Late HIV diagnosis of people from culturally and linguistically diverse backgrounds in Sydney: The role of culture and community

Men of refugee and migrant backgrounds in Australia: a scoping review of sexual and reproductive health research

Australia's National Men's Health Strategy 2020-2030 identifies refugee and migrant men from culturally and lingustically diverse backgrounds as priority groups for sexual and reproductive health (SRH) interventions. The paucity of SRH research focusing on refugee and migrant men is a significant gap to advance men's health and policy. Hence, this review aimed to synthesise the available evidence on refugee and migrant men's SRH needs, understandingsand experiences of accessing services after resettlement in Australia. A systematic search of peer reviewed literature in PubMed, Scopus, and PsyInfo was made. A World Health Organization framework for operationalising sexual health and its relationship with reproductive health was used to map the identified studies. The socio-ecological framework was applied to thematically synthesise data extracted from individual studies and identify factors that influence the SRH of refugee and migrant men. We included 38 papers in the review. The majority of sexual health studies (16) were about sexually transmitted infections (STIs), mainly HIV (12), followed by sexual health education and information (5) and sexual functioning (3). Reproductive health studies focused on contraceptive counselling and provision (3), antenatal, intrapartum and postnatal care (1) and safe abortion care (1). Several factors influenced refugee and migrant men's SRH, including a lack of access to SRH information, language barriers and stigma. We found that SRH literature on refugee and migrant men focuses on STIs, meaning other areas of SRH are poorly understood. We identified key gaps in research on experiences of, and access to, comprehensive SRH care.

Experiences, perceptions and expectations of health services amongst marginalized populations in urban Australia: A meta-ethnographic review of the literature

Background

Poor health outcomes amongst marginalized groups result in part from health inequities related to social and structural determinants of health. Marginalized people report higher incidences of comorbidities, chronic disease and adverse health behaviours than their nondisadvantaged peers. The objective of this review is to examine marginalized Australians' experiences of and access to community‐based primary health services in urban locations.

Methods

A systematic search incorporating related MeSH terms and synonyms pertaining to marginalized Australian populations and their health‐seeking was conducted across seven databases. We included qualitative studies that reported experiences of health‐seeking within community‐based primary health care in metropolitan Australia. Participant populations experiencing marginalization due to social stigma and isolation, early‐life disadvantage, poor health and/or financial hardship were included. A meta‐ethnographic framework was used to synthesize themes across selected studies and researcher triangulation was employed to develop higher‐order themes.

Results

Search results revealed 26 studies included for critical appraisal and synthesis. Seven higher‐order themes were developed describing experiences of health service engagement amongst marginalized groups: (1) Understanding the patient within the context of family and community, (2) Health and cultural beliefs influence health‐seeking, (3) Lack of information and poor cultural competence limit utilization of services, (4) Motivation for treatment influences health service engagement, (5) Accessing services, a spectrum of experience—from discrimination to validation, (6) Navigating a complex system in a complex society, (7) Preferences for health care and expectations for systemic change.

Conclusion

Marginalized Australians experience health disadvantage across micro, meso and macro levels of health system navigation and commonalities in health‐seeking were identified across each of the distinct marginalized groups in our analysis. This review outlines important areas of consideration for health care provision and policy development essential to helping address health inequities for a diversity of marginalized populations.

Patient or Public Contribution

Whilst patient voices were reported across all studies included within this review, no further patient or public contribution applies to this study.

Overcoming barriers to HIV pre-exposure prophylaxis (PrEP) coverage in Australia among Medicare-ineligible people at risk of HIV: results from the MI-EPIC clinical trial

