Methods: This dissertation met these research aims through an extensive study of relevant literature and the implementation of practical research. The latter was carried out through in depth review of available literature. It was a desk top research using the university library and access to e-journals. Search strategy involved data mining, scoping and scanning of various data sources Literature from 1999-2012.
Results: One of the main findings of the dissertation was that sexual behaviour and risk of HIV transmission are correlated such that; one cannot talk about sexual behaviour and not talk about risk of HIV transmission in black -African male in London. Similarly, level of risk is dependent on sexual behaviour whereby number of sexual partners and condom use remain factors linked to acquisition of STI's and HIV. All the studies confirmed the high HIV prevalence among black Africans, many of whom have migrated from high-prevalence areas of sub-Saharan Africa. Accordingly, high impact interventions and cost benefit HIV prevention can be proposed with evidence based and combination prevention strategies.
Conclusion: The five common risk factors to HIV transmission are: number of new partners, marital status, gender /regular sex and condom use. Hence, efforts to promote HIV testing and awareness of HIV serostatus among black Africans living in the UK should be further strengthened and culturally competent education programmes promoting risk reduction strategies must continue.
CONCEPTS AND TERMIMOLOGY:
Behaviour Change Communication (BCC)
Is an interactive process with communities (as integrated with an overall program) to develop precise messages and in situ approaches using several communication channels to change behaviours; promote and strengthen individual, community behaviour change; and maintain appropriate behaviours (USAID, 2002).
Black-African
It is a term that has achieved generally wide acceptance as a descriptor of ethnic and migrant populations with origins in sub-Saharan African, and at the same time a categorisation that includes people linked with sub-Saharan Africa in an ethnic, cultural, and religious or other personal ways.
Combination prevention:
"The strategic, simultaneous use of different classes of prevention activities (biomedical, behavioural, social/structural) that operate on several levels (individual, relationship, community, societal), to respond to the specific needs of particular audiences and modes of HIV transmission, and to make efficient use of resources through prioritizing, partnership, and engagement of affected communities" (UNAIDS, 2010, p. 8).
Determinants:
Epidemiologists also attempt to search for causes or factors that are associated with increased risk or probability of disease. (CDC, 2012).
Epidemiology:
Epidemiology is the study of the distribution and determinants of health states or events in specified populations and application of health this study to control health problems (Carneiro & Howard, 2011)
Ethnicity:
It is a noun relating to the classification of mankind into groups, especially on the basis of racial characteristics.
Heterosexual:
Heterosexual is a sexual orientation where by a man and woman are sexually attracted.
High -risk behaviour:
High risk behaviour among black African can be defined as increased risk. Definition of high risk behaviour is different between heterosexuals and homosexuals. In heterosexual black male for example, risk of HIV infection with a fellow black person showed increased risk with a significant P Value <0.00001; meaning that having sex with a fellow black person had an increased risk of HIV acquisition (Evans, et al., 1999b).
HIV:
Stands for: Human Immunodeficiency Virus. It is a lentivirus (a member of the retrovirus family) that causes acquired immunodeficiency syndrome (AIDS) a condition in humans in which progressive failure of the immune system allows life-threatening opportunistic infections and cancers to thrive
Incidence & Prevalence
Incidence and prevalence are measures of occurrence of disease. Incidence refers to the number of new cases in a particular time in a given population whereas prevalence refers to the proportion of current cases in a population at a given point in time (Stewart, 2010).
Migrant
Refer to a person or animal that moves from one region, place, or country to another.
Positive prevention
Positive prevention (PP) is an approach to prevention that seeks to increase the psychosocial well-being of PLHIV and encourage solidarity amongst and for PLHIV. Part of PP is to engage PLHIV to propagate HIV prevention through activities such as social marketing and peer education. (LIVING, 2008)
Prevention
Simply means to avoid doing; stay away from dangerous or risky things or behaviour.
Risk factors
Risk factors refer to an aspect of personal habits or an environment exposure that is associated with an increased probability of occurrence of disease. Since risk factors can be usually modified, intervening to alter them in a favourite direction can reduce the probability of disease occurrence (Bonita, et al., 2006).
Sexual behaviour:
For the purpose of this dissertation, we shall refer to sexual behaviour as having sex as involving penile-vaginal and penile-anal intercourse. (Pitts M & Rahman Q; 2001)
Strategic communications:
It means infusing communications efforts with an agenda and a master plan. Typically, that master plan involves promoting the brand of an organization, urging people to do specific actions, or advocating particular legislation.
CHAPTER 1: INTRODUCTION
Sexual behaviour is a major determinant of sexual and reproductive health. Population patterns of sexual behaviour are major determinants of sexually infected infections and HIV transmission and other sexual health outcomes (Johnson, et al., 2001). Yet the term "sexual behaviour" sounds so familiar and is widely used that it may be hard to imagine when it was unknown. After all human race has always consisted of two sexes and these have always felt drawn to each other. Men and women (heterosexual); in most cases but also men and men (homosexual); women and women (lesbians) or those attracted to both sexes (bisexual) have always engaged in intimate relations. We can indeed assume that most of them knew or rather know what they are doing and thus when we talk about sexual behaviour, we seem to be talking about a simple and universal concept as old as mankind itself as the Hirschfield Archive for Sexology, (2012) puts it.
Sexual behaviour refers to any behaviour that involves the body's sexual response or psychoanalysis. For the purpose of this dissertation, we shall refer to sexual behaviour as having sex as involving penile-vaginal and penile-anal intercourse (Pitts & Rahman ; 2001). For every sexual act therefore, there is a level of risk depending on the two people involved in a sexual act. "Number of sexual partners and condom use are both behaviours linked to acquisition of STIs" (Evans, et al., 1999 p.747). It was suggested by Kesby, et al., (2003) how sexual behaviour is different among different ethnic minorities and socially acceptable for African men to continuously or at some time have multiple partners (Anon., n.d.). Kesby et al (2003) their article, continue to argue how African men preferred to have sex within relationships (p 1577) and that they often began sexual activity in relationships before trust had been established or intimate discussions about risk commenced. Tendency to reduce condom use as the duration and intimacy of relationships increased and fidelity trust and stable relationships as the preferred model for sexual relationships than health yet with even with good knowledge of HIV, there was inconsistent safe sex behaviours. Seemingly people from a diversity of ethnic groups would rather ignore health risks than jeopardise a partner's trust by discussing safety or by questioning their fidelity. Some of the contributing factors to the frequency of HIV infection between population subgroups included sexual behaviour, background prevalence of untreated disease, and health-seeking behaviour-especially for HIV treatment and screening services. (Fenton, et al., 2005)
Similarly, migrant African men, meanwhile, may not wish to lose valued partners by being entirely open about the risk presented by, their multiple partnering behaviour (Kesby, et al., 2003). If we closely examine the abovementioned behaviours, the notion of risk is evident!
