What will it change?

This section focuses on the needs of researchers, commissioners and policy makers to contribute to the reduction of HIV transmission involving African people in England. All of the HIV prevention aims for African people are influenced by the decisions, activities and resource allocations of those people in positions of power and influence (many of whom are listed here). International research suggests that these key players have the greatest influence on, and responsibility for HIV incidence (UNAIDS 2002, Barnett & Whiteside 2006).

Many of the needs described here can be met by NAHIP partners working in partnership with the African Health Policy Network and other national organisations to address the continuing inequalities that generate HIV prevention need among African people in England. In addition to the expertise and support offered by voluntary organisations and through familiarity with strategic planning documents such as KWP, decision-makers require financial resources and the political will to reduce HIV transmission.

Organisational development

There is no single agency or institution with overall responsibility for reducing HIV incidence through sex between African people in England, nor any single group of organisations with sufficient expertise, resources and respect to ensure that it occurs. This plan requires a multi-level, strategic approach to realise its goal. This requires different organisations to select and prioritise different sets of aims and activities according to their targets and strengths. Its success rests on the commitment of a wide diversity of people and organisations and on the degree and success of our collaboration.

In order to deliver targeted HIV prevention interventions to African people in England we require a diversity of organisations that are HIV- and African-specific, working in close collaboration with organisations that are neither HIV-specific, nor African-specific. As this is a planning document for the NAHIP partnership we concentrate on the needs of organisations delivering interventions that target African people in England, regardless of whether or not the organisations provide services that are HIV-specific or African-specific. We also imagine that these organisational aims will be of use to other organisations that are not in the NAHIP partnership but deliver HIV prevention interventions to this population.

Ability to maintain financial stability: NAHIP has played a role in supporting partner organisations to secure funding for the delivery of HIV prevention interventions but their success in building capacity within the African HIV prevention sector is challenged at a time when funding has become harder to secure given the economic downturn and as the political profile of HIV diminishes.

While NHS and Local Authority HIV commissioners consistently prioritise African people in their commissioning intentions (Weatherburn et al. 2007) this prioritisation does not translate into substantial and consistent investment in meeting the HIV-related needs of Africans living in England. For example, although 70% of all Africans living in England live in London, it was a full seven years after an HIV prevention programme was established for gay men and other homosexually active men that a pan-London programme was initiated to deliver HIV prevention for the African population across the city.

Programme funding is vital for the provision and sustenance of HIV prevention interventions. Those responsible for the management of HIV prevention organisations report spending up to 80% of their time on the completion of funding applications, monitoring, and reporting back on contracts held (Weatherburn et al. 2007). This situation is likely to be particularly acute in African organisations that lack core funding.

A continuous crisis-driven existence weakens service user confidence and staff morale, and causes distraction from core prevention activities. All NAHIP partners require senior staff with the skills and resources to ensure successful competition for funding from a diverse range of sources. This requires a good understanding of the funding environment and coherent, confident relationships with those who commission NHS and Local Authority HIV prevention services and charitable funders. Senior staff will also need to understand the necessity for financial accountability and the need for effective monitoring of services contracted and provided.

Ability to provide leadership: The leadership qualities that have been actively supported by NAHIP since its inception - such as clear communication, high expectations and motivation - require ongoing strengthening across all partnership organisations, and in their dealings with each other. Staff and volunteers need to provide, and service users need to receive, HIV prevention services that are free from racism, homophobia and gender-bias. Organisations that promote and prioritise equality will function as models for such attitudes in the wider community.

Some organisations delivering HIV prevention to Africans may be inclined to retain an exclusive focus on ‘service delivery’. However, community-based organisations also have a mandate to speak for their service users by: undertaking activism; clearly articulating the HIV prevention needs of users; responding to consultations; and interacting confidently and proactively with the media. African- and HIV-specific organisations that command respect and demand action will help to change discriminatory practices and increase the attention and resources devoted to targeted HIV prevention activities among African people. The actions of such organisations will also provide models of leadership for potential service users.

Political campaigning by local and national HIV organisations working in partnership has led to significant policy change in the past. Some examples include: the Disability Discrimination Act 2005, the repeal of Section 28 of the Local Government Act 1988, and modifications to Crown Prosecution Service policies. All demonstrate that activism and community leadership can have an impact on government policies and hence HIV prevention need. Continued achievement of such change depends on HIV prevention managers working collaboratively to develop and implement joint policy priorities and also to influence local and national decision-makers, in order to increase the priority given to the HIV prevention needs of Africans. While national policy campaigns may emanate centrally from within the African HIV Policy Network, it is essential that organisations understand, value and participate in such campaigns.