Background Overseas-born people who are ineligible for government-subsidised health care experience barriers to accessing HIV pre-exposure prophylaxis (PrEP) in Australia. This study aimed to assess a program providing free PrEP to overseas-born adults at risk of acquiring HIV. Methods Medicare-Ineligible Expanded Implementation in Communities (MI-EPIC) was a single-arm, open-label trial of daily tenofovir disoproxil fumarate/emtricitabine as PrEP. Six clinics recruited Medicare-ineligible adults who met HIV risk criteria in New South Wales, Australia. We recorded data on HIV and sexually transmitted infection (STI) diagnoses, and PrEP dispensing from July 2019 to June 2020. PrEP adherence as a medication possession ratio (MPR) was calculated as pills dispensed divided by days. We administered an optional survey on behaviours and attitudes to PrEP and sexual health. Results The 221 participants (206 men; 93.2%) had a median age of 29years (IQR 26-34). Participants were mostly born in Asia (53.4%), Latin America or the Caribbean (25.3%), or Europe (10.9%). Adherence was high; 190 participants (86.0%) had an MPR of >60%. Of 121 survey participants, 42 (34.7%) completed the survey in a language other than English. Of participants who had not used PrEP in the 6months before enrolment (n=45, 37.2%), the most common reasons were cost (n=22, 48.9%), and lack of knowledge about accessing PrEP (n=20, 44.4%). Conclusions Medicare-ineligible people at risk of HIV demonstrate high adherence when given access to free PrEP and translated information. Increasing PrEP awareness and reducing barriers to accessing PrEP in this high-risk population should be priorities in HIV prevention.

Stigma Mechanisms and Outcomes among Sub-Saharan African Descendants in Belgium-Contextualizing the HIV Stigma Framework

HIV-related stigma and discrimination are recognized barriers to HIV prevention, testing and treatment among people of Sub-Saharan African descent (SSA) origin living in Belgium, but insights into HIV related-stigma mechanisms and outcomes are lacking for this population with high HIV prevalence. Guided by Earnshaw and Chaudoir’s stigma framework (2009), we conducted this qualitative study using 10 focus-groups with 76 SSA community members and 20 in-depth interviews with SSA descendants living with HIV to explore specific HIV-stigma mechanisms and outcomes and underlying drivers. Inductive and deductive thematic analysis showed high degrees of stigma among SSA communities driven by fear of HIV acquisition and misconceptions in a migration context, negatively affecting SSA descendants living with HIV. The results allowed for contextualization of the framework: At the community level, prejudices and stereotypes were major stigma mechanisms, while physical distancing, gossips, sexual rejection, violence and increased HIV prevalence emerged as stigma outcomes. Among SSA descendants living with HIV, enacted, anticipated and internalized stigmas were validated as stigma mechanisms, with witnessed stigma as an additional mechanism. Self-isolation, community avoidance and low utilization of non-HIV specialized healthcare were additional outcomes. These results are relevant for tailoring interventions to reduce HIV-related stigma.

Getting the right message: a content analysis and application of the health literacy INDEX tool to online HIV resources in Australia

Health literacy is considered by some as a determinant of health. Research suggests that different levels of health literacy may be associated with human immunodeficiency virus (HIV) knowledge and behaviour, including willingness to test. This study assessed the health literacy demands of existing Australia HIV prevention resources available online using a health literacy assessment and content analysis. Two reviewers assessed 66 resources using the Health Literacy INDEX. Sixty-one (92%) scored below 50%, with an average score of 35.5%. A coding frame was developed to conduct a content analysis of the resources excluding videos, multiple webpages and booklets (n = 52). We coded for six categories of knowledge: HIV knowledge (100% of resources), transmission (96%), acquired immune deficiency syndrome (AIDS) knowledge (88%), testing (87%), consequence of infection (85%) and prevention (77%). We found that resources required a reading grade above grade 8, and very few resources considered audience appropriateness. There were missed opportunities to encourage HIV prevention or testing. Some resources used incorrect language to refer towards people living with HIV, and transmission and prevention messages were often inconsistent. Guidelines for developing HIV prevention resources are warranted to improve health literacy, accessibility and appropriateness of resources and ensure consistent messages and framing of HIV risk.

