Africa includes 54 countries and several thousand languages and dialects. As a result, African people living in England comprise a very diverse population on which to target HIV prevention planning. Africans living in England comprise people of different colours, with differing religious faiths and practices, political affiliations and migration histories, food and household practices, as well as variety in gender, sexuality, age, region of origin and length of time in England. This means no single intervention can be appropriate for all African people living in England.
The notion of ‘black African’ identity is commonly used in HIV prevention policy, programme planning and intervention delivery but there is little clarity about whom or what it describes. Both the validity and the utility of the category ‘black African’ is unclear. The term is fuzzy, masking linguistic, national and religious differences and rendering invisible discrete national groups, as well as ethnic groups that are sub-divided within and across geo-political boundaries (Aspinall & Chinouya 2008). Some people from Africa do not identify themselves as ‘black Africans’, instead choosing to describe themselves in terms of nationality (Elam et al. 2001). People with one parent of African heritage may not include themselves in a ‘black African’ category.
‘Black African’ may not always be a personally meaningful form of identity, and the group itself is not fixed, being subject to personal choices and experiences underscored by socio-political contexts. NAHIP agencies therefore aim to meet the needs of a population that is, by its very definition, a contested one.
The history of many organisations working in this field is rooted in service delivery for groups of African migrants from particular national and ethnic backgrounds, with founding members often motivated to meet the needs of their fellow expatriates (resulting in the formation of organisations such as Ugandan AIDS Action Fund, Congolese Youth Association, Community of Congolese Refugees in Great Britain) and those from regions (such as the West African Networking Initiative, and NAZ Project London’s services for people from the Horn of Africa).
Over time, and as population shifts and funding demands have changed, many partner organisations now define potential service users as anyone who considers themself to be African (inclusive of race, country of birth, migrancy etc.).
Where we use the term ‘black African’ in the remainder of this website – we are specifically referring to research data that uses black African as a self-selected identity category (for instance, the Census). Otherwise, we use the term ‘African’ to refer to people who consider themselves African, be they African nationals, migrants from Africa, or direct or indirect African descendants.
The experiences and viewpoints of particular groups are often described under the umbrella heading of culture. This results in concepts such as youth culture or of African culture being used to categorise and account for a diverse set of behaviours. Yet the idea of a singular culture is largely an illusion, masking differences between people. The idea of a singular culture can also freeze an imagined community in time and space, with little recognition that location, information and changing social and material circumstances will inﬂuence the way that people respond and behave. It encourages us to skim past particulars, in favour of a generalised and stereotyped view of motivations and actions. As a result, the idea of culture is often burdened with impossible and contradictory meanings.
We do not pretend that there is one African cultural approach to dealing with sex and sexuality, as this would obscure potentially valid health promotion options. At the same time, some African people living in England (like other diaspora groups) can beneﬁt from close contact with other people from their home continent. This ‘pan-Africanism’ which purposefully overrides national, linguistic or other group differences, can help to foster a network that provides emotional and material support (Dodds et al. 2004). This can be of signiﬁcant value for those who confront racism and xenophobia in their daily lives, and for UK-born Africans who are developing their own experience and identity. Taking these features into account allows us to better focus on the actual social networks, life experiences and beliefs that inﬂuence Africans living in England. Needs assessment and prevention planning should be cautious not to make assumptions about the cultural backgrounds of service users. These processes will therefore require the participation of a broad range of African men and women.
According to data from the 2001 Census, about two-thirds of black Africans in the UK are Christian (Office for National Statistics 2005). People from particular regions in Africa (particularly in the North, and the Horn of Africa) are predominantly Muslim, and Africans accounted for six percent of Muslims in England in the 2001 Census. One-in-eight Africans (12.5%) taking part in the Bass Line 2008-09 survey identified as Muslim.
There is a considerable amount of attention being paid to the potential for HIV prevention interventions in faith-based settings (see the NAHIP website). Such work starts from the standpoint that faith based approaches to mutual care and responsibility often share much in common with health promotion approaches. However, there are also considerable challenges to interventions in such settings, given religious prohibitions against sexual activity that is pre-marital, extra-marital or non-procreative.
