisition –
determinate cases 209
8.5 Measure of agreement of indeterminate cases 210
8.6 Influencing factors in assessing region of acquisition –
indeterminate cases 212
8.7 Comparison between adults associated with Africa newly diagnosed
with HIV in London in 2004-2005 and SONHIA participants 216
9.1 Characteristics of interviewes 26

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List of figures
Figure Title Page
1.1 The spread of HIV in Africa 19
1.2 Exposure category of HIV-infected individuals by year
of diagnoses, UK, 194-203 32
1.3 UK HIV diagnoses by the two main routes of
transmision 1985-203 3
2.1 Total international migration by country of birth;
United Kingdom 193-202 51
2.2 Grants of settlement to African nationals, 1993 to 2003 54
2.3 Applications received for asylum in the UK from African
nationals, excluding dependants, by nationality, 1995 to 2003 55
3.1 Schematic representation of derivation of final
multivariate model 86
4.1 Schematic of Pathways to HIV Care 114
6.1 Recruitment flow chart 146
7.1 Conceptual framework underlying analysis 178
7.2 Percentage of HIV infected adults diagnosed late; 1995- 2004 195
8.1 Agrement betwen thre asesors 219
10.1 Geographical distribution of HIV-1 clades 273

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