"Moving from one environment to another, it doesn't automatically change everything". Exploring the transnational experience of Asian-born gay and bisexual men who have sex with men newly arrived in Australia

Asian-born gay, bisexual and other men who have sex with men (gbMSM) who are newly arrived in Australia are at a higher risk of acquiring HIV than Australian-born gbMSM. We used a social constructionist framework to explore HIV knowledge and prevention strategies used by newly-arrived Asian-born gbMSM. Twenty four Asian-born gbMSM, aged 20–34 years, attending Melbourne Sexual Health Centre, who arrived in Australia in the preceding five years, participated in semi-structured, face-to-face interviews. Interviews were recorded, transcribed verbatim and analysed thematically. Participants described hiding their sexual identities in their country of origin, particularly from family members, due to fear of judgement and discrimination resulting from exposure to sexual identity and HIV related stigma in their countries of origin, although some were open to friends. Despite feeling more sexual freedom and acceptance in Australia, many were still not forthcoming with their sexual identity due to internalised feelings of stigma and shame. Exposure to stigma in their country of origin led many to report anxiety around HIV testing in Australia due to a fear of testing positive. Some described experiencing racism and lack of acceptance in the gay community in Australia, particularly on dating apps. Fear of discrimination and judgement about their sexual identity can have a significant impact on Asian-born gbMSM living in Australia, particularly in terms of social connectedness. Additionally, HIV-related stigma can contribute to anxieties around HIV testing. Our data highlights the potential discrimination Asian-born gbMSM face in Australia, which has implications for social connectedness, particularly with regard to LGBTQI communities and HIV testing practices. Future studies should determine effective strategies to reduce sexual identity and HIV-related stigma in newly-arrived Asian-born gbMSM.

HIV in practice: current approaches and challenges in the diagnosis, treatment and management of HIV infection in Australia

As treatment improves, people living with HIV (PLWHIV) can now expect to live longer, which means that the foci of HIV-related care for them and their medical practitioners continue to change. With an increasingly older cohort of patients with HIV infection, practitioners' key considerations are shifting from issues of acute treatment and patient survival to multiple comorbidities, toxicities associated with chronic therapy, and ongoing health maintenance. Within this context, this paper explores the current standard of practice for the management of HIV infection in Australia. We surveyed 56 Australian practitioners currently involved in managing HIV infection: 'HIV section 100' (HIV therapy-prescribing) general practitioners (s100 GPs; n = 26), sexual health physicians (SHPs; n = 24) and hospital-based physicians (HBPs; n = 6). Survey results for practice approaches and challenges were broadly consistent across the three practitioner specialties, apart from a few key areas. s100 GPs reported less prophylaxis use among patients whom they deemed at risk of HIV infection in comparison with SHPs, which may reflect differences in patient populations. Further, a higher proportion of s100 GPs nominated older HIV treatment regimens as their preferred therapy choices compared with the other specialties. In contrast with SHPs, s100 GPs were less likely to switch HIV therapies to simplify the treatment protocol, and to immediately initiate treatment upon patient request in those newly diagnosed with HIV infection. Considerably lower levels of satisfaction with current HIV practice guidelines were also reported by s100 GPs. It appears that greater support for s100 GPs may be needed to address these identified challenges and enhance approaches to HIV practice. Across all specialties, increasing access to mental health services for patients with HIV infection was reported as a key management issue. A renewed focus on providing improved mental health and wellbeing supports is recommended, particularly in the face of an ageing HIV-infected population.

Two decades of surveillance data show late presentation among a diverse group of women diagnosed with HIV in Victoria, Australia

OBJECTIVE

To develop an HIV response suited to women and to inform appropriate services, we describe the characteristics of women diagnosed and living with HIV using 22 years of high-quality surveillance data.

METHODS

Data on women newly diagnosed with HIV between 1994 and 2016 and women living with diagnosed HIV in Victoria at 31 December 2016 were extracted from the Victorian Public Health Surveillance System. Descriptive analysis by place of birth was performed and Poisson regression used to assess trends over time.

RESULTS

There were 465 new diagnoses among women in Victoria between 1994 and 2016 and 613 women living with HIV in 2016. Women were diagnosed late, and frequently reported no HIV testing history, AIDS-defining illness or other symptoms of HIV at diagnosis. These indicators of delayed diagnosis were even greater for non-Australian-born women. Conclusions and implications for public health: For Victoria to reach the ambitious targets for diagnosis, treatment and viral suppression in 95% of people living with HIV, prevention programs and efforts to increase early diagnosis as well as support services must consider the epidemiology and diversity of women.