Understanding the definition and meaning of the word ''sex'' has implications for sexual medicine, Human Immune Virus/ Acquired Infection Disease Syndrome (HIV/AIDS) research, and clinical practices. And previous studies have reported variations in the definition of having ''had sex'' and the necessity of using behaviourally specific terminology when taking sexual histories and assessing sexual risk.
The Centre for Disease Control and Prevention's (CDC's, 2003) guidelines for assessing risk include: whether a participant or patient has been engaging in sex; the number and HIV serostatus of sex partners; types of sexual activity; and condom usage. Given that an individual's definition of ''sex'' influences the number of reported ''sexual partners' and the frequency of reported ''sexual activity,'' it is crucial that researchers and clinicians minimize ambiguity and utilize behaviourally specific criteria when making sexually transmitted infection (STI) and HIV/AIDS risk assessments (Hill, et al., 2010). Arguably, HIV infection is controlled by antiretroviral (ARV) drugs.
"Not surprisingly, nearly half of the Africans reported risk of HIV infection by heterosexual intercourse with an African" (Evans, et al., 1999 p.747). Risk of HIV infection with a fellow black person showed increased risk with a significant P Value <0.00001; meaning that having sex with a fellow black person had an increased risk of HIV acquisition.
Risk was classified in two categories; High risk and Risk. While high risk is explored by Sadler, et al., (2007) and Fenton, et al., (2005), risk which comes below high risk is discussed in Evans, et al., (1997a); Evans, et al., (1999b) and Fenton, et al., (2005). High risk behaviours included a higher proportion of black African men who reported having at least one new heterosexual partner in the past year and reported new sexual partnerships outside the UK in the past 5 years compared to all other groups: an indication of migration of these communities (Evans, et al., 1997a & Fenton, et al., 2005). Any such risk with an infected person would lead to progression the need to access ARV's in order to maintain good health. Effectiveness of ARVs' has other confounding factors which for the purpose of this dissertation, we will not address in detail.
However, despite current treatment advances with ARV drugs, there is still no cure for HIV since its discovery, three decades ago. HIV is a retrovirus that infects cells of the immune system, destroying or impairing their function. As the infection progresses, the immune system becomes weaker, and the person becomes more susceptible to infections. HIV is transmitted through unprotected sexual intercourse (anal or vaginal), transfusion of contaminated blood, sharing contaminated needles and between a mother and her infant during pregnancy, childbirth and breastfeeding (WHO, 2012).
The number of people living with HIV continues to rise despite existing strategies (UNAIDS, 2010). By the end of 2010, there was an estimated 34 million people living with HIV worldwide, with an increasing trend by 17% from 2001. HIV is an epidemic that remains extremely dynamic, growing and changing character as the virus exploits new opportunities for transmission. The epidemic is not homogeneous with regions; some countries are more affected than others. For now, the Sub-Saharan Africa remains the most hit by the pandemic. In the UK, individuals born in sub-Saharan Africa currently bear the brunt of the heterosexual HIV epidemic. The study by Sadler, et al., (2007) confirms relatively high HIV prevalence among black Africans, many of whom have migrated from high-prevalence areas of sub-Saharan Africa, and yet are often unaware of their HIV serostatus.
The ability to monitor levels of high-risk sexual behaviour and to measure its association with diagnosed and undiagnosed HIV infection is an integral part of improving the delivery and quality of evidence-based HIV prevention interventions within the black African community (Sadler, et al., 2007).
HPA (2009) estimated that there were 83,000 persons living with HIV in the United Kingdom (UK) in 2008 equivalent to 1.3 per 1,000 populations in the (UK) (1.8 per 1,000 men and 0.88 per 1,000 women) with London remaining the centre of the UK HIV epidemic. By the end of 2010, an estimated 91,500 (85,400-99,000) people were living with HIV in the UK, of whom 24% (19%-30%) remained undiagnosed and were therefore unaware of their infection (HPA, 2011).
The 2001 Census established that there were just over 480,000 people in England who described themselves as black African. This represents just 0.97% of the population. Notably, over three- quarters of African people in England live in Greater London, with the highest numbers living in the inner London boroughs accounting for 8.3% of the population (DOH, 2005). HIV prevalence in black Africans in England is estimated to be 3.7%, compared to 0.09% among the white population with African men being underrepresented due to underreporting rather than a true difference (HPA, 2008; DOH, 2005).
Indeed, HIV remains one of the most communicable diseases in the UK. It is an infection associated with serious morbidity and high costs of treatment and care, with significant mortality. The infection is still frequently regarded as stigmatizing and has prolonged 'silent' period which if a test is not done, often remains undiagnosed.
The success of HIV treatment delaying AIDS may be causing complacency among those infected. New research should therefore seek to determine underlying social causation more than just extend to limited descriptive observable patterns in sexual health. Both methodological and ontological shifts are necessary in the existing pattern. Subsequently African sexual behaviours and nature of sexual decision-making need to further be investigated.
Kesby, et al., (2003), further suggest that it would then be possible to address the crucial question of whether "the social conditions known to cause high risk behaviours and facilitate HIV infection in black Africans". This is a key and neglected dimension in the role of relational sexual decision-making and social relationships. Furthermore issues like domestic violence, gender identities and knowledge about sex in African communities need to be further investigated. "Researchers should therefore seek ways to work with; not on: African communities, in order to facilitate their own informed management of sexual health" (Kesby, et al., 2003 p. 1573).
Findings by Sadler, et al., (2007) suggest targeted prevention strategies aimed at intensifying efforts to promote repeat HIV testing and collection of test results, while other studies have confirmed the delays in healthcare access and late diagnosis of HIV infection among Africans in Britain.
Estimates of the total number of prevalent HIV infections attributable to the major routes of infection make an important contribution to Public Health Policy, as they are used for planning services (NATSAL, 2000). Promotion of safer sex practices including the use of condoms is a global health priority in reducing many sexually transmitted infections (STI) including HIV (Scriven & Garman, 2005). Although scientific breakthroughs have provided better resources for clinical programmes to prevent HIV transmission and manage HIV pathology, the principal means of deterring further spread of HIV remains behavioural prevention interventions (UNAIDS, 2001; Dodds, 2011). Current limited approaches to behavioural interventions result in ineffective clinical intervention and less targeted use of resources for HIV transmission, a case in point being the relationship between sexual attitudes and HIV prevention.
