PrEP knowledge, attitudes and usage among Black African communities in England

There is overwhelming evidence of the effectiveness of PrEP at preventing HIV transmission. Public Health England has credited PrEP as a key factor for the dramatic drop in new HIV diagnoses in the UK, particularly among gay, bisexual and other men who have sex with men (GBM) (PHE, 2019). Recently, it was announced by the UK government that PrEP would become routinely available across England by autumn 2020.

Despite making up less than 3% of the British population, Black Africans (BA) are over-represented in the rates of new HIV diagnoses every year. The latest figures showed that they constituted 41% of all new heterosexual HIV cases (PHE, 2019). This population stands to benefit from PrEP, however, there is very limited evidence answering the following questions:

Whether Black African communities in the UK are aware of PrEP.
Whether Black African communities in the UK are willing to use PrEP.
Whether Black African communities are currently using PrEP.
Whether the current and forthcoming access options are acceptable for Black African communities.

To determine the knowledge of and attitudes towards PrEP in BA communities in England ahead of the rollout of routine commissioning of PrEP, HIV Prevention England (HPE) is currently reviewing available research and health promotion programme data, including HPE community and evaluation survey results and PHE innovation fund reports.

Key findings

PrEP Knowledge

Initial data suggests that knowledge of PrEP is very low among BA men and women particularly compared to GBM counterparts. HPE ran a small face-to-face community survey in 2019 for BA men and women where only 22% (15/68) people were aware of PrEP. An online survey that was run as part of the It Starts With Me (ISWM) 2019 campaign evaluation found also that just 53% (124/234) of BA had heard about PrEP before, compared to 84% (465/554) of GBM.

In some cases where BA have reported hearing of PrEP, individuals may conflate it with PEP (post-exposure prophylaxis) or believe it to be for GBM only. For example, 21% of people who said they knew what PrEP was in HPE’s face-to-face community survey had these misunderstandings (4/19).

PrEP attitudes

Once BA people know what it is and how it works, many say that they would be willing to take PrEP under certain circumstances. In the HPE community survey, when asked if they would be willing to take PrEP in a scenario where condoms were unavailable, 63% (43/68) said that they would in the following situations:

Where personal risk perception is high. For example, if sexual risk-taking behaviour increased or if other methods, such as condoms, were not available or individuals did not want to use them.
For protection (‘to be safe’) as a general precaution towards others’ unknown status.
Due to belief in the science, that it is effective at prevention.

At the same time, a number of BA people were hesitant to take PrEP for some of the following reasons:

Needing more information on PrEP.
Scepticism and worries regarding the evidence/science: whether they could trust messages regarding side effects and interactions, PrEP effectiveness.
A dislike of taking ‘Western’ medication unless absolutely necessary.
Finding it not personally relevant (‘I don’t do those things anymore’ or ‘I prefer condoms’).

PrEP Use

In the ISWM evaluation findings, BA men and women consistently report low condom use: only 18% used condoms ‘all the time’ or ‘often’; 77% ‘never’ or ‘sometimes’ only. Despite this, none reported using PrEP. This contrasts with GBM, where 38% of low condom use individuals reported using PrEP.

When considering data from the rest of the UK, from July 2017-June 2019, there were only 14 individuals with African ethnicity taking PrEP in Scotland (0.4% of all PrEP users) (HPS, 2019). In Wales, from July 2017-March 2019, <10 individuals taking PrEP were of Black ethnicity (<1% of all PrEP users) (PHW, 2019).

Summary

In these examples there is a low level of knowledge among Black Africans about PrEP, which is markedly different from GBM cohorts. In addition to this, people who have heard of PrEP may have misconceptions about what it means, who it is for and how to access it.

A significant proportion of BA individuals are open to taking PrEP in situations where they have the correct information about it and can recognise that they may benefit from taking it.

According to available data, extremely few Black Africans are currently using PrEP in the UK.

As England prepares for the routine commissioning of PrEP in the autumn, it is important that the issues outlined in this article are considered further and appropriate steps taken to ensure that everyone who may stand to benefit, including Black African communities, are aware of and can access PrEP appropriately.

Hepatitis C: testing in sexual health services and HIV co-infection

In May, Public Health England (PHE) published their Hepatitis C in England 2020 [PDF] report. In order to improve national surveillance of the cascade of care for the first time, PHE included data on people attending sexual health services and people who are homeless.