Ability to assess and meet need: As outlined in the assessing need section, needs assessment involves making informed judgements about the extent to which health promotion aims are unmet in target groups. It requires skills to interpret existing research, knowledge of local need, and ability to advocate for the collection of evidence. It also requires partnership work with service users and researchers to ensure that needs assessments result in information that is coherent and useful. The assessment of need is vital to planning - it ensures that resources are targeted in areas of greatest need.

The health promotion needs of African people described in African targets and aims are broadly similar for all women and all men, but the extent to which they are met will vary between sub-populations and between individuals. Undertaking a needs assessment for a sub-population requires an individual or a team that knows how to make an estimate of its size, its relationship to other population groups and make an assessment of how far away each is from the aims described. Whether or not an aim is met for a target group is not dependent on the availability of a service to address that need. An assessment of need should not be guided by the range or configuration of existing services.

Ability to prioritise and promote confidentiality: Potential clients need to know exactly how information about their sex lives and other private details will be managed by staff and volunteers providing an HIV prevention service. Staff and volunteers must be able to operationalise and clearly communicate their agency’s confidentiality policy with all potential service users.

Confidentiality policies should not confuse service users nor be any impediment to service users being open about HIV if they choose. Services must do their utmost to protect the safety and security of service users, staff and volunteers. Concerns about lack of privacy (and its implications) keep African people from accessing HIV prevention interventions. NAHIP agencies must ensure that confidentiality policies are developed, described, enforced and widely publicised. No African person attending an HIV prevention service should fear that their identity or private information will be the subject of gossip.

Ability to work in partnership: HIV prevention interventions across the NAHIP programme should be designed to be complimentary rather than contradictory. This requires ongoing and active communication within and outside the partnership about current research, effective planning and prevention activities. Close working relationships, joint planning, and the provision of HIV training for local statutory and voluntary sector organisations will enable effective referrals and support for individuals and families with complex needs. Other partner organisations and institutions can include (but are not limited to):

  • migrant and BME support charities,
  • local organisations delivering HIV prevention, treatment and care that targets Africans,
  • African cultural and home country organisations,
  • social services providers (and commissioners),
  • local NHS Primary Care and Acute Trusts (and commissioners),
  • Strategic Health Authorities,
  • faith groups,
  • African and BME media outlets and businesses,
  • schools, colleges and universities,
  • Lesbian Gay Bisexual and Transgender (LGBT) community organisations,
  • citizen’s advice bureaux,
  • local police,
  • housing associations.

Partnership working within and beyond the HIV sector can provide an opportunity for a broader range of trustees and board members to offer their varied skills and experience to service providers.

Workforce development and retention

Staff and volunteers are central to ensuring that effective HIV prevention interventions reach people who need them. They often provide the first point of contact for service users. This means that direct contact staff and volunteers require a set of characteristics and abilities that instil confidence in the organisation and the services being provided.

A key challenge for NAHIP partners and other African HIV organisations is workforce development and retention of staff and volunteers who have developed skills and expertise. Where staff receive sufficient pay and are supported and valued in their work, they will stay in post for a longer period of time. Where volunteers are motivated and appreciated, they are more likely to dedicate more of their time to HIV prevention, and will be more likely to pursue paid work in the field.

Participation in peer education programmes and volunteer skills training can be motivated by a desire to improve job prospects elsewhere. This can mean that the potential for ongoing application and further development of skills relating to HIV prevention is undervalued. All health promotion training that is delivered within the NAHIP partnership should include structures that help to retain contact with participants (ie. short-term organisational placements, newsletters and contact databases) in order to sustain individuals’ interest through awareness of research developments, campaigning issues, sector updates and staff vacancies.

Sharing characteristics and understandings with target audiences: People using services may be more likely to identify with health promoters who share some of their own personal characteristics, including an African language, and an understanding of their experiences, values and beliefs. Shared identity increases people’s trust in staff and volunteers, and will help them to feel that they will benefit from an intervention. African people accessing HIV interventions require health promoters who are similar to themselves across a range of basic dimensions, including age, gender, sexuality, religious background and ethnicity.

Skilled and approachable staff and volunteers: Shared demographic characteristics are not sufficient to ensure the success of interventions that are delivered face-to-face. Respondents to one survey were asked: For you, what is the most important characteristic or quality of someone giving you information or advice about HIV? (Weatherburn et al. 2005). Answers focussed on the following themes:

  • Honesty, confidentiality and non-stigmatising approaches.
  • Being able to identify with the service user and gain their respect.
  • Keeping a professional distance, speaking with authority, appearing to be trustworthy, knowledgeable and credible.
  • Having the required skills and competence in the topic, being easy to understand and being approachable.

All people accessing HIV interventions, including Africans, require health promoters to provide information honestly and credibly and without moral judgement. Ensuring credibility will require that service providers are constantly updating their knowledge through access to training, seminars, conferences, online and print resources relating to the issues that are of greatest interest to the population they serve.