Some African faith leaders hold conservative views on same sex relationships (particularly between men) and are disinclined to support men who have sex with men (MSM) with HIV. However, many are willing to support heterosexuals and children affected by HIV in order to reduce the stigma associated with the disease (Chinouya & Muza 2007).
Many Africans living with HIV find that prayer is a source of strength, and many report that their religion plays an important part in taking their medication as prescribed (Chinouya & Davidson 2003). Africans with HIV often identify church as a supportive place but do not share their diagnosis with faith leaders whose preaching about HIV generates and compounds stigma (Chinouya & O’Keefe 2005).
African migration to the UK takes place within a twenty-first century context where global mobility is extensive. Given the UK’s role in the Commonwealth, and its historical colonial connection with so many African countries, it is unsurprising that many African people seek to spend time and to live here. In 2008, more than one million African people entered the UK under a wide variety of circumstances and access arrangements, including:
- Ordinary and business visitors (approximately 612,000 in 2008).
- Work permit holders and their dependants (approximately 8,300 in 2008).
- Student visas (approximately 28,000 in 2008).
- Applicants under the points based system (approximately 700 in 2008).
- Commonwealth citizens with a UK-born grandparent and eligible for settlement (approximately 1,900 in 2008).
- Spouses or fiancées of UK residents (approximately 6,300 in 2008).
- As persons seeking asylum at ports or in country (approximately 10,300 in 2008).
- As persons who evade border or immigration controls (a notoriously difficult figure to estimate).
(These estimates relate specifically to UK entries by African nationals and were obtained from the Research, Development and Statistics Directorate of the Home Office 2008).
The figures above should take account of the fact that in 2008, only 40,395 African nationals were accepted for settlement in the UK. The majority of Africans entering the country are visitors who leave.
Africans living in England are concentrated in Greater London (home to three quarters of Africans in the country) and also in Birmingham, Manchester, Leeds and Liverpool. However, the government’s policy of dispersing asylum seekers has resulted in many towns with transitional populations of people from a large number of backgrounds, including Africans.
A refugee is a person who has been granted permission to stay in the UK under the terms of the 1951 Refugee Convention because of a well-founded fear of persecution due to race, religion, nationality, political opinion or membership of a social group. Those who have applied for refugee status (or asylum) are referred to as asylum seekers. Although the British media has tended in the past to characterise most African migrants as asylum seekers, the figures given above demonstrate that these only make up a small proportion of African people entering and living in the UK. Changes to UK immigration policy mean that the number of people claiming asylum is now far lower than it was at its recent peak in 2002. The numbers of people seeking asylum in the UK also reflects the political situation in other countries. In 2009, 11,050 applications for asylum were received from African nationals, and 8,090 of these initial applications were refused (Home Office 2010)
Health planners in the UK have often been confused about the rights and entitlements of asylum seekers to health care. Asylum seekers with pending applications, including appeals, are entitled to free primary and secondary health care services. This means that planners and providers of HIV services have an obligation to make services freely accessible to men, women and young people who are seeking asylum or who have refugee status. There are a range of forces that shape the health of asylum seekers and refugees, including: experiences of persecution; rape and sexual violation; overcrowding and poor quality housing; racism and hostility in the media; and difficulties in communicating their needs (Wilson et al. 2007). All of these issues require consideration when designing interventions and services for this population.
Irregular migrants are people who are liable for deportation for issues related to their immigration status (Farrant et al. 2006). This includes those who were never given valid leave to enter the country, whose leave has expired, or whose asylum applications have been unsuccessful. Some irregular migrants will be African, although their numbers are unknown.
The majority of African migrants living in the UK are legally entitled to full residency and / or citizenship and all of the social and economic benefits that accompany legal status. In contrast, the lives of irregular migrants are generally characterised by destitution, which directly impacts on the extent to which their HIV prevention needs are met. Charities supporting migrant populations (upon whom the burden of support has fallen) have protested that migration policy has served to deny such individuals their most basic human rights (Refugee Council 2004, Kelley & Stevenson 2006)
Government policy has increasingly focussed on returning irregular migrants (as well as migrants with criminal convictions) to their country of origin. Some of those awaiting deportation are placed in detention centres (alongside some who await the outcomes of their pending asylum applications). At the end of December 2009 there were 965 African nationals held in detention because of their immigration status, comprising 37% of all detainees. (Home Office 2010: Supplementary Table 0).