Of the estimated 89,000 people in England who are chronically infected with hepatitis C (HCV), many are from marginalised and underserved groups in society. It is hoped the new and updated data will help to identify where improvements can be introduced to stop people falling through the net.

Co-infection in people living with HIV can be common in certain population groups. The liver has an essential role in processing medicines used to treat HIV and other conditions. Viral infections that affect the liver, such as hepatitis A, hepatitis B and hepatitis C, can make the liver less able to process medicines properly. This is one of the reasons the British HIV Association (BHIVA) have introduced targets for the micro-elimination of HCV in people with HIV.

Testing in sexual health services (SHS)

The number of individuals tested for HCV in sexual health services shows an increase of 37.4% between 2014 and 2018.
The proportion of individuals testing anti-HCV positive (reactive or positive antibody test means you have been infected with the hepatitis C virus at some point in time) shows little change over the same time period, remaining at around 1.3% (1.2 to 1.4%).

GUMCAD data (from 2014 to 2018)

Decrease in rates of HCV diagnoses in all individuals attending specialist SHSs in England.
Among attendees of negative or unknown HIV status, rates decreased from 48 per 100,000 attendees to 21 per 100,000 attendees (fall of 56.3%).
Among HIV-positive attendees, the decrease was greater from 14 to 3 per 100,000 over the same period (fall of 78.6%)/
- The lower rates are attributed to people living with HIV (PLWH) being diagnosed with HCV in their HIV care rather than in SHS.
Compared to the overall rate in all attendees, men who have sex with men (MSM) showed elevated rates of HCV diagnoses regardless of HIV status: likely due to high-risk behaviours including higher number of condomless anal sex partners, and injecting recreational drug use.

HIV HCV PHE 2020 rates

HIV/HCV co-infection

BHIVA has targets for the micro-elimination of HCV in people with HIV: curing HCV in 80% of those co-infected by April 2019, 90% by April 2020, and 100% by April 2021.

HARS data suggests that of people with HIV accessing care in England:

0.69% (598/86,997) tested positive for either an acute or chronic HCV infection in 2017
1.47% (1,298/88,002) in 2018

In 2018 HCV prevalence highest in:

People living with HIV who inject drugs (27%)
MSM living with HIV who inject drugs (6.5%)

Lowest in:

Heterosexual men living with HIV (0.8%)
Women (0.5%)

HIV HCV PHE 2020

Impact and opportunities of COVID-19

While the COVID-19 pandemic poses a threat to HCV elimination targets, it has also presented opportunities to test and link individuals from some underserved groups into care.

Many local authorities and charities worked together during lockdown to support homeless people and rough sleepers by moving them off the streets into individual hotel rooms. This provided a unique, short-lived opportunity to reach out to this group to address some health needs while their accommodation was more secure.

In June The Martin Fisher Foundation and EmERGE M-Health Ltd launched a new partnership to provide Hepatitis and HIV testing in Brighton and Hove for approximately 200 temporarily housed rough sleepers in the city.

Working with outreach workers from Brighton & Sussex University Hospitals NHS Trust and the Terrence Higgins Trust, aided by St Mungo’s support workers, colleagues visited hotels to offer screening using a simple finger-prick test. All face-to-face interactions involved the use of personal protective equipment (PPE). The project incentivised people to test by offering them £5 food vouchers for their engagement.

107 people had been tested through the programme by 20 July 2020. Processing lab results takes some time but from the cohort of the first 25 individuals tested, five HCV infections had been identified, which is broadly in line with the anticipated HCV prevalence. There were no HIV diagnoses within the first 25 tests returned.

Normalising testing and enabling early access to treatment, which reduces onwards transmission risk of both viruses, has the potential to significantly reduce the public health impact of HIV and HCV during the next decade.

A combined method of upscaling integrated testing and exploring innovative ways to reach people most likely to be affected by HIV/HCV co-infection (as we have seen during the COVID-19 epidemic) would help to achieve this.

Time to test campaign

Test now before lockdown ends The Time to Test campaign, founded by 56 Dean Street (Chelsea and Westminster Hospitals NHS Foundation Trust), seeks to maximise the current social distancing situation to identify everyone who has undiagnosed HIV so that they can start treatment early, improve their health and prevent them from passing on HIV to anyone else.