Dodds, (2010 a) argues that change in attitude requires understanding which helps both partners to be safer and not a reason for distrust. Behavioural interventions namely; abstinence, delayed sexual debut, reduced number of sexual partners, routine condom use, and reduced needle sharing or clean needle use among injecting drug users as highlighted by Myron, et al., (2008) were the first prevention methods to be broadly implemented. Since then new biological interventions have been introduced for example; male circumcision, treatment of other STIs and use of Highly Active Anti-retroviral Therapy (HAART). There is also hope in future vaccines and microbicides. Microbicides are agents that kill microbes, minute forms of life (e.g. bacteria, fungi, and protozoal parasites), some capable of causing human disease (Medicine Net, 2012).
The new vision intended to be fulfilled the joint United Nations Programme on HIV/AIDS (UNAIDS) of zero new infections will require a hard look at the societal structures, beliefs and values systems that present obstacles to effective HIV prevention efforts. Poverty, gender inequality, inequality in health and the education system, discrimination against marginalized people and equal resource pathways all affect the HIV response. In a world that has had to learn to live with an evolving and seemingly unstoppable epidemic over the course of three decades, AIDs-related deaths pose a challenge (UNAIDS 2011).
UNAIDS (2011) confirms how positive behaviour change is able to alter the course of the epidemic and reduce new infections. Involving men therefore in approaches that transform gender roles is vital in fostering constructive roles for men in sexual and reproductive health.
London, as a global city, has a unique set of urban characteristics which create an impact upon a number of factors including the sexual health of its residents. Some of the factors include: social inequality, migration, changing patterns of social and sexual change (REF)
Data from (Natsal 2000) to investigate the frequency of high-risk sexual behaviours and adverse sexual health outcomes in five ethnic groups in Great Britain was investigated. A stratified probability sample survey of 11 161 individuals was done. Findings showed a major public concern in the UK as being the variations of spread of sexually transmitted infections including HIV with consistent information across settings and over time, showing higher prevalence in black ethnic groups. There were more black African single men living in London (Fenton, et al., 2005, p.1247) of 68.5 % with a significant P value <0.0001.
Rationale, Aim and Objectives
Rationale
Since HIV is a behaviourally driven infection, the need for understanding sexual risk behaviour is an essential tool for developing strategies and interventions in order to reduce HIV prevalence in black-African men. In addition to this, there is also a gap in existing research that has solely been done on sexual behaviour and attitudes of African men in London. While most of the research has been done on men who have sex with men, there is currently limited literature focusing solely on black African men and thus the need for further research.
Aim
To investigate sexual behaviour and risk of HIV transmission in black African male in London.
Objectives
To analyse the epidemiology of HIV in London
To identify different sexual behaviours and risk factors
To analyse the link between sexual behaviour and HIV transmission
To identify factors which can be used to propose high impact interventions for HIV prevention.
1.2 Methodology &Search Strategy
While methodology refers to the approach to the whole research process; including data, information collection, management, presentation and analysis, explaining the research paradigm or methodological approach chosen; search strategy (methods) on the other hand involves precise tools and instruments used in data collection and analysis. Both answer how the study is going to be done. It is therefore more applicable to talk about search strategy rather than methods when doing secondary data analysis. The research employed was desk-top orientated. The goal for choice of qualitative research was to develop theory using data synthesis and abstraction. The author used this inquiry in order to identify patterns and concepts, identifying concepts and creating theoretical explanations explaining reality (Morse & Field, 1995). For validity purposes, the researcher gathered reliable data on sexual behaviour and risk of HIV transmission among black-Africans in London. However, attitudes and behaviour cannot be quantified; they are subjective and not objective. They depend on individuals feelings so cannot be quantified. Nonetheless, quantitative techniques were used to express facts and figures on HIV epidemiology.
In depth review of available literature was researched. It was a desk top research using the university library and access to e-journals. Search strategy involved data mining, scoping and scanning of various data sources including; University Library, Hospital Reports, Online Databases and Statistics Archives; for instance publications like: Medline, PubMed, PsycARTICLES, PsycINFO, SocINDEX, DOH, WHO, HPA, UNAIDS, MRC, SIGMA Research, HPN, NATSAL, PADARE, MAYISHA 1 & 11 , University databases, Global Health and other related websites. Secondary data analysis is data analysis which was collected previously for other purposes (California State University Long Beach, 2012). This is because the data is unobtrusive and less expensive than gathering new data. It may allow for larger scale studies on a small budget and does not exhaust one's good will by re-collecting readily available data (California State University Long Beach, 2012). The resources were suitable because data available focused on the black-African males and included reports by the global HIV Practioners, leading academic institutions and organisations at the forefront of control of HIV in the African communities. An audit trail was followed to document all the steps taken for the generation of data. Key search questions were identified by defining the focus of the review; and guidelines for literature review were set. Original questions were used to search for literature covering the topic and the research question.
My research methodology requires gathering relevant data from the specified sources namely; SIGMA, NATSAL and Mayisha Studies in order to analyse material and arrive at a better understanding of sexual behaviour related to high impact intervention on HIV prevention in an ethnic community. The research question formulated was: "What are the common factors of high risk behaviour in black-African male in London and how do they influence high impact interventions in the prevention of HIV transmission? This was based on the hypothesis; "Factors of sexual behaviour can predict high risk of HIV transmission in black-African male communities and the same factors can influence behavioural change by high impact intervention in prevention of HIV.
Table 1: Exposure Variables of Interest
Exposure measurements
Variables/Factors
Sources
Demographics
Age; Sex; Education; Marital or live-in status
Mayisha study
Sigma study
Sexual Behavior
No. new partners in past 12 months
Mayisha study
Sigma study
Gender of sex partners in past 12 months
Mayisha study
STI clinic attendance*
Mayisha study
STI diagnosis*
Mayisha study
Ever had an HIV test*
Mayisha study
Last HIV test result*
Mayisha study
Current perceived HIV status*
Mayisha study
Regular sexual partners and extra relational sex
Sigma study
Likelihood of sero-discordant unprotected intercourse
Sigma study
Condom use
Sigma study
Experience of condom failure
Sigma study
*Not investigated in this dissertation
Source: (Sadler, et al., 2007) ; (Hickson et al., 2009)
Literature from 1999-2012 was used since this is the period with significant HIV incidence in black-African heterosexual male in London. The search strategy initially included the following words: following words: Sexual behaviour, HIV/AIDS, Black African men, Infection Risk and London .The search came up with over 100 articles. Search words were then refined to: Sexual behaviour, HIV, Black male, African, Risk and London. The search came up with 62 articles. The author then "scheme read" the 62 and choose the top 10 and later narrowed it to 5 to form a bibliography. The top 5 articles were critically analysed and formed the basis of the research question formulation and presentation of chapter 1. It is needless to say that, all the 62 articles plus others relevant articles will form part of the references.