Those accessing HIV interventions require health promoters that establish a professional distance, which allows for mutual respect, and clarity about the anonymity and confidentiality of the interaction. African people accessing HIV prevention interventions require workers with the skills to assess their existing level of knowledge and needs.

African people accessing face-to-face HIV interventions need contact with African health promoters who can model open and frank discussion about sex that does not involve censorship, squeamishness, judgment or surprise. This modelling will ultimately influence the acceptability of open discussion about sex in the community and between sexual partners.

The needs of African people accessing interventions are best served when staff and volunteers make it clear what expectations they can meet, and which ones are best addressed elsewhere. This requires that staff and volunteers can utilise resources and contacts relating to a broad range of voluntary and statutory organisations that can help the service user best meet a range of other needs and follow clear referral protocols.

All of the skills described above require continuous organisational maintenance of the basic principles and practices of equality. It must always be made clear to staff, volunteers, board members and service users that homophobia, racism and sexism have no place in NAHIP agencies.

Influencing central government

For sexual ill-health in England to be minimised, sexual health and HIV must be given adequate resources and attention across Government policies.

The impact of policy changes on the incidence of HIV requires consideration by governmental departments beyond the Department of Health. For instance, policy decisions relating to immigration, criminal justice, prison and detention services, social services, education, and international development can all impact on the transmission of HIV to and from Africans in England.

Health policy: There are many successes in the delivery of HIV prevention, treatment and care services in England that provide a strong foundation upon which all future prevention activity can build. For example, self-referred HIV and STI testing is freely and confidentially provided in clinical and non-clinical settings across England, regardless of residency or migration status, and high quality HIV treatment and care is freely available for all eligible residents. In addition, the National Sexual Health Strategy (Department of Health 2001) has led to a widespread reduction in waiting times for appointments in clinical sexual health services.

However, spending on HIV prevention targeting African people living in England is no longer increasing and most organisations perceive funding to be diminishing and inadequate (Weatherburn et al. 2007). We believe this is because the Department of Health’s intentions to expand specialist sexual health services are frequently over-ridden by re-prioritisation of funds at local level, although this is difficult to confirm because there is no monitoring or control of the ways in which PCTs allocate their spending (House of Commons Health Committee 2005) .

Continued leadership from the Department of Health on HIV prevention for African people is clearly required. Further change requires that the Health Protection Agency continues to communicate the extent to which the heterosexual HIV epidemic in England is primarily comprised of African people, and that national HIV prevention funding provided through the Department continues to prioritise the prevention needs of Africans alongside those of men having sex with men. The high costs of HIV treatment can mean that HIV prevention lacks priority in local NHS planning but the public health and economic benefits of ensuring that fewer people ever require treatment must be used to challenge such tendencies.

There is a need for political leadership to support the Department to find innovative ways to ensure that local services prioritise targeted HIV prevention for African people with the highest degree of unmet need. HIV is the only serious communicable disease for which the Department of Health charges irregular migrants for the provision of treatment and care. Whereas public health outcomes take priority for other sexually transmitted infections or contagious illnesses (such as tuberculosis), the immediate costs of HIV treatment for irregular migrants appear to outweigh concern for longer-term costs to individual and public health (House of Commons Health Committee 2005). Where African people with HIV are undiagnosed and/or untreated they have an increased likelihood of participation in transmission as well as a higher viral load without effective treatment. Thus, it is difficult to understand how a government that campaigns for universal access to HIV prevention, treatment and care, simultaneously denies free treatment to anyone within its own borders.

The policy of charging a minority of African migrants for HIV treatment and care further impacts on HIV prevention need within the entire population because it leads to confusion about who is eligible for free treatment, and in what settings service users may be asked for evidence of their immigration status. More must be done by the Department of Health and service providers to ensure that African migrants understand exactly who is liable to pay for HIV treatment, and what the confidentiality of services entails. Without clarity, confusion is likely to affect the perceived benefits of HIV testing. At a time when political and public discourse is filled with anti-migrant sentiment, the Department will require political will to ensure that its charging policies do more to support health.

Education policy: Educational settings are an important place for young people to explore and learn about sex and relationships. NAHIP partners believe that Sex and Relationships Education (SRE) that reflects the experiences and practices of people of diverse sexualities and diverse religious and ethnic backgrounds should be a mandatory element of the National Curriculum. This will help to ensure that expert teachers deliver a holistic programme of education that meets HIV prevention needs among all young people, including Africans. In establishing SRE as a mandatory element of education, the government would signal to parents and families that this is a valuable and necessary aspect of developing healthy attitudes and practices among all young people. SRE that is delivered by confident, open, professionals is judged to be the best way of meeting parents’ and young people’s information and support needs and can mprove communication about sex and sexuality within the home. Such an approach would require that the Department for Education understands and applies evidence about best practice in SRE delivery to its curriculum planning, as outlined in a consultation paper drafted by the previous government (Department for Children, Schools and Families 2010). Forthcoming guidance from the National Institutes for Clinical Excellence should provide some clarity on these issues.