What Works? Prevention and Control of Sexually Transmitted Infections and Blood-Borne Viruses in Migrants from Sub-Saharan Africa, Northeast Asia and Southeast Asia Living in High-Income Countries: A Systematic Review

Migration is a significant risk factor for the acquisition of human immunodeficiency virus (HIV), hepatitis B virus (HBV) and other sexually transmitted infections (STIs). An increasing proportion of these infections in high-income countries, such as Australia, are among migrants moving from low and middle-income countries with a high prevalence of HIV, HBV and other STIs. This systematic review explored the prevention and control of HIV, HBV and other STIs in migrants (>18 years) from Southeast Asia, Northeast Asia and sub-Saharan Africa living in high-income countries with universal health care. This systematic review followed PRISMA guidelines and was registered with PROSPERO. Six academic databases were searched for articles published between 2002 and 2018. Sixteen peer-reviewed articles met the inclusion criteria, consisting of fourteen quantitative and two qualitative studies conducted in Australia, the Netherlands, Canada, Spain, Italy, and Germany. Three levels of interventions were identified: individual, community and structural interventions. Most studies addressed factors at an individual level; interventions were most commonly outreach testing for HIV, HBV and other STIs. Few studies addressed structural factors or demonstrated comprehensive evaluation of interventions. Limited population-specific findings could be determined. To prevent further transmission of HIV, HBV and other STIs, comprehensive public health approaches must consider the complex interactions between migration, health care system determinants, and broader socioeconomic and sociocultural factors.

Why I Can't, Won't or Don't Test for HIV: Insights from Australian Migrants Born in Sub-Saharan Africa, Southeast Asia and Northeast Asia

People born in sub-Saharan Africa and Southeast Asia are overrepresented in HIV notifications in Australia. Just under half of all notifications among people from sub-Saharan Africa and Southeast Asia are diagnosed late. Increased HIV testing among these communities is necessary to ensure early diagnosis, better care and reduce likelihood of HIV onward transmission. Recently, Australia has made new HIV testing methods available: rapid HIV testing and self-testing kits. We conducted 11 focus groups with 77 participants with people from sub-Saharan Africa, Southeast Asia and Northeast Asia in four jurisdictions in Australia. Focus groups discussed barriers to HIV testing and the acceptability of new testing methods. Barriers to HIV testing included: cost and eligibility of health services, low visibility of HIV in Australia, HIV-related stigma, and missed opportunities by general practitioners (GPs) for early diagnosis of HIV and linkage into care. Participants had low levels of knowledge on where to test for HIV and the different methods available. Diverse opportunities for testing were considered important. Interventions to increase HIV testing rates among sub-Saharan African, Southeast Asia and Northeast Asian migrants in Australia need to be multi-strategic and aimed at individual, community and policy levels. New methods of HIV testing, including rapid HIV testing and self-testing, present an opportunity to engage with migrants outside of traditional health care settings.

Sexual Health Help-Seeking Behavior among Migrants from Sub-Saharan Africa and South East Asia living in High Income Countries: A Systematic Review

The number of migrants has increased globally. This phenomenon has contributed to increasing health problems amongst migrants in high-income countries, including vulnerability for HIV acquisition and other sexual health issues. Adaptation processes in destination countries can present difficulties for migrants to seek help from and gain access to health services. This study examined migrants’ from sub-Saharan Africa (SSA) and South East Asia (SEA) sexual health help-seeking behavior in high-income countries with universal health coverage. The systematic review followed PRISMA guidelines and was registered with PROSPERO. Several databases were searched from 2000 to 2017. Of 2824 studies, 15 met the inclusion criteria. These consisted of 12 qualitative and three quantitative studies conducted in Australia, Spain, the United Kingdom, Belgium, Scotland, Ireland, and Sweden. Migrants experienced a range of difficulties accessing health services, specifically those related to sexual health, in high-income countries. Few studies described sources of sexual health help-seeking or facilitators to help-seeking. Barriers to access were numerous, including: stigma, direct and indirect costs, difficulty navigating health systems in destination countries and lack of cultural competency within health services. More culturally secure health services, increased health service literacy and policy support to mitigate costs, will improve health service access for migrants from SSA and SEA. Addressing the structural drivers for stigma and discrimination remains an ongoing and critical challenge.