Inclusion criteria consisted of literature from; 1999-2012, studies in English, studies conducted in England, studied relating to sexual attitudes and risk of HIV transmission and both published and unpublished data.
Exclusion criteria consisted of: Literature before 1999, studies published in other languages, studies conducted elsewhere other than in the UK, studies relating to other behaviours and personal stories.
However, it was not necessary to seek ethical approval for this particular research since this was not empirical and not directly dealing with individuals. This was so because there weren't any issues of confidentiality as it didn't involve primary research or the use of humans. However, only studies that had previously sought appropriate ethical approval, where necessary were included in the review. Otherwise any researcher should appreciate through reflection that our actions when doing research can have an ethical dimension. It may be that the outcome of decisions some researchers have made about their ethical stance may have resulted in studies which are "authentic" in that they are rich in detail but which would have otherwise been difficult to obtain had they taken a different stance (Hart, 2006).
1.3 Limitations
The author will not be investigating testing behaviour and non-sexual behaviour factors like STI clinic attendance, STI diagnosis, ever had an HIV test, last HIV test result and current perceived HIV status (Table 1). I will not investigate testing behaviour and non sexual behaviour factors like STI clinic attendance, STI diagnosis, ever had an HIV test, last HIV test result and current perceived HIV status. In addition, like with any scientific inquiry and social research, limitations are bound to be encountered. In this case primary data collection was not possible due time and financial restrictions. There was therefore need for ample time for appropriate data collection to minimize bias and correct responses. Consequently, this investigation was limited to secondary analysis of data already published and literature review. Investigating sexual attitudes is also a very sensitive issue because it deals with the individual's sexual life which is a private matter whereby not everybody feels comfortable talking about what happens to them "behind their closet".
Additionally, instruments or data collection methods may have changed over time leading to results not really "tallying" to current situation. The author also experienced limited access to data available (California State University Long Beach, 2012) on black-African male in London so had to sometimes refer to the UK.
CHAPTER 2: EPIDEMIOLOGY OF HIV IN AFRICAN MALE IN LONDON
According to Fenton & Lowndes, (2004) "Sexual behaviour is, nonetheless, the key determinant of STI transmission and EU-wide changes in the pattern distribution of high risk sexual behaviour are undeniably contributing to the changing disease epidemiology". Furthermore, AIDS is not a simple disease because it's a pandemic which means a world's epidemic. According to data from the Joint United Nations Program of HIV/AIDS (UNAIDS) and the World Health Organization (WHO), (WHO, 2011a) towards the end of 2010, there were 34.0 million adults and children living with HIV infection. This total does not include the 1.8 million individuals around the world who have already died of AIDS. Of the 34.0 million currently alive, 30.1 million are adults, 16.8 million are women, and 3.4 million are children (< 5 years). The majority rising to almost three quarters of HIV cases globally are from Sub-Saharan Africa. The number of people living with the HIV (PLWH) in 2010 is estimated at 34 million; an increase of 17 % compared with 2001. This is due to the significant expansion of access to antiretroviral treatments (ART) which contributes to reduced deaths linked to AIDS. Nevertheless, there was a decline of 21 % in infection rate between 1997 and 2010. Indeed, the number of people who died from AIDS fell by 1.8 million in 2010; compared to 2.2 million in the middle of 2000 (2004-2006). All in all, 2.5 million deaths were avoided since 1995 due to HAART introduction. The biggest part of this success was registered these last three years due to the fast advancement of access to HAART. In 2010, 700,000 deaths due to HIV infection were avoided. However, progress remains slow and number of new infections continues to exceed the number of people on treatment. Undoubtedly, great majority of the infections due to the HIV has been evident in developing countries, in particular sub-Saharan Africa.
According UNAIDS (2011), the total number of people infected with HIV in North America and Western and Central Europe rose from an estimated 1.8 million to 2.3 million in 2001 and 2009 respectively by 30%. In these regions, HIV transmission through unprotected sex between men continues to lead its pattern.
2.1 Setting the scene
Lyles, et al., (2006) argues that "knowing your epidemic" alone is not enough to act upon it. Failure to appreciate political dimensions of HIV can frustrate efforts to promote and implement evidence-informed policy. For a better understanding of the situation of black-African male in London it's better to begin by the epidemiology of the countries where they are born.
In Sub-Saharan Africa, HIV prevalence in West and Central Africa remains comparatively low, with the adult HIV prevalence estimated at 2% or under in 12 countries in 2009 (Mali, Democratic Republic of the Congo, Gambia, Benin, Burkina Faso, Ghana, Guinea, Liberia, Mauritania, Niger, Senegal, and Sierra Leone). Prevalence of HIV is highest in Cameroon at 5.3%, Central African Republic 4.7%, Ivory Coast 3.4%, Gabon 5.2%, and Nigeria 3.6%. However, East and Southern Africa remain the most heavily affected by the HIV epidemic (UNAIDS, 2011).
In 2010, about 68 % of all People Living with HIV/AIDS (PLWH) were from sub-Saharan Africa, a region which represents only 12 % of the world population. Sub-Saharan Africa represented the 70 % of new infections in 2010, although there was a recorded considerable reduction in this rate in this continent; the total number of new infections in sub-Saharan Africa was 1.9 million in 2010 compared to 2.6 million in 1997. This fall, more than 27 %, interests some of the countries the most affected by the epidemic, such as South Africa, Ethiopia, Nigeria, Zambia, Zimbabwe. In sub-Saharan Africa there are were important variations of prevalence of HIV in the above named regions, but no country knew exactly why there was such an increase in the incidence of HIV/AIDS in 2010. (UNAIDS, 2011)
Southern Africa is the fragment of the continent which is most affected. HIV prevalence remains high. The annual incidence in South Africa, although still high, fell by a third between 2001 and 2009, falling from 2.4 % to 1.5 %. In addition, the epidemic in Botswana, Namibia and Zambia seems to decline, whereas in Lesotho, the epidemic in Mozambique and Swaziland seems to stabilize although prevalence remains high. It is known that the highest prevalence in the world was 25.9 % in Swaziland in 2009: with South Africa having the highest number of people infected (5.6 million). East Africa, a region first affected by the epidemic, prevalence is currently stable (between 7 % in Uganda and 3 % in Rwanda). In western Africa, prevalence is also stable, but there are important differences as for the extent of the epidemic (1 % in most of the countries, between 3 and 4 % in Ivory Coast and in Nigeria) (UNAIDS, 2011).
