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 1.8% of the British population (ONS, 2020), Black Africans (BA) are over-represented in the rates of new HIV diagnoses every year. The latest figures showed that they constituted 44% 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.

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 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%)

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.