Public Health England (PHE) and HIV Prevention England (HPE) are supporting the campaign in the following ways:

PHE opened the National Home Sampling Service via https://freetesting.hiv on Friday, 5 June 2020 and residents in all local authorities in England can now order a free self-sampling kit.
PHE has committed to supplying 7,000 free HIV tests, including syphilis opt-out testing throughout the promotional period.
PHE will also provide co-ordination and leadership of the public health system through liaison with local authorities, professional bodies and ADPH to ensure that activity is as effective as possible.
HPE will promote the campaign via It Starts With Me using PR and targeted digital promotion across England.
Promotion will be targeted to black African people and gay and bisexual men across England, with 56 Dean Street fulfilling promotion to gay and bisexual men in London.

Campaign Information Briefing [PDF]

Download social media assets (Please contact [email protected] if you are unable to access Dropbox from your workplace)

Sexual health in lockdown: experiences from 56 Dean Street

Guest blog by Dr Diarmuid Nugent, Consultant Physician, 56 Dean Street

It has been over six weeks since the UK went into lockdown to tackle the COVID-19 pandemic and the fabric of our everyday life changed beyond recognition almost overnight.

Like many other sectors, we in sexual health have had to adapt rapidly to the ‘new normal’. From the outset of the pandemic there has been no question that provision of sexual health and HIV services is vital and must continue, both for the health and well-being of those who need them, and to avoid undue pressure on other medical services like A&E and GP surgeries. Our challenge at 56 Dean Street has been to do all we can to maintain the excellent standards in the care that we provide while keeping our patients safe and, where possible, at home.

A new way of working

For our sexual health services, we asked our patients to phone ahead first before attending in person. We find that a remote consultation with an experienced sexual health clinician means that many concerns can be managed with advice, support, sending out medication or prescriptions by post where needed and referring for self-testing for STIs.

We’re lucky in that there is already established service for home STI testing in London, managed by Sexual Health London (SHL). Typically this has been for people with no symptoms, but with the right support some individuals with low-risk symptoms can be directed to home testing alongside the expert advice and treatment they receive from us.

Those with urgent symptoms who need to be assessed or to receive treatment in person still come in but with fewer patients needing to attend, we have the space to maintain effective social distancing measures.

Patients living with HIV

For our patients living with HIV, many have understandably been really anxious about what the COVID pandemic means for them. The advice from the British HIV Association (BHIVA) has been very clear and reassuring that there is no evidence that those living with well controlled HIV are at any greater risk of either getting COVID-19 or becoming unwell if they do become infected.

That said, those with a low CD4 count, who are not on treatment or have recently had an infection associated with HIV will be at greater risk of infections in general and so may be at increased risk. We’re providing extra support to these people; however this is a small proportion of our patients and a minority of people living with HIV in the UK.

For the majority, the priority has been to maintain an uninterrupted supply of antiretroviral medication. To do that we reached out to all our patients who were due to come in, and then set up a telephone service where patients can contact us when approaching their last month of medication. If the most recent blood tests were stable and there are no urgent health concerns we prescribe and supply six months of antiretroviral medication without the need for additional blood tests or a face-to-face review. But for the few that do need to see us, the fact that most patients have been reviewed virtually means we have the capacity to see those who do need to come in quickly and safely.

PrEP and lockdown

At Dean Street we estimate that we support over 10,000 PrEP users either through the IMPACT study, purchased directly through our PrEPshop and self-sourced on-line. For many people on PrEP, lockdown means they are not sexually active and therefore not at risk of HIV.

Through our social media channels we promoted video advice about how PrEP can be started and stopped safely but we have continued to provide PrEP to those who remain at risk with telephone support, home HIV testing and posting out medication when it’s still needed.

Trends in STI transmission and behaviour

As a busy clinical service we tend to see trends in STI transmission and behavior quite quickly here at Dean Street. What was clear in the first week or two of lockdown was that our rates of STI diagnoses had dropped dramatically – we went from 350 cases of gonorrhoea each week to around 50.

When it’s in the penis, gonorrhoea has a short time lag before symptoms show so most cases urethral gonorrhoea will have been picked up quite recently. So when gonorrhoea cases fall, that may indicate that people have been having less sex recently. Of course, it may also be that people are testing less during lockdown, in particular as gonorrhoea in the throat and rectum often shows no symptoms, so it might be that it’s there but we are just not finding it.