Anglewicz, (2012) undermines the position that it has long been accepted that population mobility played an important role in the spread of HIV throughout sub-Saharan Africa and in Western Europe. He shows the relationship between migration and HIV infection in sub-Saharan Africa because migrants at higher risk of HIV infection are more likely to engage in HIV risk behaviours than non migrants, and they tend to move to areas with a relatively higher HIV prevalence. The increased HIV risk among migrants may be due to the selection of HIV-positive individuals into migration. He found that HIV-positive individuals are more likely to migrate than those who are HIV negative and the explanation appears to be marital instability, which occurs more frequently among HIV-positive individuals and leads to migration after marital change.
In the same way, "Mobility and population migration are important human processes affecting a broad range of social outcomes" and it is a key driver of the HIV epidemic, both linking geographically separate epidemics and intensifying transmission through inducing riskier sexual behaviours. (Deane et al., 2010, p.458).
2.1 Analysis of the Health Protection Agency Data 2011
The Health Protection Agency (HPA) is an independent UK organisation was set up by the government in 2003 to protect the public from threats to their health from infectious diseases and environmental hazards. From April 2013 the HPA will become part of Public Health England. This Agency puts public health and scientific knowledge, research and emergency planning within one organisation. It works at all levels: internationally, nationally, regionally and locally. HPA monitors data on all populations in UK including migrants. However, the analysis of this data for minority groups is not its high priority! One of the problems is a gap in the information available for the minority groups. In fact, there isn't sufficient information available for populations with high prevalence rate (HPA, 2005).
Reporting system
The Health Protection Agency has developed a new reporting system, the HIV and AIDS Reporting System (HARS) that will underpin national HIV surveillance. This will replace current HIV surveillance systems including the new HIV and AIDS diagnoses and death surveillance and the Survey of Prevalent HIV Infections Diagnosed (SOPHID) and new HIV diagnoses. HARS has been designed to fulfil five main aims namely; reduce the reporting burden for reporting sites, increase efficiency of HIV surveillance, enhance standard HIV surveillance outputs, produce quality of care indicators and directly support commissioning services (HPA, 2012).
The HARS dataset will be attendance based, disaggregate and submitted on a quarterly basis. The dataset has been modelled against the NHS data model and dictionary (to ensure data are consistently reported across the NHS) and will flow via an XML Schema. XML is a compulsory component of all new NHS datasets and improves data quality. Like previous standards, the dataset will be submitted through the HPA secure web portal (HPA, 2012).
"The dataset itself contains 61 variables. The majority of these fields have been collected electronically through SOPHID and the new HIV and AIDS diagnoses and deaths for many years". Some additional fields have been included to directly inform the commissioning of services. The inclusion of fields to support commissioning within a public health data eliminates the need to create a separate flow of data for commissioning (HPA, 2012).
2.2.2 Trend of HIV Testing in UK
Towards the end of of 2010, an estimated 91,500 (95% confidence interval [C.I.] 85,400-99,000) people were living with HIV (PLWH) in the UK; about one quarter (22,200, 24% [19%-30%]) of whom were unaware of their infection (i.e. undiagnosed) (Figure 2). In 2009 the number was 86,500 PLWA. Over 90% of these were heterosexually acquired HIV infections diagnosed in the UK; probably acquired in high prevalence countries of origin, mainly sub- Saharan Africa, with 38% acquired uptake in Zimbabwe. By the end of 2012 the number of people infected with HIV in the UK is projected at 100 000 (HPA, 2011)
According HPA (2011), there was an estimated 47,000 (43,900-50,400) heterosexuals were infected with HIV, roughly 19,300 (17,700-21,100) were African-born women and 9,900 (8,800-11,300) were African-born men. One in three heterosexuals living with HIV were born in the UK or countries other than Africa (8,800 [8,100-9,700] women and 8,900 [8,000-10,300] men) (2011). These statics are alarming such that if nothing is done to improve prevention programmes for people from these communities, a public health problem is bound to arise. Amongst heterosexuals, men were less likely to be aware of their HIV infection with 28% (22%-35%) undiagnosed. While the problem of low rates of undiagnosed HIV infection in women is revealed, the place of men in success of prevention of mother-to-child transmission (PMTCT) is real by the implication of couple in health services. The proportion of those diagnosed late was the highest among black African men (66%) and black African women (61%), followed by black Caribbean women (59%) and black Caribbean men (47%).
Thus, current qualitative data has shown that among migrant African communities fears of an HIV diagnosis and HIV-related stigma and discrimination are key factors among those reluctant to access voluntary confidential testing for HIV. This is a result of the fact that the prevalence of previously undiagnosed HIV infection was 2.7% among sub-Saharan African heterosexuals attending sentinel GUM clinics in London during 2004, and 7.1% elsewhere in England, Wales and Northern Ireland.
Table 2: HIV test coverage of STI clinic attendees not known to be HIV positive, by sexual orientation and heterosexual ethnicity: England, 2010
Population
Number of people attending STI clinics
Number of people offered an HIV test
Number of people tested
HIV test coverage % (tested/attending)
MSM
62,995
55,656
51,587
82%
Heterosexual Man
Black African
16,936
15,218
13,363
79%
Black Caribbean
16,747
15,159
12,459
74%
White
306,336
273,122
219,379
72%
Other ethnicities
44,317
39,326
33,646
76%
Women
Black African
24,924
20,170
17,187
69%
Black Caribbean
26,273
22,833
18,929
72%
White
456,697
386,967
298,660
65%
Other ethnicities
66,522
56,183
45,988
69%
Not Known1
166,265
135,914
114,038
69%
Total
1,188,012
1,020,548
825,236
69%
1 Includes people where any of the following variables are not known: ethnicity, sexual orientation, gender, or area of residence
Source: HPA report, 2011
Table 3: Estimated number of people living with HIV (both diagnosed and undiagnosed): United Kingdom, 2010
Exposure group
Number diagnosed
(credible interval)
Number undiagnosed
(credible interval)
Total
(credible interval)
% Undiagnosed
(credible interval)
Men who have sex with men
29,900
(29,200, 30,550)
10,300
(5,500, 16,800)
40,100
(35,300, 46,700)
26%
(16, 36%)
People who inject drugs
1,800
(1,600, 2,000)
500
(200, 800)
2,300
(1,900, 2,700)
22%
(12, 32%)
Heterosexuals
35,600
(34,800, 36,500)
11,400
(8,400, 14,800)
47,000
(43,900, 50,400)
24%
(19, 29%)
Men
13,500
(13,200, 13,900)
5,300
(3,900, 7,200)
18,900
(17,400, 20,700)
African born
7,300
(7,100, 7,500)
2,600
(1,500, 4,000)
9,900
(8,800, 11,300)
Non-African born
6,200
(6,000, 6,400)
2,700
(1,800, 4,100)
8,900
(8,000, 10,300)
Women
22,100
(21,500, 22,700)
6,000
(4,300, 7,900)
28,100
(26,400, 30,100)
African born
15,400
(15,000, 16,000)
3,900
(2,300, 5,600)
19,300
(17,700, 21,100)
Non-African born
6,700
(6,500, 6,900)
2,100
(1,500, 3,000)
8,800
(8,100, 9,700)
Grand total
69,400
(67,800, 70,800)
22,200
(16,300, 29,600)
91,500
(85,399, 99,000)
24%
(19, 30%)
1 Includes people where any of the following variables are not known: ethnicity, sexual orientation, gender, or area of residence
Source: HPA report, 2011
Trend of HIV positive black African male in London
Roughly, the estimated prevalence of HIV in the UK (2010) , was 1.5 per 1,000 (1.4 - 1.6) overall with (2.0 per 1,000 [1.8 - 2.2] men and 0.9 per 1,000 [0.9 - 1.0] women). Black-African men and women living in the UK were found to have a high HIV prevalence, at 47 per 1,000 populations (England and Wales only). Among black-African men, prevalence of HIV was 31 per 1,000 populations, and among black- African women it was 64 per 1,000 populations (HPA, 2009).