Schools are an important place for sharing core social values. This theme has featured prominently in policy shifts toward the prevention of bullying (Smith 2000, Jennet 2004) and the addition of Citizenship to the mandatory curriculum. Schools are now expected to take a proactive stance against discrimination and harassment - including racism, sexism and homophobia.

As a result of such interventions, young people and those who educate them should be increasingly aware of the importance of promoting diversity and equality for a healthy and prosperous society. Such work needs to be sustained with appropriate resources - which requires that the Department for Education and the Children’s Commissioner monitor and evaluate current practice and extend the interventions that are most successful.

Prison and detention policy: People who are confined in prisons or detention centres (due to either criminal or immigration matters) often lack the resources to avoid involvement in sexual HIV exposure (National AIDS Trust & Prison Reform Trust 2005). This vulnerability and its sexual health (and human rights) implications should be recognised by the Home Office and the Ministry of Justice. Departmental support of sexual health promotion programmes currently being carried out in prisons and detention centres (largely funded by PCTs) requires assessment of the level of HIV infection and HIV risk in custodial settings. The Home Office and the Ministry of Justice will also benefit from conferring with one another, and with health professionals and relevant communities when considering intervention and policy options for incarcerated populations.

Established health policies in prisons tend to mean that expert treatment and care for inmates with HIV is available. However, provisions for the health of irregular migrants and asylum seekers being held in detention can be ad hoc and intermittent (National AIDS Trust 2007). This is particularly detrimental for people with diagnosed HIV who require regular clinical checks and ongoing treatment.

Where people with diagnosed HIV are in regular contact with HIV clinical specialists, their health outcomes are improved, and they are less likely to transmit HIV as a result. The UK Border Agency (a part of the Home Office) will require close liaison with the Prison Service (a part of the Ministry of Justice), Offender Health (a joint initiative of the Department of Health, the National Offender Management Service, and the Ministry of Justice), clinical HIV specialists and community organisations in order to develop its delivery of specialist HIV and general health care to detainees.

Criminal prosecution policy: Since 2003, fewer than twenty individuals have been criminally prosecuted for the reckless sexual transmission of HIV in England, under the Offences Against the Person Act 1861. Many of the defendants (as well as complainants) have been African migrants, resulting in custodial sentences that are accompanied by recommendations that deportation is considered. Despite the small number of prosecutions to date, ill-informed and sensationalist media coverage has increased concerns about discrimination among African people with diagnosed HIV (Dodds & Keogh 2006) and undermined the public profile of HIV as a long-term, manageable condition.

Some countries have drafted HIV-specific legislation, and some undertake criminal prosecutions for HIV exposure (rather than transmission). The current application of existing assault law to cases in England involves only those where HIV transmission has occurred. Despite a host of legal and academic discussion, there remains little clarity about what may specifically be used as evidence in order to bring a prosecution, and which preventive actions would provide a legal defence (Weait 2007). HIV support organisations report that there is wide variation in the approaches to such cases taken by police investigators, crown prosecutors and HIV clinicians. The Department of Health, Ministry of Justice and a range of HIV organisations have consulted with the Crown Prosecution Service in their development of prosecution guidelines for such cases, which offer some clarity on the issues raised above.

Concerns about the detrimental effect that criminal prosecutions have on HIV prevention aims have been brought to the attention of the Department of Health and the Home Office. Ongoing liaison between the two departments on the particular issue of criminal prosecutions is to be encouraged. HIV experts’ contribution to the development and provision of HIV guidance and training with the Association of Chief Police Officers, the Crown Prosecution Service and the judiciary may help to diminish the harmful impact of such prosecutions. Furthermore, the provision of basic legal, data management, and media training for health professionals, including HIV service providers, will help them to better meet the needs of service users. Detailed information and recommendations to help achieve these aims can be found elsewhere (see Anderson et al. 2006, Bernard 2010.

Immigration policy: People who are able to exercise control over their daily lives will be more able to control the extent to which they avoid participating in HIV transmission. Immigration policy that dictates that asylum seekers cannot be gainfully employed and cannot choose the town or city in which they live, places conditions on individuals and families which effectively eliminate control over their own circumstances (African HIV Policy Network 2006) .

Among African asylum seekers, such policies exacerbate HIV transmission risk. Enabling those seeking asylum to earn and pay taxes while their claims are processed would benefit the lives of other migrants, as well as local and national economies. 

