Jane Anderson Homerton University Hospital London & Public Health England Black and minority ethnic groups and HIV: What's new?

Black and Minority Ethnic Identities (BME) BME represent a diverse set of communities and identities. Self-identification may be complex and vary between settings. Country of origin, parental origin, faith and cultural identity all intersect. Categorisation is important for epidemiology and statistics, but does not translate into lived experience. The experience and stage of migration gives additional complexity

STI diagnosis rate, by ethnic group, England, STIs in the BAME population 8.3% 7.8% 13.6% 12.3% Data source: GUM returns to GUMCADv2 (data as of ) *First episode ** Primary, secondary or early latent

HIV: An evolving epidemic 107,800 people are now living with HIV in UK (26,000 unaware). 6,000 people newly diagnosed with HIV infection in New HIV diagnoses among MSM is the highest number ever reported in UK. One in four people living with diagnosed HIV infection is now aged 50 years or more (improved survival and continued transmission). HIV prevalence of HIV approximately 30 times higher for MSM and black-African men and women compared to the general population in EnglandI Public Health England. HIV in the United Kingdom: 2014 Report

HIV: An evolving epidemic : where? Nearly 1 in 3 local authorities have diagnosed HIV prevalence of ≥ 2 per 1,000 population HIV prevalence among MSM: 1 in 8 living with HIV in London 1 in 26 elsewhere in UK HIV prevalence: highest in most deprived areas 6Public Health England. HIV in the United Kingdom: 2014 Report

Estimated number persons living with HIV infection (diagnosed and undiagnosed), UK

HIV: An evolving epidemic People living with HIV can expect a near-normal life span IF diagnosed promptly and access NHS care. A quarter of people estimated to be living with HIV: unaware of their infection. The proportion of people diagnosed late is far too high at 42%. Changing definition of “Late” following results of START trial. 8 Public Health England. HIV in the United Kingdom: 2014 Report

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World region of birth: People newly diagnosed with HIV 11 Data Courtesy of Public Health England

Newer communities: Latin American people High risk sexual activity, including sex work Latin Americans living in areas of high HIV prevalence. 1 in 8 MSM diagnosed with HIV in 2011 were born in Latin America. Brazilian born MSM high rates of newly diagnosed HIV in London: in % were infected in the UK STI diagnoses in Londoners born in Latin America twice the national average. Poor engagement with UK health services

“Lets Stop HIV” partnership CLAUK – work to gain recognition of LA as an ethnic minority Partnership with NAZ Project London 226 Latin American people 68% had never accessed health services in the UK Significant increase in HIV related knowledge, skills and behaviour 137 HIV tests carried out – 2 new reactive tests Data courtesy NAZ Project London

Heterosexually Acquired HIV

What about Women? 82% of women living with HIV in the UK are from BAME communities 75% of women newly diagnosed with HIV are from BAME communities 67% of women living with HIV are Black African Thank you to NAZ Project London for infographic

31% of black African women are undiagnosed compared with 23% of non-black African women 51% women Black African women 31% Undiagnosed Other women 23% Diagnosed late 31% MSM Thank you to NAZ Project London for infographic

One Thousand Women Aim to develop a social movement to improve the mental and sexual health of Black, Asian and Minority Ethnic (BAME) Women Collaboration between The Afiya Trust and NAZ. Utilises social and professional networks of women to reach other BAME women Peer-to-peer network for learning and development of BME women to promote health and wellbeing and increase individual and community leadership

Overall question How do African women living with HIV in the UK engage with HIV services and interventions during and after pregnancy?

Group diagnosed before pregnancy: association between ethnicity and late booking *Adjusted for maternal age, parity and reporting region; AOR, adjusted odds ratio; CI, confidence interval Late antenatal booking AOR (95% CI)p White (reference)1.00- African1.98 (1.27, 3.07)0.002 Other black1.21 (0.60, 2.43)0.596 Other0.86 (0.37, 1.96)0.713 Unpublished data and slide courtesy Dr Shema Tariq.

Group diagnosed during pregnancy: association between ethnicity and late booking *Adjusted for maternal age, parity and reporting region; AOR, adjusted odds ratio; CI, confidence interval Late antenatal booking AOR (95% CI)p White (reference)1.00- African2.98 (1.45, 6.11)0.003 Other black3.74 (1.28, 10.94)0.016 Other1.02(0.35, 2.93)0.978 Unpublished data and slide courtesy Dr Shema Tariq.