In 2009, HPA reported that HIV prevalence as being a major public health issue for London. Reported new HIV diagnoses in London clinics rose to 2,851 individuals. Prior to that in 2004, the government had adopted a change of migration policies. Due to the effectiveness of HIV treatment, the number of cases of AIDS or deaths in HIV infected individuals is declining. However, the number of new HIV diagnoses in 2009 was still 21% higher than in 2000. This year 47% of people diagnosed with HIV were white and 32% were black-African. It is estimated that 26% of Londoners who have HIV were unaware of their HIV status in 2009, which in return has an impact on incidence rates.
Data on main factors on Sexual Behaviour
Monitoring of high risk sexual behaviours can help to evaluate the effectiveness of public health and HIV prevention programmes. Data from research studies and surveillance activities have provided insights into the behaviour of the general public and of specific communities at risk, although there are difficulties in safeguarding that those surveyed are characteristic and comparable over time. In 2010, behavioural surveys indicate that 37 to 50% MSM report having a test in the last 12 months, and 38% of black Africans have never tested and have a late test. (HPA, 2011)
CHAPTER 3: SEXUAL BEHAVIOUR IN AFRICAN MALE
Sexual behaviour in black-African male can have various connotations in the African community. Over a period of time, researchers into sexually transmitted diseases (STD) have been trying to measure sexual behaviour (Aral, 2004). Following the emergence of the HIV pandemic in the 1980s and 1990s, the focus on sexual measurement intensified. Researchers attempted to measure sexual behaviour in a wide variety of contexts for various purposes, often without explicit attention to the impact of context and purpose on measurement. Dodds, (2010a) argues that change in attitude requires understanding which in turn helps both partners to be safer and not a reason for distrust. The UK HIV/AIDS epidemic is dynamic and reflects global trends. As we move into the third decade of the HIV/AIDS epidemic, its end will depend upon local as well as external factors.
Previous researchers have criticised the use of ethnicity in epidemiological studies of sexual behaviour (Bhopal, 1997; MacKenzie & Crowfort, 1996) because the term "Africans" includes diverse nationalities, cultures, and ethnic communities. Such ethnic subgroups may show as much or even more diversity among them than exists between nation states.
In the United Kingdom (UK) there are two major bodies that have predominantly done research on sexual behaviour and attitudes. They are called NATSAL and Mayisha.
The National Survey of Sexual attitudes (NATSAL 2000) by Johnson, et al., (2001) argues that population patterns of sexual behaviour are major determinants of conception rates, sexually transmitted infections (STI) and HIV transmission, and other sexual health outcomes. NATSAL have gathered data on sexual behaviour, fertility, contraceptive use and sex related diseases across UK. The first NATSAL 1990 was funded by the Wellcome Trust and the second study NATSAL 2000 was carried out with the Medical Research Council (MRC) funding. The third NATSAL 2010 will be published in 2013. It includes a survey of sexual attitudes and lifestyles, from a probability sample of 15,000 men and women aged 16-74years and resident in Britain. It will be done using computer-assisted interview techniques. The study design will be based on methods published in 1990 and 2000 to ensure comparability, however there are several innovations for NATSAL 2010 including: an extended age range; enhanced biological measures ( STI's and sex hormones); additional questions exploring new areas; a qualitative component and methodological advances (NATSAL, 2010).
Mayisha is a name derived from the Swahili term maisha meaning lifestyles or behaviour. Mayisha study aimed to determine the feasibility and acceptability of actively involving a number of London's at-risk migrant African communities (Fenton, et al., 2002c). The Mayisha study was conducted in 1999 followed by the second one in 2005. Behavioural characteristics included number of sexual partners in the last year and condom use. Mayisha 11 is one of the largest community recruited samples of black African in Britain and for the first time community sexual health survey and HIV seroprevalence data on black-Africans resident in and out of London has been collected (Sadler, et al., 2007).
Kesby, et al., (2003), found evidence to suggest that sexual behaviour in black African male varied among different ethnic minorities. Similar findings have been supported by Evans, et al.,(1997a); Evans, et al., (1999b); Fenton, et al., (2001b) (Fenton, et al., 2002c); Fenton, et al., 2005d); Sadler, et al.,( 2007) ;Scott & Njaka, (2010). Most importantly as previously stated in chapter one, hidden behind any sexual behaviour, there is an element of risk. Sexual behaviour in African male in London was classified in two groups namely risk behaviour and high risk behaviour. African sexual behaviours and nature of sexual decision-making need to further be investigated. It would then be possible to address the crucial question of whether "the social conditions known to cause high risk behaviours and facilitate HIV infection in black Africans". A key and neglected dimension is the role of relational sexual decision-making and social relationships (Kesby, et al., 2003). Possible need for researchers to address the crucial question of whether the social conditions known to cause high-risk behaviours that facilitate transmission in black African male persist, or are transformed, after migration to the UK.
There was significant differences in sexual behaviour between cultural groups, researchers need to illuminate their significance for HIV related risk. The question is: what are the regionally/culturally specific factors that place Africans at a greater risk of HIV infection and how do these change after migration? Previous studies done on black men and white men ignoring possible ethnic differences within racial groups have found that racial differences affect sexual behaviour and HIV infection. (Evans, et al., 1999b)
A growing body of evidence points to the complexity of sexual behaviour and HIV risk behaviour is influenced by factors at three levels: within the person, within the proximal context (interpersonal relationships and physical and organisational environment) and within the distal context (culture and structural factors) (Kesby, et al., 2003 &Fenton, et al., 2005d).