HIV knowledge and use of health services among people from South-East Asia and sub-Saharan Africa living in Western Australia

BACKGROUND

HIV notifications among people born in sub-Saharan Africa and South-East Asia have increased in Australia in the last decade. People born in these regions have the highest rates of HIV diagnosis by region of birth and are overrepresented in late or advanced presentation of HIV infection.

METHODS

This study developed and tested a questionnaire for reliability through test-retest. A cross-sectional survey using intercept and online recruitment of HIV knowledge and use of health services was then undertaken among people born in sub-Saharan Africa and South-East Asia, who had arrived in Australia less than 10 years ago and were living in Western Australia (n = 209). Results were reported on by gender and length of time in Australia.

RESULTS

Participants had a reasonable knowledge of HIV transmission, but held a number of incorrect beliefs. Two-thirds (65%) of participants reported a barrier to accessing health services in Australia. Just over a third (34%) of participants had ever tested for HIV, despite indicating that they believed HIV testing was important.

CONCLUSIONS

This project indicates a very low rate of HIV testing among this priority population. Further action is required to improve early diagnosis of HIV and reduce onward transmission of HIV infection within these communities. SO WHAT?: We need targeted interventions that extend beyond knowledge to increase HIV testing rates among this population.

Motivations and Barriers to Treatment Uptake and Adherence Among People Living with HIV in Australia: A Mixed-Methods Systematic Review

In Australia, approximately 30% of people diagnosed with HIV are not accessing treatment and 8% of those receiving treatment fail to achieve viral suppression. Barriers limiting effective care warrant further examination. This mixed-methods systematic review accessed health and social sector research databases between November and December 2015 to identify studies that explored the perspective of people living with HIV in Australia. Articles were included for analysis if they described the experiences, knowledge, attitudes and beliefs, in relation to treatment uptake and adherence, published between January 2000 and December 2015. Quality appraisal utilised the Mixed Methods Appraisal Tool Version 2011. Seventy-two studies that met the inclusion criteria were reviewed. The interplay of lack of knowledge, fear, stigma, physical, emotional and social issues were found to negatively impact treatment uptake and adherence. Strategies targeting both the individual and the wider community are needed to address these barriers.

Migrant Sexual Health Help-Seeking and Experiences of Stigmatization and Discrimination in Perth, Western Australia: Exploring Barriers and Enablers

Increasing HIV notifications amongst migrant and mobile populations to Australia is a significant public health issue. Generalizations about migrant health needs and delayed or deterred help-seeking behaviors can result from disregarding the variation between and within cultures including factors, such as drivers for migration and country of birth. This study explored barriers and enablers to accessing sexual health services, including experiences of stigma and discrimination, within a purposive sample of sub-Saharan African, Southeast Asian, and East Asian migrants. A qualitative design was employed using key informant interviews and focus group discussions. A total of 45 people with ages ranging from 18 to 50 years, participated in focus group discussions. Common barriers and enablers to help seeking behaviors were sociocultural and religious influence, financial constraints, and knowledge dissemination to reduce stigma. Additionally, common experiences of stigma and discrimination were related to employment and the social and self-isolation of people living with HIV. Overcoming barriers to accessing sexual health services, imparting sexual health knowledge, recognizing variations within cultures, and a reduction in stigma and discrimination will simultaneously accelerate help-seeking and result in better sexual health outcomes in migrant populations.