Association between maternal African region of birth and not taking ART in pregnancy AOR 1.77 p=0.005 Source: Tariq et al. IAS 2011: abstract TUPE283 Slide courtesy of Dr Shema Tariq

8/15 women described negative experiences of maternity care Source: Tariq et al. BHIVA 2014: abstract P136 “I could hear the midwife outside telling the other one to be careful as I was ‘high, high risk” When I think about the experiences I had…I wanted four or five kids. Now I said to my husband ‘no, this is the end of it’.

Infant feeding: The balance of risks Newer Data : Effective ARV therapy reduces breastfeeding transmission. BUT in these studies transmission rates are higher than the 0.1% achieved in the UK with replacement feeding UK advice remains that women with HIV should avoid breastfeeding Mofenson, L.M., Antivir Ther, (4): p Taylor, G., et al. HIV Med, (7): p

African women with HIV in London The majority of HIV-positive mothers abstain from breastfeeding. Formula-feeding comes at high social and personal cost. There are significant structural, cultural and personal barriers to formula-feeding for African women living with HIV in the UK A potentially significant intervention is the free and consistent provision of formula milk and feeding equipment to all HIV-positive women across the UK. Important sources of support include partners, peer support groups, voluntary sector organisations and healthcare professionals Tariq,S In press

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Ethnicity, Sexual Orientation and Health Black men who have sex with men (MSM) are 15 times more likely to be HIV positive compared with general population. 1 A third of Asian men and mixed ethnicity men experience domestic abuse since 16yrs compared to 1 in 5 white gay and bisexual men. 2 7% of black gay and bisexual men have never tested for any sexually transmitted infection compared to 26% white gay and bisexual men. 3 Significantly higher rates of suicide, self harm and mental ill health. 4 Ethnic minority gay men living with HIV are prone to more psychological stress than white gay HIV positive men Supporting the Health and Wellbeing Needs of Black and Ethnic Minority Gay and Bisexual Men

PHE: BME MSM Project AIM- to improve the understanding, visibility and response to the health and wellbeing needs of BME MSM Managed and run by PHE with partner organisations Supported through funding from the MAC AIDS Foundation for 12 months

Wider context of Gay/Bi/MSM Men Work 29BME MSM Project Update

30BME MSM Project Update Behavioural Change Interventions Learning Sets Learning Sets E-learning Module E-learning Module Online Platform BME LGBT Image Bank BME MSM Project Behaviour change pilots - individual intervention pilot (METRO) Behaviour change pilots - group intervention with HIV positive men (NAZ) Behaviour change pilots - group intervention (NAZ) Targeted pilot – group intervention (The Quest)

31BME MSM Project Update Behavioural Change Interventions E-learning Module E-learning Module Online Platform BME LGBT Image Bank BME MSM Project LGBT – (GMFA) Faith – (Faith Action) BME – (Race Equality Foundation) Joined sets – (All partners) Learning Sets Learning Sets

32BME MSM Project Update Behavioural Change Interventions Learning Sets Learning Sets E-learning Module E-learning Module Online Platform BME LGBT Image Bank BME MSM Project Royal College of General Practitioners | RCGP (Online learning environment) 2 Modules Evaluation: pre- and post-course assessment, qualitative user feedback, usage report Peer-review (by Friday 15 th May 2015)

33BME MSM Project Update Behavioural Change Interventions Learning Sets Learning Sets E-learning Module E-learning Module BME LGBT Image Bank BME MSM Project North East - Yorkshire Mesmac North west - Manchester Lesbian and gay Foundation Midlands - Birmingham LGBT Centre Leicester - Trade Sexual Health. Online Platform.org.uk

35BME MSM Project Update Behavioural Change Interventions Learning Sets Learning Sets E-learning Module E-learning Module BME MSM Project GMFA-NAZ joint initiative to deliver a range of high quality and diverse images of BME LGBT people For use in Public Health England and Department of Health materials. Online Platform BME LGBT Image Bank

36BME MSM Project Update Evaluation tool (De Montfort University) Behavioural Change Interventions Learning Sets Learning Sets E-learning Module E-learning Module BME LGBT Image Bank  Individual (Metro)  Group (NAZ)  Group (Quest)  HIV + (NAZ)  Faith (Faith Action)  Race (REF)  MSM (GMFA)  Royal College of General Practitioner  NAZ  GMFA / NAZ Advisory Board BME MSM Project Online Platform

HIV amongst black and minority ethnic populations and migrants is an unacceptable health equity issue. Tension between targeted and inclusive universal provision and the trajectory for change. In some areas the ethnic population is now the majority, how will that reframe the approach? Success will require a comprehensive approach with joined up and collaborative working across sectors and institutional boundaries. Coproduction approach to interventions and solutions key to success Talking about and tackling racism and discrimination is part of the solution. 37 Supporting the Health and Wellbeing Needs of Black and Ethnic Minority Gay and Bisexual Men In Summary