3.1 FINDINGS FROM LITTERATURE REVIEW
It was suggested in the last chapters that there is a supposed link between sexual behaviour and risk of HIV transmission among black-African male. The author will be referring to the Health Belief Model (HBM), first developed by Rosenstock, (1974).
This model was developed out of dissatisfaction with informational approach. It focuses on attitudes and beliefs of individuals and proposes that an individual will take a health-related action such as condom use for example if certain conditions are met. It is based on the theory that individuals make an analysis of the perceived threats and net benefits of their behaviour. The theory suggests that when deciding whether to use condoms, an individual makes an appraisal of for example; how likely they feel it is that they will catch an STI, how threatening they find the idea if getting an STI, how effective they think using condoms will be preventing STI's, or worse still concerns about using condoms, such as feeling too embarrassed to talk to their partners about it! All these notions bear a burden of risk which can be classified either risky or very risky. Sexual behavioural factors included increased sexual activity with new partners, practice of high risk behaviours for example …., unprotected intercourse (non-condom use). REF
NASTAL 2000 was a probability sample of men and women aged 16-44 years resident in Britain computer-assisted interviews. Population patterns of sexual behaviour are major determinants of conception rates, STI's, and HIV transmission. Probability sample surveys made a major contribution to understanding the diversity of human sexual behaviour (Johnson, et al., 2001).
Results have been widely used to model the extent of the HIV epidemic and plan sexual health services and preventative interventions in Britain. Altogether there were 11,161 respondents (4762, men and 6399 women). Stratified sample of addresses was selected using post code addresses with focus on where prevalence was expected to be higher. Participants developed a questionnaire for combination of face to face computer- assisted personal interviews which were carried out by trained interviewers, and computer-assisted self- interview (CASI) (Johnson, et al., 2001).
Surveillance data indicate higher STI incidence rates in 2000 than 1990 suggesting that sexual behaviours may have changed over time. Advances in understanding transmission dynamics of STI's have created demands for population estimates of new variables such as prevalence of monogamy and concurrency, social and sexual mixing including age, ethnicity and location and rates of partner acquisition. Methodology was improved to provide update estimates and to assess changes in reported sexual behaviour over time.
Data was weighed to adjust for the unequal probabilities of selection. To correct for differences in gender and age group, the study used a non-response post-stratification weight. Comparison with the 1998 Health Survey of England showed that after application of the final weights, there were no major differences in sample structure by marital status, social class and proportion of households with children (Johnson, et al., 2001).
Statistical analysis using complex survey functions of STATA (version 6) which incorporated the weighing, clustering, and stratification of data was used. The odds ratio (OR) was used to compare estimates between the 1990 and 2000 surveys. Logistic regression to calculate adjusted ORs to control for any variation in age, gender, and marital status distribution between the two surveys were used. Consideration of variability by ethnicity was not considered due to the fact that the proportion of respondents from minority ethnic groups was too small for reliable analysis (8.8%). The study is currently undertaking a focused study among Britain's different ethnic minorities to address the above question.
Fenton, et al., (2005) and Johnson, et al., (2001) in their studies presented data of reported numbers of heterosexual partners in the last five years. There was strong association between age and new partnerships with higher proportion of unmarried respondents. High mean rates of new partner acquisition were evident in single or previously married respondents (81%) (Johnson,et al., 2001).
Table 4: HIV prevalence and associations with characteristics of male participants of Mayisha study
Males
Variable
HIV prevalence % (95% CI)
OR (95% CI)
Adjusted OR (95% CI)_
Base
All respondents
13.1 (10.2 to 16.3)
-
-
513
Area
p = 0.07
p = 0.58
London
12.6 (9.3 to 16.6)
1
1
342
Luton
9.0 (4.2 to 16.4)
0.7 (0.3 to 1.5)
0.6 (0.2 to 2.1)
100
West Midlands
21.1 (12.3 to 32.4)
1.9 (1.0 to 3.6)
0.5 (0.1 to 2.3)
71
Age group
p = 0.02
p = 0.43
Under
8.1 (4.1 to 14.1)
1
1
135
25-29
8.8 (4.1 to 16.1)
1.1 (0.4 to 2.7)
0.9 (0.2 to 3.6)
102
30-34
14.0 (7.4 to 23.1)
1.8 (0.8 to 4.4)
2.0 (0.5 to 8.9)
86
35-39
21.1 (12.5 to 31.9)
3.0 (1.3 to 6.9)
3.6 (0.8 to 17.0)
76
40+
19.7 (11.2 to 30.9)
2.8 (1.2 to 6.5)
1.8 (0.3 to 9.5)
71
Region of birth
p,0.001
p = 0.001
Eastern Africa
21.8 (16.6 to 27.7)
1
1
225
Horn of Africa
2.7 (0.6 to 7.6)
0.1 (0.0 to 0.3)
0.0 (0.0 to 0.3)
112
Southern Africa
18.2 (5.2 to 40.3)
0.8 (0.3 to 2.5)
0.4 (0.1 to 2.7)
22
Central Africa
7.1 (1.5 to 19.5)
0.3 (0.1 to 0.9)
0.2 (0.0 to 1.5)
42
Western Africa
7.0 (2.3 to 15.7)
0.3 (0.1 to 0.7)
0.5 (0.1 to 2.0)
71
Other and outside Africa
10.7 (2.3 to 28.2)
0.4 (0.1 to 1.5)
0.4 (0.1 to 2.4)
28
Marital status
p = 0.04
p = 0.70
Married (partner abroad)
18.0 (8.6 to 31.4)
2.2 (0.9 to 5.2)
0.9 (0.2 to 4.1)
50
Married
15.9 (10.0 to 23.4)
1.9 (1.0 to 3.7)
1.0 (0.3 to 3.7)
126
Widowed/separated/divorced
31.3 (11.0 to 58.7)
4.5 (1.4 to 14.4)
1.8 (0.3 to 12.4)
16
Living with partner
18.4 (7.7 to 34.3)
2.2 (0.9 to 5.8)
1.4 (0.3 to 6.2)
38
In relationship
8.6 (3.2 to 17.7)
0.9 (0.4 to 2.4)
0.4 (0.1 to 1.8)
70
Single
9.1 (5.6 to 13.9)
1
1
208
STI clinic attendance
p,0.001
(5 years ago
21.9 (15.7 to 29.3)
2.7 (1.6 to 4.6)
-
155
.5 years ago
3.6 (0.1 to 18.3)
0.4 (0.0 to 2.7)
-
28
Never attended
9.5 (6.5 to 13.3)
1
-
315
STI diagnosis
p,0.001
p = 0.001
(5 years ago
32.2 (20.6 to 45.6)
4.6 (2.4 to 8.7)
5.4 (1.8 to 16.5)
59
. 5 years ago
22.9 (10.4 to 40.1)