Transmission and prevention of HIV among heterosexual populations in Australia

In Australia, unlike much of the rest of the world, HIV transmission through heterosexual contact remains a relatively rare occurrence. In consequence, HIV-prevention efforts have been firmly focused on male-to-male sex as the most frequent source of HIV transmission. There are emerging signs that this epidemiological landscape may be shifting, which raises questions about current and future HIV prevention strategies. Over the past decade, national surveillance data have shown an increase in HIV notifications for which exposure to HIV was attributed to heterosexual contact. This paper offers an epidemiological and sociocultural picture of heterosexual HIV transmission in Australia. We outline recent trends in heterosexually acquired HIV and discuss specific factors that shape transmission and prevention among people at risk of HIV infection through heterosexual contact. To illustrate the contextual dynamics surrounding HIV in this diverse population, we detail two key examples: HIV among people from minority ethnic backgrounds in New South Wales; and overseas-acquired HIV among men in Western Australia. We argue that, despite their differences, there are significant commonalities across groups at risk of HIV infection through heterosexual contact, which not only provide opportunities for HIV prevention, but also call for a rethink of the dominant HIV response in Australia.

HIV testing in primary care: feasibility and acceptability of provider initiated HIV testing and counseling for sub-Saharan African migrants

Provider-initiated HIV testing and counseling (PITC) is recommended to reduce late HIV diagnoses, common among Sub-Saharan African migrants (SAM) residing in Europe. Primary care represents an ideal entry point for PITC. To support Flemish general practitioners (GPs), we developed a culturally sensitive PITC tool. Over a 12-week period, 65 GPs implemented PITC to assess acceptability and feasibility of PITC. The qualitative evaluation showed high acceptability among physicians. Routine PITC was challenged by physicians' personal discomfort, assumptions of patients' sexual risk, perceived incoherence with reasons for consultation, and time pressure. The best opportunity for PITC was an indicated blood analysis for other medical reasons. Counseling skills improved during the implementation, but participants still advocated for reduced counseling requirements. PITC proved to be feasible in primary care settings, but the up-scaling requires a reformulation of counseling guidelines, a policy stipulating the role of GPs in the prevention-care continuum, and an investment in (continuous) training.

HIV among immigrants living in high-income countries: a realist review of evidence to guide targeted approaches to behavioural HIV prevention

BACKGROUND

Immigrants from developing and middle-income countries are an emerging priority in HIV prevention in high-income countries. This may be explained in part by accelerating international migration and population mobility. However, it may also be due to the vulnerabilities of immigrants including social exclusion along with socioeconomic, cultural and language barriers to HIV prevention. Contemporary thinking on effective HIV prevention stresses the need for targeted approaches that adapt HIV prevention interventions according to the cultural context and population being addressed. This review of evidence sought to generate insights into targeted approaches in this emerging area of HIV prevention.

METHODS

We undertook a realist review to answer the research question: 'How are HIV prevention interventions in high-income countries adapted to suit immigrants' needs?' A key goal was to uncover underlying theories or mechanisms operating in behavioural HIV prevention interventions with immigrants, to uncover explanations as how and why they work (or not) for particular groups in particular contexts, and thus to refine the underlying theories. The realist review mapped seven initial mechanisms underlying culturally appropriate HIV prevention with immigrants. Evidence from intervention studies and qualitative studies found in systematic searches was then used to test and refine these seven mechanisms.

RESULTS

Thirty-four intervention studies and 40 qualitative studies contributed to the analysis and synthesis of evidence. The strongest evidence supported the role of 'consonance' mechanisms, indicating the pivotal need to incorporate cultural values into the intervention content. Moderate evidence was found to support the role of three other mechanisms - 'understanding', 'specificity' and 'embeddedness' - which indicated that using the language of immigrants, usually the 'mother tongue', targeting (in terms of ethnicity) and the use of settings were also critical elements in culturally appropriate HIV prevention. There was mixed evidence for the roles of 'authenticity' and 'framing' mechanisms and only partial evidence to support role of 'endorsement' mechanisms.

CONCLUSIONS

This realist review contributes to the explanatory framework of behavioural HIV prevention among immigrants living in high-income countries and, in particular, builds a greater understanding of the suite of mechanisms that underpin adaptations of interventions by the cultural context and population being targeted.