NHS charging arrangements stipulate that unless HIV treatment has already begun, irregular migrants diagnosed with HIV in the UK will be charged for their treatment and care (Department of Health 2007). NAHIP contracted agencies provide HIV prevention interventions irrespective of immigration status, in the interests of improved public health among the population of Africans living in England.
Work and study
As a whole, African people are among the most highly educated in the UK (Office for National Statisitics 2004), yet some sub-populations of Africans are likely to be among the least educated. For instance, Muslims are by far more likely than those from other religious backgrounds not to have any qualifications (Office for National Statistics 2006)
In 2006 more than 24,000 Africans entered the UK on student visas. This indicates a large number of African people who enter the country with strong academic and professional aspirations. In addition, the international student market is a significant element of the British higher education economy, with African countries being a major target for recruitment (Universities UK 2006)
Ethnic minorities have higher unemployment rates than white British people (Office for National Statistics 2004)
African people in the UK are frequently employed in work that does not reflect their educational qualifications (Elam et al. 2001)
Gender and sexuality
Having an extended family living in the UK, in Africa, and elsewhere in the diaspora is a common feature of the lives of African adults in the UK. There is often an expectation (particularly for older siblings) to send money to family members back home. These responsibilities can coincide with supporting dependents in the UK. Global remittances make up a significant element of the global economy, including $300 billion that is sent from the UK to other countries, including many in Africa (Ratha et al. 2007).
Many Africans have dependent children. Most children are born to married or cohabiting couples. However, data from the 2001 Census shows that around half of black African and other black households with dependent children were headed by a lone parent, while this was only the case for a fifth of white British households (Office for National Statistics 2004). Some African children provide informal care to relatives, whereas the need to care directly for older relatives is less common because they frequently live elsewhere (Chinouya & O’Brien 1999).
African family life is diverse, and there is increasing recognition of the roles that gay men, lesbians and bisexuals play as mothers, fathers, brothers and sisters (Lubbe 2007). A quarter of black African adults report a spouse / partner living abroad (Mayisha II Collaborative Group 2005). Trans-national living arrangements can involve leaving children behind in the country of origin, and geographical distance makes communication about HIV between family members problematic (Chinouya 2006)
There is a tendency for first generation migrants from Africa to have a strong attachment to values such as family dignity, honour, and respect for the authority of men and of elders (Chinouya & O’Keefe 2004). African women may be particularly subjected to domestic violence in households where these values are undermined by poverty, instability and stress (Kesby et al. 2003), and a recent study undertaken at Homerton Hospital's HIV clinic in London revealed that more than half of all female (mostly African) patients had experienced violence from an intimate partner at some time in their lives (Dhairyawan 2012).
Africans reflect the same diversity of human sexuality as most other geographically defined groups of people. Sexual attitudes and practices can differ across African regional, ethnic and religious backgrounds. For instance, as a value system in some regions of Africa, polygamy (having more than one spouse at the same time) plays a significant function in the economic and social life of communities. Although its prevalence in African and diaspora settings has changed over time, polygamy and the existence of multiple concurrent sexual partners continues to be highly valued by some, while being quite far outside the experience of others (Hayase & Liaw 1997).
As in many other communities, open discussion of sexuality in public, or in mixed social settings is a taboo for most African people (Department of Health et al. 2004). As is the case among people from a broad range of backgrounds, many African parents tend not to offer information about sex to their children, with this responsibility passing (formally or informally) to other family adults or to peers (Elam et al. 1999, Chinouya 2006). Young Africans in the UK find (as do many other young people) that there is often a gulf between a silence at home, sex and relationships education at school, and the apparent sexual freedom displayed in British media and marketing.
Muslim men and women can perceive particular social and cultural distance from prevalent norms relating to sexuality and gender (Camden Primary Care Trust 2007)
Significant sexual contact between same-sex partners takes place among Africans in Africa as well as in the UK (Mayisha II Collaborative Group 2005, Johnson 2007, Dodds et al. 2008). When dealing with same-sex desire and practice, language becomes an ideological battleground. Terms such as ‘gay’, ‘lesbian’, ‘homosexual’ and ‘bisexual’ mean different things to different people and will sometimes, but not always be chosen by African men who have sex with men (MSM) and women who have sex with women (WSW) to refer to themselves. On the other hand the terms MSM and WSW have been criticised as terms by which heterosexist authorities erase the social context and networks of lesbian, gay, bisexual and transgendered people (Young & Meyer 2005).