International policy: All the investment in HIV prevention, treatment and care that occurs at a global level inevitably impacts on the domestic HIV epidemic among Africans in England. Throughout the past two decades, Britain has maintained its international leadership on issues of international development including attainment of the Millennium Development Goals and global debt repayment. Through the Department of International Development, the UK continues to strive for Millenium Development Goal 6: to have halted by 2015 and begun to reverse the spread of HIV and AIDS. To this end, their work has gone far to improve access to treatment for HIV/AIDS, despite missing the global target of universal access by 2010. UK research funding continues to drive progress toward the development of safe and effective HIV vaginal and rectal microbicides as well as a preventive HIV vaccine. The UK is at the forefront of development and international HIV prevention goals, and all departments involved, from the Prime Minister’s Office, to the Treasury, to the Department for International Development require ongoing support from non-governmental organisations and the broader public to achieve their aims (House of Commons International Development Committee 2006).

Influencing local government and NHS

Strategic planning in the NHS: At the time of writing, the NHS is structured by 10 Strategic Health Authorities (SHAs) in England that oversee the activities of 150 Primary Care Trusts (PCTs). SHAs are responsible for developing plans to improve local health services, ensuring that local NHS organisations are performing well, increasing capacity, and making sure that national priorities are delivered at a local level. For the time being, SHAs are responsible for performance management of NHS services in their area.

Where the Department of Health releases additional monies with specific spending priorities attached, it is the responsibility of the SHAs to ensure that PCTs deliver. However, the coalition government’s plans for the NHS, outlined in Equality and excellence: Liberating the NHS (Department of Health 2010)  and in Liberating the NHS: Commissioning for patients (Department of Health 2010)  mean that commissioning and governance arrangements are set to be completely restructured in the coming years.

Under the current system, SHAs require awareness of the strategic plans and patterns of commissioning and service delivery in the PCTs in their area. Prioritising (local) HIV prevention requires transparent monitoring of spending and activity as distinct from general sexual health spending and investment in clinical services. This process is supported by local HIV prevention needs assessment and Race Equality Impact and Health Impact Assessments, in close collaboration with local HIV and African organisations. We anticipate that future monitoring and evaluation will be increasingly driven by assessment of health outcomes.

Commissioning of NHS and community-based HIV prevention: Primary Care Trusts currently control approximately 80% of all NHS spending. Commissioners within the NHS are responsible for making sure that HIV prevention is adequately resourced. Commissioners require a high degree of familiarity with the HIV prevention interventions that they fund, as well as reliable evidence of uptake and effectiveness (National AIDS Trust 2007). Strong relationships with African organisations, and up-to-date knowledge of local HIV prevention need among Africans will enable commissioners to advocate for appropriate resources. Consortia commissioning for programmes of HIV prevention for African people across PCT boundaries will improve the extent to which knowledge, expertise and resources are efficiently shared. We hope that in the move away from PCT towards GP commissioning in the re-structuring of the NHS, that the value of consortia commissioning for HIV prevention will be recognised.

Clinical sexual health (GUM) services should prioritise sexually active African people as a client group. This will require resources in order to better promote services among African people, and to provide services that are available at accessible times of the day, in accessible places, and in languages that are most likely to increase uptake.

Provision of NHS services: Local NHS services are partly or wholly responsible for HIV prevention interventions that target African people. Provision for the sexual health needs of this population requires understanding and recognition of traditional, religious and sexual practices that will impact on sexual health outcomes. African organisations’ participation in the design and delivery of services targeting Africans is therefore crucial to their success.

Further to this, all health providers (from general practitioners, to maternity unit staff, to specialist HIV clinicians) must ensure that health decisions are always subject to informed consent, and that security of personal health information is prioritised. In addition, the NHS is responsible for ensuring that all service users are treated with respect and dignity. This will require that local NHS providers proactively address racism, xenophobia, gender-bias, homophobia and HIV-related stigma in the attitudes and practices of their staff, and in recruitment and employment practices. NHS managers therefore require the resources and skills to enable them to prioritise equality in all healthcare settings.

African people without diagnosed HIV who access primary care and sexual health services need to know that HIV testing is available in these settings. This requires that GPs, nurses, acute care specialists and GUM (clinic and community-based) staff have the resources and skills to offer HIV testing to African service users with informed consent.

The work that has been undertaken to improve homosexually active men’s access to post-exposure prophylaxis (PEP) following sexual exposure to HIV has dramatically improved this population’s awareness of PEP as a treatment option (Dodds et al. 2006). It is likely that in time, more people exposed to HIV through homosexual and heterosexual contact – including African people – will come forward to request PEP treatment. Local NHS managers should work in conjunction with HIV voluntary organisations, community groups, and professional HIV clinical associations (BHIVA) to ensure that staff in acute services (Accident and Emergency) and sexual health (GUM) service providers understand and can apply the correct assessment and prescribing protocols in such situations (Fisher et al. 2006).

Commissioning and provision of services other than health: The provision of essential services such as safe and accessible housing, social services, policing, legal advice and welfare benefits advice for African people in England will help to meet HIV prevention needs. Improving HIV prevention outcomes means that the social care needs of African people with diagnosed HIV are a priority, followed by the social care needs of all African people.