However our presentations for PEP, emergency medication after a potential exposure to HIV after condomless sex, have also dropped dramatically, from around 50 cases per week to less than 10. We think PEP is a clear indicator of sexual behavior, and as most of our PEP and gonorrhoea presentations are in gay and bi men, we think this means that gay and bi men are having much less sex during lockdown.

It might seem like a simple observation, but we felt it presented us with a fantastic opportunity. When people have acquired HIV very recently, within the last four weeks, it may be too early to show up on even the best tests and so if someone with recent HIV tests negative they can continue to pass on the infection unknowingly. Also, those who have acquired HIV recently will often be highly infectious to their sexual partners, again without realising.

Under normal circumstances, this kind of HIV transmission is very difficult to eliminate. But our lockdown data suggests that the number of people with recent HIV is greatly reduced at the moment, so there’s much less chance of missing an infection on the tests and fewer people who are highly infectious.

Time to Test

We created our #TimeToTest campaign based on the above trends. If as many gay and bi men can test as possible now, before the end of lockdown, we have a real chance to break the chain of new HIV infections that result from undiagnosed or recent infections. We could also make a similar impact on other STIs like gonorrhoea and syphilis.

Our Test Now Stop HIV site aims to encourage people to take a test and to access home testing kits. As local authorities across the UK differ in how they offer HIV and STI testing for their residents, we have also tried to bring this information into one place to make it easier for people to find out how they can access HIV testing not matter where they live.

While the COVID-19 pandemic has been devastating for so many, we feel that a drop in new HIV infections could be one unexpected silver lining on a very dark cloud. We may not get a similar opportunity again which is why we’re encouraging everyone to take a test.

Using online video conferencing platforms safely and securely

As we navigate new ways to deliver care and support through online services, it’s important to ensure the safety and security of people accessing these services, especially where their personal information is concerned.

The following information provides some guidance for people working in HIV and sexual health organisations who are currently delivering services through popular webinar, virtual meeting and video conferencing platforms.

Platforms and applications

Zoom has become the video conferencing platform of choice for most organisations and the majority of information herein will refer to this application. However, there are alternatives available:

Suitable for work with service users

Google Duo provides video conferencing for up to 12 people and is available via web and mobile devices. Video and audio calls are end-to-end encrypted.
Webex is a popular video conferencing and webinar platform already used by many businesses. Video calling supports end-to-end encryption.
GoToMeeting provides a similar service and includes end-to-end encryption as standard. There are no free plans.

Suitable for work with teams and colleagues

Microsoft Teams is a ‘full-package’ collaborating tool which is one of the most comprehensive options available; with good security features and streamlined synchronisation with other Microsoft Office applications. However, it can be complicated and clunky compared to Zoom, which is simple and straightforward to use, or other options.
Skype, Slack (paid plan only) and Facebook Messenger provide means to communicate by video but without full end-to-end encryption.

Using Zoom safely and securely

There has been noticeable media attention relating to ‘zoombombs’ in which uninvited trolls enter meetings and disrupt them by talking over meeting hosts or sharing undesirable content via video or screen share options.

There are some simple steps to avoid this practice:

Do not share Zoom meeting numbers publically, send the joining information in private emails to registered attendees.
Create a new meeting ID for each event or meeting rather than using your own personal meeting ID.
Create a password for your meeting, and never share this publicly.
Enable a waiting room (see advanced options), this will allow you to block anyone from joining who you were not expecting.
As a meeting host you can decide whether you want to give all meeting attendees the option of sharing their screens.
Once all of your attendees have arrived you can lock meetings to prevent anyone else from joining.

Recording meetings

Hosts can record audio and video from meetings and capture the chat function via meeting reports, including private 1-2-1 conversations between attendees.

Hosts should advise people in advance if they intend to record and share webinars and other educational meetings.
Avoid discussing confidential matters with other attendees if you do not want the information shared with the meeting organiser.

Zoom provides a comprehensive guide to security of their platform including information on:

Protecting your meetings
Protecting your data
Protecting your privacy

If you are concerned about the security and privacy in relation to providing services where personal information may be shared (for example online counselling), read more about Zoom’s security features and specific information regarding encryption for meetings.