The rate of undiagnosed HIV infection among heterosexual
black Africans living in London remains unacceptably high, according to
research published in JAMA Network Open. Oral testing showed that
over 50% of men and 40% of women who reported they were HIV negative/untested
were in fact HIV positive. There were also high levels of HIV risk behaviour,
with a fifth of women and quarter of men reporting condomless last sex with a
partner of different or unknown HIV status in the past year.

“Despite efforts to increase HIV testing, uptake in black
African communities in London remains modest,” comment the investigators. “This
study identified a large fraction of undiagnosed infection – greater than other
at-risk populations – suggesting that the prevention and care needs of this
group are not adequately met.”

In the UK, black African heterosexuals are one of the
groups most affected by HIV. Surveillance data for 2016 suggests that 13% of
new diagnoses and almost a quarter of all HIV infections are in this
population. An estimated 12,300 black African heterosexuals were living with
HIV in London. Public Health England estimated that the rates of undiagnosed
HIV infection among black African men and women residing in London were 12% and
4%, respectively.

Dr Ibidun Fakoya of University College London and colleagues
wanted to determine the proportion of black African men and women in London who
had been tested for HIV in the past five years and to see what proportion of
these were living with HIV – both diagnosed and undiagnosed.

They therefore designed a cross-sectional study using
self-completed anonymous questionnaires that were distributed at social and
commercial venues popular with black African communities across London in late
2016. Participants were asked about their HIV testing history over the past
five years, HIV status, sexual behaviour, use of health services and knowledge
of pre-exposure prophylaxis (PrEP). They were also asked to provide a saliva sample for anonymous HIV
testing; the results were linked to the answers provided about HIV status in
the self-completed questionnaire.

Similar surveys were conducted in 1999 and 2004, and one of
the aims of the investigators was to see if rates of HIV testing and
undiagnosed infections had changed in the intervening years.

The final study population consisted of 604 individuals –
292 women (median age 31 years) and 312 men (median age 35 years). A saliva
sample for anonymous HIV testing was provided by 496 individuals, but in 33
instances (7%), testing was unsuccessful.

Ever testing for HIV was reported by 70% of women and 66% of
men, with 33% of women and 24% of men reporting a test in the previous 12 months. The proportion testing in the previous five years increased among both
men (40% to 51%) and women (51% to 53%) since the 2004 survey.

Factors associated with testing for HIV within the previous
five years among women included shorter period of residence in the UK (less
than five years vs more than 20 years), recent attendance at AE, ever
using a sexual health clinic and increasing number of sexual partners. Recent
testing among men was associated with being in the 25-34 age group, higher
education, being African born, using health services in the previous year,
sexual health clinic attendance and a previous diagnosis with an STI.

Oral HIV testing showed that 93% of women and 90% of men
were HIV negative. Tests were positive in 22 men (41% undiagnosed) and 16 women
(56% undiagnosed). In the previous survey, over 70% of infections were
undiagnosed in both men and women.

The investigators urge that the undiagnosed percentages
revealed in the present analysis should be viewed with some caution – other
surveillance data suggests that approximately 10% of HIV infections among black
African heterosexuals in the UK are undiagnosed.

In other findings, sexual health clinics were the most
popular location for HIV testing, followed by GP surgeries.

A fifth of women and a quarter of men said their most recent
sexual experience had involved condomless sex with a partner of different or
unknown HIV status. Only 72 women and 69 men said they had heard of PrEP and
only a very small proportion said they would be interested in using it.

“Almost half of respondents who supplied an HIV-positive
oral fluid specimen self-reported that they were HIV negative or untested,”
conclude the authors. “Increasing access to initiated HIV testing initiated by
health care professionals in primary care and other health care services, as
well as access to HIV self-testing and self-sampling may bolster HIV testing
rates so that they are similar to those in other populations disproportionately
represented by the HIV epidemic in England.”