2.9 (1.2 to 6.7)
6.4 (1.6 to 26.1)
35
Never STI diagnosis
9.4 (6.7 to 12.7)
1
1
405
No. new partners in past 12 months
p = 0.92
p = 0.99
0
13.0 (9.0 to 17.8)
1
1
247
1
15.3 (7.9 to 25.7)
1.2 (0.6 to 2.5)
1.1 (0.4 to 3.7)
72
2
13.0 (4.9 to 26.3)
1.0 (0.4 to 2.6)
1.4 (0.4 to 5.4)
46
3+
16.3 (6.8 to 30.7)
1.3 (0.5 to 3.2)
1.1 (0.3 to 4.4)
43
Gender of sex partners in past 12 months
p = 0.12
Homo/bisexual
22.2 (10.1 to 39.2)
2.0 (0.9 to 4.6)
-
36
Heterosexual
12.6 (9.6 to 16.1)
1
-
436
Site of recruitment
p = 0.15
p = 0.002
Social network (+weddings and christenings)
8.7 (3.8 to 16.4)
0.7 (0.3 to 1.7)
0.2 (0.1 to 0.6)
92
Churches
5.9 (0.1 to 28.7)
0.5 (0.1 to 3.7)
0.2 (0.0 to 2.6)
17
University/college
6.3 (1.8 to 15.5)
0.5 (0.2 to 1.5)
0.1 (0.0 to 0.6)
63
Pubs, restaurants, bars, nightclubs
23.8 (12.1 to 39.5)
2.3 (1.0 to 5.4)
1.3 (0.4 to 4.3)
42
Barbers, hairdressers, markets, shops
4.3 (0.1 to 21.9)
0.3 (0.0 to 2.6)
-
23
Events, concerts, football
11.8 (7.7-17.0)
1
1
204
Other
12.5 (1.6-38.3)
1.1 (0.2-5.0)
0.4 (0.0-4.8)
16
Source: (Sadler, et al., 2007 p.527)
Table 4 shows prevalence estimates for different sexual partners by gender. London had the highest HIV prevalence rates of 12.6 with Confidence Interval (CI 9.3 to 16.6). Males aged 35-39, originally from East Africa, who were either widowed or divorced, with a previous STI, and who had been recruited in pubs, restaurants, bars or nightclubs had a higher prevalence rates HIV than any other respondents. For black-Africans therefore, those variables were associated with increased prevalence rates (Sadler, et al., 2007 p 527).
Natsal 2000 provided new estimates of patterns of sexual behaviour in Britain and found wide variability in sexual lifestyles, by age, gender, relationship status, and residence. These behavioural factors are key determinants on sexual health status. Increase in mean numbers of reported partners may in part be a reflection of demographic changes in relation to marriage in the past decade, with a higher proportion of people now cohabiting rather than marrying. Cohabitation is associated with increased partner change, and our analysis suggests that patterns of cohabitation are related to the observed increases (Johnson, et al., 2001).
Mayisha II was a cross-sectional community-based survey of HIV prevalence, sexual attitudes and lifestyles among black Africans aged 16 years and over attending social and commercial venues in London, Luton and some other parts of the UK. The study areas were the sites of the largest, most diverse, and well-established African communities in the UK. The study adopted a participatory approach through the involvement of key African community-based organisations (CBOs) in all stages of the study design, development and implementation (Sadler, et al., 2007).
The survey comprised of a short (24-item) self-completion questionnaire that collected demographic, health service use, behavioural and attitudinal information from respondents. The questionnaire design, wording and response options had previously been tested and refined to ensure they were culturally appropriate. The study design, wording and response options had previously been tested and refined to ensure they were culturally appropriate (Sadler, et al., 2007). Completed questionnaires and oral fluid samples were linked by a unique bar code, sealed in a tamperproof envelope and forwarded to the research team for processing. The oral fluid samples were stored and tested at the Health Protection Agency Centre for Infections for antibodies to HIV-1 and HIV-2. (Clonesystems Detect)
HIV (protocol modified for oral fluids) and, in some cases, by Western Blot (Genelabs HIVBlot 2.2) according to a standard tested algorithm (Sadler, et al., 2007). For each prevalence, a 95% confidence interval was calculated, and Fisher's exact tests were used to detect significant differences between sub-groups. Odds ratios were used to measure the association of demographic, behavioural and service use factors with HIV prevalence. Logistic regression was used to calculate adjusted odds ratios to identify factors independently associated with HIV prevalence. All analyses were carried out using STATA version 8.2 (Stata Corporation, College Station, TX), (Sadler, et al., 2007). Uptake of HIV testing was highest in London (80.6%) among respondents who reported they had never been diagnosed as having an STI compared with those who had (77.7% cf. 67.9%, p=0.001); and among those who had previously had a negative HIV test compared with those who previously tested HIV positive with a significant P value of 0.001 (Sadler, et al., 2007). Overall HIV prevalence of 14.0% (95% CI 11.9 to 16.3; 13.1% in men varied significantly (p,0.05) by area, age group, region of birth, marital status, previous STI clinic attendance and previous STI (Sadler, et al., 2007).
Whereas black African men attending social and commercial venues reported an HIV prevalence rate of 14.0%, prevalence varied between sub-groups and was high in respondents with a previous STI diagnosis, in men born in East Africa or recruited in pubs, bars, restaurants or nightclubs and in women aged over 25 years, born in East or Southern Africa or who had had two or more new sexual partners in the past 12 months (Sadler, et al., 2007).
A key element of future analysis will be to understand the changing patterns of behaviour between the two Mayisha surveys (1999 and 2004), taking into consideration the different sample populations and locations and comparison of data derived from Natsal 2000 will also help to estimate how representative the Mayisha II findings are of the UK black African population.
3.2 ANALYSis OF SEXUAL BEHAVIOR OF AFRICAN MALE
Analysis will be done based on the most important variables discussed in the most top relevant studies done involving black-African male in London namely; sexual partners, high risk behaviour and condom use.
3.2.1 Sexual partners
The Mayisha study presented key behavioural and service use characteristics of the sample with most respondents (58.8% men) reported having had no new sexual partners in the past 12 months, with 21.3% of men reporting having had two or more and 5.8% of men reporting having only