Although the human rights of sexual minorities are recognised and protected in the South African Constitution, this has not translated into freedom from violence. In other African countries the state is complicit in persecution (Human Rights Watch & The International Gay and Lesbian Human Rights Commission 2003). Rather than championing the rights of their gay and lesbian citizens, some governments justify state homophobia through the existence of societal homophobia. In language, practice, and tradition, heterosexuality is generally portrayed as the only acceptable option for African men and women. This approach is often justified (in both Africa and by Africans in the UK) by identifying homosexuality and gay culture as white and therefore alien to Africa. African MSM living with HIV in the UK report rejection by families due to the ‘double stigma’ of HIV and homosexuality (African HIV Policy Network 2007, Paparini et al. 2008).
African women and men are represented in the commercial sex industry and have been for a long time. Africans who find themselves unable to earn a living wage may turn to sex work. There also exist people traffickers who entice and trap women and children from a range of countries into sex work in the UK (Home Office & Scottish Executive 2009).
A project in South London found that many female African sex workers were irregular migrants, and they tended to express shame about the work they undertook to survive (Othieno 2006). As a result, many isolated themselves from friends and relatives in the community and socialised exclusively with other sex workers. Need for money meant many did not insist on the use of condoms or negotiate less risky sexual practices with clients requesting unprotected intercourse. Fear of contact with the Home Office means sex workers are unlikely to be registered with a GP and most may be unaware of sexual health services including those that offer HIV testing. The experiences and needs of African men engaged in commercial sex work remain relatively unknown.
Social attitudes toward sex and sexuality can have a great deal of inﬂuence over what is generally acceptable to display or discuss in public. These attitudes are patterned by age, ethnicity and religion. People often present a publicly acceptable sexual identity (ie. monogamous married couple; or celibate daughter) that is in accord with socially acceptable standards held by family members and peers. This public identity can be radically different from private sexual practice, and it is incumbent on health promotion planners to recognise the difference between these two realities.
HIV in context
Experiences of HIV in Africa inform understandings of HIV in England. Global goals toward universal treatment access have meant that by 2008, an estimated 44% of people who needed HIV treatment in sub-Saharan Africa were receiving it (World Health Organisation et al. 2009)
Lacking knowledge of HIV treatments (and therefore not perceiving the beneﬁts of diagnosis and being very fearful of ﬁnding out their status) is one of the reasons why some Africans with HIV spend a long time undiagnosed, and have poorer health outcomes. Findings from the Bass Line surveys reveal that 16% of African people responding did not know about HIV treatments at all, and more than one third did not know that the treatments work better if people take them before they become ill (Hickson et al. 2009)
Misinformation and HIV-related stigma tend to reinforce one another. Past experiences of discrimination and perceptions of anti-migrant and anti-African stigma prevent some Africans from accessing services (Anderson & Doyal 2004, Dodds et al. 2004). For many Africans, HIV is associated with inﬁdelity, promiscuity, homosexuality and (consequently) sinfulness. There is some evidence that fear of stigma and discrimination prevents Africans from accessing HIV testing services (Elam et al. 2006, Dodds et al. 2008), and that the uptake of testing for HIV is relatively low among many Africans despite a higher utilisation of GP and outpatient care (Burns et al. 2008)
Stigma also plays a role in the very common perception that HIV happens to ‘other people’. HIV stigma threatens the most valued means of support in England for Africans – their personal network of migrant African family and community members (Dodds et al. 2004). Stigma can result in social rejection, physical hostility and homelessness. Fear of rejection causes some people to keep their diagnosis to themselves, creating a sense of isolation (Flowers et al. 2006). Others ﬁnd that disclosing to loved ones, when they are able to exercise control over the process, results in emotional and practical support.