Local service providers (schools, police forces, social services etc.) should be vigilant about racism, homophobia and HIV-related stigma in their own employment practices, among their staff, and among those who access their services. This requires clearly articulated and continually enforced equality policies. Those who manage the delivery of services will need access to the resources and skills to enable them to prioritise equality in the work environment.

Influencing planning and the evidence base

Needs assessment plays an important role in the delivery of statutory service delivery. All PCTs currently have a statutory responsibility (Department of Health 2001, Department of Health 2003) to assess the HIV health promotion needs of their resident population. They also have a responsibility to commission services to meet as much need as possible in the most equitable manner. However, the extent to which some health promotion aims are met, the obstacles to them being met and the health promotion initiatives that may best achieve them, can transcend PCT boundaries. Some needs therefore require assessments across geographic areas larger than single PCTs. Provision and planning for such assessments will require support from Strategic Health Authorities, from the Department of Health, and from HIV and African organisations.

From April 2008 the Local Government and Public Involvement in Health Act (2007) imposed a duty for PCTs and upper-tier local authorities to undertake Joint Strategic Needs Assessments (JSNAs) in order to better understand the current and future health and well-being needs of their populations. This system of joint strategic needs assessment currently informs the commissioning evidence base for interventions that result in improved health and well-being outcomes, and in the reduction of health inequality (Department of Health 2007). In addition to this, the Equality and Human Rights Commission (EHRC) operates to safeguard policy and practice responding to the particular needs of ethnic and sexual minorities. Support from the EHRC will be critical for those agencies and voluntary sector consortia seeking to ensure that the HIV prevention needs of Africans are appropriately met.

A reliable sexual health and HIV evidence base requires not only the participation of individuals and service providers, it also requires that local commissioners and national funders collect and make available transparent data for evaluating policy change, including the surveillance and publication of resource allocations.

There is an increasing amount of attention being paid by funders to evidence of cost effectiveness for proposed HIV prevention interventions. The Centers for Disease Control and Prevention in the United States has produced an overview guide to assessing HIV prevention cost effectiveness that has relevance in all localities.

Organisational aims summary

ORGANISATIONAL AIM 1: NAHIP partner organisations increase the amount of funding they receive to undertake HIV prevention interventions. This will require:

  • Skilled senior staff (and board members) with an understanding of the funding environment, awareness of diverse funding sources and fund-raising experience.
  • Implementation of financial transparency, service monitoring and evaluation.
  • Confident relationships with NHS, local authority and charitable funders.

ORGANISATIONAL AIM 2: Organisations increase the priority given to HIV prevention needs by improving their leadership profile. This will require:

  • Board members and senior staff who model and maintain a commitment to lobbying and community-led activism and encourage the take-up of such activities among all workers and volunteers.

ORGANISATIONAL AIM 3: Organisations increase the extent to which they collect and utilise evidence in order to better meet HIV prevention need. This will require:

  • Recognition of the value of specific HIV prevention needs data.
  • Skills to interpret existing data and access to emerging evidence.
  • Commitment to participation in local and national needs assessments, and to ensuring that their value is recognised by staff, volunteers and service users alike.
  • Recognition of the different ways in which need can be assessed, and being sure not to be guided by existing service provision in the assessment of need.
  • Access to PCTs, local authorities and national research organisations to ensure that their assessments of need capture the specific health needs of migrants, members of Black and ethnic minorities, and people with diagnosed HIV.

ORGANISATIONAL AIM 4: Organisations prioritise and promote confidentiality. This will require:

  • A written policy on how confidentiality is managed in the organisation, and how breaches of confidentiality are managed.
  • Ability to use and store private information, and to explain the policy to service users.
  • Board members and senior staff with the communication skills and managerial ability to enforce the policy.

ORGANISATIONAL AIM 5: Organisations increase the extent to which they work in partnership with HIV-specific, African-specific and other specialist organisations and institutions. This will require:

  • Recognition that partnership work increases skills and strengthens outcomes.
  • Management in planning priorities and aims in partnership with relevant organisations.
  • Development of local and national databases of relevant organisations alongside the development of referral protocols with those agencies.

ORGANISATIONAL AIM 6: Organisations recruit and retain board members, workers and volunteers who share characteristics and experiences with the target group. This will require:

  • Community-based recruitment, and a commitment to ensuring that staff and volunteers feel valued, well-regarded and supported in their work.

ORGANISATIONAL AIM 7: Organisations ensure that workers and volunteers have the skills and attitudes that ensure they are approachable and trustworthy. This will require:

  • Clearly articulated expectations of the non-stigmatising approach to be undertaken.
  • Access to, and ability to interpret current HIV prevention evidence.
  • Job specifications and recruitment processes that clearly identify essential criteria.