Trends in the location of the HIV-positive population in Australia: Implications for access to healthcare services and delivery

Background: Examining existing and potential trends in the HIV-positive population in Australia is important for current and future healthcare service development and delivery. Methods: A new analysis of existing data on this population from the HIV Futures 5 survey was based on linking a geographic breakdown of respondents based on ‘area type’ – capital city or inner suburban, outer suburban, regional centre and rural – with patterns of healthcare service access. In addition, the distance between the postcode of the respondent’s residence and the postcode of the doctor seen for HIV-related treatment was calculated. An analysis of ‘area type’ by income and age was also conducted. Results: The ‘area type’ analysis showed important differences in patterns of access to antiretroviral prescriptions and choice of provider for HIV-related and general healthcare. The median distance travelled to see a doctor for HIV-related treatment was higher for those living in outer suburbs than those living in regional centres. Discussion: Differences in service use appear to be related to geographic accessibility of different service types. However, there may be other important social, economic and cultural factors involved. Ageing and socio-economic pressures may be influencing a move away from inner suburban areas where most HIV-specific care is located. This new analysis assists in finding the right balance between increasing the accessibility of HIV-specific services and ‘mainstreaming’. Longitudinal data collection would further assist in tracking trends in geographic location, and how often and at what intervals people living with HIV utilise healthcare services.

"It's better not to know": perceived barriers to HIV voluntary counseling and testing among sub-Saharan African migrants in Belgium

This study explored perceptions, needs, and barriers of sub-Saharan African migrants in relation to HIV voluntary counseling and testing (VCT). Using an inductive qualitative methodological approach, data were obtained from focus group discussions. Results showed that participants were in principle in favor of VCT. However, they indicated that barriers outweighed advantages. Such barriers included fear of positive test results and its related personal and social consequences, lack of information, lack of preventive health behavior, denial of HIV risk, and missed opportunities. Limited financial resources were only a concern for some subgroups like young people, asylum seekers, and recent migrants. This study identified multiple and intertwined barriers to VCT from a community perspective. In order to promote VCT, interventions such as raising awareness through culturally sensitive education should be adopted at community level. At level of service provision, provider initiated HIV testing including target group tailored counseling should be promoted.

Assessing the role of individual and neighbourhood characteristics in HIV testing: evidence from a population based survey

OBJECTIVES

Individuals living in deprived neighbourhoods have poor health outcomes, including human immunodeficiency virus (HIV) infection mortality. We assessed the association between individual and neighbourhood characteristics, and HIV testing across Canada.

METHODS

We used logistic regression modelling to evaluate this association in 2219 men and 2815 women, aged 18-54 years, in Canada, using data from the National Population Health Survey (1996/7),. Socio-economic characteristics and presence of a sexually transmitted infection (STI) were the individual level characteristics. Small area of residence was classified according to categories of material and social deprivation; these were the 'neighbourhood' variables in the model.

RESULTS

Ethnic minority women were less likely to report an HIV test than white women (OR 0.44, 95% CI: 0.23 to 0.86). Women without a regular doctor were significantly less likely to report ever having had an HIV test (OR 0.57, 95% CI: 0.35 to 0.93). Adjusting for individual level characteristics, we found that men and women living in the most materially deprived neighbourhoods were slightly less likely to report HIV testing than those living in the least deprived neighbourhoods (Men - OR 0.61, 95% CI: 0.34 to 1.08; Women - OR 0.62, 95% CI: 0.38 to 1.00).

DISCUSSION

Thus, living in poor neighbourhoods was associated with poor uptake of an HIV test. These economic disparities should be taken in account while designing future prevention strategies. Ethnic minority women were less likely to go for HIV testing and culturally appropriate messages may be required for prevention in ethnic minorities.

Implications and impact of the new US Centers for Disease Control and prevention HIV testing guidelines

Of the 1.2 million Americans estimated to be living with HIV in the United States, approximately 250,000 are unaware of their diagnosis and therefore unable to access clinical care and life-sustaining treatment. The revised 2006 US Centers for Disease Control and Prevention's guidelines for HIV testing recommend universal, routine, and voluntary HIV screening in public and private health care settings for all adults and adolescents between 13 and 64 years old. These major revisions present new challenges for health care providers, hospitals, government agencies, and community advocacy groups. In this review, we discuss the important issues in diverse care venues such as opt-out testing, consent and confidentiality, barriers to treatment, and financial impact. The implications of the revised recommendations for HIV testing are addressed in the context of a fragmented, overstressed, underfunded US health care system.