African women with diagnosed HIV are more likely than their male counterparts to access service and support from statutory providers. However, a number of women report domestic violence, homelessness and emotional abuse from partners and other family members following a disclosure of their HIV status within the family context (Doyal & Anderson 2005). African men with HIV can feel isolated and emasculated by ill health and often experience difﬁculty providing ﬁnancial support for their family (Anderson & Doyal 2004, Doyal et al. 2005). Local networks and support groups for Africans living with HIV are a valuable resource for emotional and information support. Many Africans who are unable to read or understand English receive informal translation support from support group members and staff (Ssanyu Sseruma 2007). At a broader, societal level, interventions to support the mainstream and BME media can help to reduce the extent to which they contribute to HIV-related stigma (African HIV Policy Network 2007).
Approximately twice as many African females as males are diagnosed with HIV in the UK each year. Epidemiological surveillance undertaken in the UK (Health Protection Agency 2011) provides estimates that suggest there is higher incidence among heterosexual African women than men. Given that this is reported in numbers rather than population proportions, it could be attributable to other types of factors such as different proportions of women and men emigrating to the UK, or differences in their social circumstances before and after arrival. The epidemiology is similar within most sub-Saharan countries, where women with HIV far outnumber men, and three quarters of all women living with HIV in the world are sub-Saharan African (UNAIDS 2008, Magadi 2011). Recent analysis suggests that in the African context, this gender difference is directly attributable to the lack of meaningful engagement with African men in HIV prevention and testing interventions, and that lower rates of diagnoses amongst men should not be taken as an indicator of lower HIV incidence (Mills et al. 2012). Without further investigation, it is impossible to know with certainty what the explanations for differences in transmission rates between men and women in different local settings may be.
Another gendered aspect of the HIV epidemic is its disproportionate impact on African gay men, bisexual men and other men who have sex with men. There is evidence that among African men in England, men who have sex with men are twice as likely to have HIV as those who do not have sex with men (Mayisha II Collaborative Group 2005). Within research undertaken among men who have sex with men in England, African men were twice as likely to be living with HIV as white men (Hickson et al. 2004). Findings from Bass Line demonstrate that behaviourally bisexual men are significantly more likely to have multiple concurrent sexual partnerships than other men, which dramatically increases the likelihood that they will acquire or pass on HIV (Hickson et al. 2009).
Why target Africans?
The African population in England is in constant change with people moving in and out of the country, both with and without HIV infection. In addition, some Africans living in England are passing on and acquiring HIV. Infection is diagnosed in some Africans while they live in England and others will leave the country (or die) before any diagnosis is made. The figure below illustrates HIV prevalence (how many people have HIV) and HIV incidence (the rate at which people become infected with HIV).
The whole triangle represents the sexually active population of Africans living in England. The population is split into those with HIV infection (the upper triangle) and those who do not have HIV infection. Those with HIV are divided between those who have had their HIV diagnosed, and those who have not yet been diagnosed.
Individuals can join the population by becoming sexually active or arriving in England. They can join the population, with HIV (diagnosed or undiagnosed), or without HIV. Individuals can leave the population by departure from England, by ceasing sexual activity or by death. They can leave with or without HIV infection. Within the population, moving from the HIV uninfected section into the (undiagnosed) HIV infected section represents a new infection. These events are the main concern of this document.
The second movement within the population is people with undiagnosed HIV infection moving to the diagnosed section by having their infection diagnosed. Diagnoses occur in both people who moved to England with HIV infection and in people living in England who acquire HIV. So the number of people with HIV increases as people move to England with HIV and as people in England acquire HIV, and it declines only when people with HIV leave England or die.
The total number of people living with HIV in the UK continues to rise, with an estimated 91,500 (85,400-99,000) people living here with infection by the end of 2010. Just under half of all those with HIV in the UK are African-born, and over a quarter were unaware of their infection (Health Protection Agency 2011). For up to date figures regarding HIV incidence and prevalence among African people in the UK, see this section of the Health Protection Agency website.
Given the extent of HIV among African people in England (estimated by the Health Protection Agency at about 1-in-20), NAHIP believes that targeting HIV prevention interventions for African people is the best use of limited resources. This is an approach that recognises that sexual risk is not evenly distributed among all Africans, nor are the unmet HIV prevention needs that contribute to HIV risk evenly distributed. This website helps planners and service providers consider in detail, which sub-groups of African people are more likely to be at risk of HIV transmission and acquisition. Following on from that, it supports planners and service providers to develop interventions that clearly undertake to meet a particular need, while targeting those who are most likely to benefit.
The KWP approach section
Page last updated: 23 August 2012