ORGANISATIONAL AIM 8: Organisations ensure that all board members, workers and volunteers can model frank and open discussion about sex and sexuality. This will require:

  • Clearly articulated expectations of the professional and non-judgmental approach toward all expressions of sexuality.
  • Access to sexuality training and an ability to nterpret sexual behaviour research data.
  • Job specifications and recruitment processes that clearly identify essential criteria.

ORGANISATIONAL AIM 9: Organisations ensure that all board members, workers and volunteers can identify which service users’ needs they are not able to meet, and make appropriate referrals. This will require:

  • Understanding of the organisation’s mission and aims.
  • A database of related specialist organisations and strong working relationships with those agencies where the highest number of referrals are likely to be made.
  • Referral protocols that pay attention to issues of consent and privacy.

ORGANISATIONAL AIM 10: Organisations ensure that all board members, workers and volunteers adhere to clear standards of equality. This will require:

  • Awareness and application of equalities legislation as it applies to gender, race, sexuality and disability.
  • An organisational equalities statement that includes clear protocols for action when equalities standards are not met.

Policy aims summary

POLICY AIM 1: The Department of Health provides strategic and financial support for the appropriate national delivery of HIV prevention interventions for Africans. This will require:

  • Knowledge of PCT spending on sexual health promotion and HIV prevention.
  • Evidence of the social, medical and economic impact of the HIV epidemic in the UK.
  • Knowledge of interventions that meet HIV prevention needs.
  • Pressure from HIV and African community-based organisations.

POLICY AIM 2: The Department of Health reconsiders its view on charging irregular migrants with HIV for their treatment and care in recognition that it is a practice that costs more than it saves. This will require:

  • Political support from MPs, local councillors, and African community-based organisations.
  • Research evidence collected by public health and social science experts with support from statutory and community based organisations delivering services to African people.

POLICY AIM 3: The Department for Education incorporates into the national curriculum, a programme of sexual health and relationships education that reflects the experiences and practices of people of diverse sexualities and backgrounds. In order to do so, it will require:

  • Support from MPs, parents, teaching associations, and faith groups.
  • Research evidence collected by public health and social science experts.
  • Resources to establish a curriculum and train professionals for its delivery.

POLICY AIM 4: Anti-racist and anti-homophobic education initiatives are maintained and extended throughout the education system. This will require:

  • Initial and continuing provision of equality training for all staff (including non-teaching staff).
  • Improved access to resources.
  • Equality auditing in all educational settings that includes input from students and staff.
  • Evaluation of the Citizenship curriculum in relation to equality outcomes.

POLICY AIM 5: All agencies involved in criminal prosecutions for the reckless sexual transmission of HIV (Home Office, Crown Prosecution Services, NHS services and the Association of Chief Police Officers) continue to improve their approaches to such prosecutions in light of the detrimental public health impact that they are likely to have. In order to do so, they require:

  • Evidence of the health and race equality impact of prosecution.
  • Interaction with people representing people with HIV and those working with them.
  • Collaboration with and support from the Department of Health.

POLICY AIM 6: The UK Border Agency and Offender Health increase their actions to ensure prison and detention services meet the HIV prevention, treatment and care needs of inmates of prisons, young offenders institutions and migrant detention centres. In order to do so, they require:

  • Liaison with each other and cross-departmental consultation on best practice in detention.
  • Evidence from clinical HIV specialists and public health experts on the needs of inmates and detainees.
  • Political and public support for improved conditions in migrant detention settings, prisons and youth offender institutions.

POLICY AIM 7: The Home Office reconsiders its policy of dispersing asylum seekers across the country in light of the general health and HIV prevention needs that can be met when people are able to socialise and live in areas of their choosing. This will require:

  • Evidence from Local Authorities, Strategic Health Authorities, voluntary sector organisations and PCTs assessing the race equality and health impact of dispersal.
  • Political and public support for improved living conditions for people seeking asylum in England.

POLICY AIM 8: The Home Office reconsiders its policy of disallowing asylum seekers from seeking legal employment in light of the impacts that this restriction has on health and well-being in general and HIV transmission in particular. This will require:

  • Evidence from Local Authorities, Strategic Health Authorities, voluntary sector organisations and PCTs on the social and health impact of poverty and unemployment.
  • Political and public support for improved living conditions for people seeking asylum in England.

POLICY AIM 9: Central government departments (particularly the Department for International Development) intensify their roles in the development of international policies and activities that directly and indirectly influence the HIV pandemic. This will require:

  • Motivation to deliver on international level agreements.
  • Improved cross-departmental collaboration between the Home Office, Ministry of Justice, Department of Health and Department for International Development to ensure that domestic and international agendas are mutually supportive.
  • Lobbying from HIV and anti-poverty organisations.
  • Collaboration among scientists in order to ensure that advances are shared fully and expediently.
  • Continuing pressure on pharmaceutical companies to reduce the costs of all HIV anti-retroviral treatments.
  • Contributing the promised amount to the Global Health Fund.
  • Meaningful participation in global monitoring exercises including those carried out in relation to the United Nations International Declaration on HIV / AIDS (2001), to which the UK is a signatory country.
  • Continued support to strengthen health professional infrastructure (i.e. resources for training, improved pay and working conditions) in developing countries.

POLICY AIM 10: An increase in the proportion of Strategic Health Authorities that include targets for HIV in their planning and performance monitoring mechanisms. This will require:

  • A nominated lead for sexual health and HIV at every SHA.
  • Knowledge of local HIV epidemic, priority groups and prevention needs.
  • Health promotion expertise.
  • Data on HIV prevention spending in each PCT (disaggregated from sexual health spending).

POLICY AIM 11: NHS commissioners ensure that HIV prevention is adequately resourced, and that such funds are not diverted to help manage shortfalls in other areas. This will require:

  • Accessible information on current and past HIV prevention spending (clearly disaggregated from sexual health spending) in every PCT.
  • Access to evidence of local HIV prevention need among Africans, alongside Race Equality Impact, Health Impact and Joint Strategic Needs Assessments, as well as the skills and capacity to interpret and act on these.
  • Lobbying from HIV and African organisations.

POLICY AIM 12: All NHS and local authority commissioners increase consortia commissioning arrangements for programmes of HIV prevention for African people across PCT and local authority boundaries. This will require:

  • A planning framework with real input from the community organisations and individuals.
  • A consensus between PCTs and HIV health promoters on the minimum standards for local HIV prevention programmes.

POLICY AIM 13: An increase in sexual health promotion interventions for African people already diagnosed with HIV by HIV care and treatment providers. This will require:

  • An understanding of unmet HIV prevention need among service users.
  • Knowledge of interventions that meet HIV prevention need.
  • Knowledge of other (non-clinical) services for referral.

POLICY AIM 14: NHS service providers ensure that HIV prevention interventions targeting Africans are accessible, appropriate and effective. This will require:

  • Confidentiality policies that are understood by service users.
  • Knowledge of the practical and linguistic needs of service users.
  • Understanding and recognition of traditional, religious and sexual practices that will impact on sexual health outcomes.

POLICY AIM 15: NHS providers reduce the extent to which service users are subjected to discrimination based on ethnicity, sexuality, gender, migration status or HIV status. This will require:

  • Access to evidence of discrimination in the delivery of health services.
  • Knowledge of interventions that reduce practices of inequality in the delivery of health services.

POLICY AIM 16: All clinical staff in primary care, emergency services, specialist care and GUM services (either clinic or community-based) increase offers of HIV tests to African men and women attending for STI screening or presenting with HIV-related illnesses, and seek informed consent for testing. This will require:

  • Policy on offering HIV testing and the skills to identify opportunistic illnesses that indicate HIV infection.
  • Ability to raise and talk about HIV testing without making service users feel obliged to take a test.
  • Ability to explore past and potential opportunities for infection and onward transmission with clients.
  • Ability to educate service users about the benefits and drawbacks of both a positive and negative test results.
  • Ability to clearly identify for service users who is and is not eligible for HIV treatment without charge.
  • An appreciation that some Africans will decline HIV testing without wishing to disclose a reason.
  • Agreed minimum quality standards for testing services.

POLICY AIM 17: All emergency and GUM services (either clinic or community-based), increase the availability of post-exposure prophylaxis (PEP) to African people (and the sexual partners of African people) that may have been sexually exposed to HIV. This will require:

  • Access to guidance on the use of PEP.
  • Clinicians with the skills to assess men’s and women’s need for PEP.
  • An accessible evidence base about the performance qualities of interventions.
  • Community support and lobbying for making PEP available.

POLICY AIM 18: Local service providers increase the delivery and commissioning of services which reduce the HIV prevention needs of African people. This will require:

  • Understanding of and access to local and national evidence of HIV prevention need among African people.
  • Knowledge of interventions to meet HIV prevention need.
  • Clearly articulated and continually enforced equality policies.
  • Lobbying from equality bodies such as the Equality and Human Rights Commission to undertake Race Equality and Health Impact Assessments on procurement and delivery of services.
  • Collaboration with community-based HIV and African organisations.

POLICY AIM 19: All local authority and NHS commissioners responsible for HIV and / or sexual health increase their contribution to the national sexual health and HIV evidence base by collecting and making available transparent data for evaluating policy change, including the publication of resource allocations. This will require:

  • Adequate and stable intervention monitoring systems.
  • Research designs that take account of the context of service delivery.
  • Research funders to specify service involvement in research design.

Page last updated: 17 January 2012