Published: 15/04/2004, Volume II4, No. 5801 Page 10 11
New AIDS cases in the UK rose 20 per cent last year, with African migrants accounting for most of them.The government must act swiftly - but the wrong tack could lay it open to accusations of prejudice.
'We have to make sure churches do not preach that prayer - not medication - is the only cure.'
The Reverend Elias Moyo is chair of the nationwide Faith Health Project, which is battling to stop the rising rates of HIV and AIDS among the UK's African population from spiralling out of control. For him, education and efforts to reduce stigma around diagnosis go hand in hand with tackling cultural and religious messages around HIV and AIDS.
The vast majority of newly diagnosed cases of HIV in the UK are among migrants from the former British colonies of Africa. In February, the Health Protection Agency announced that there were 7,000 new cases of HIV in 2003, up 20 per cent in a year. As around 70 per cent of those are heterosexual African migrants, they have overtaken gay men as the largest single source of new HIV infections in the UK.
While black Africans make up less than 1 per cent of the UK population in the 2001 census, the HPA said they constituted 32 per cent of all HIV cases in the UK.
And nearly three-quartrs of HIV infections among heterosexuals diagnosed in 2001-02 were probably acquired in Africa, the HPA says. These statistics have already led to knee-jerk reactions from the usual political suspects raging about asylum seekers eating up hundreds of millions of pounds' worth of antiretroviral drugs.
Newspapers have published think pieces calling for compulsory testing for HIV and other serious infections such as tuberculosis at ports of entry. They point to the US and Australia, where prospective citizens must provide medical evidence that they are free of infection. Some European countries bar people with HIV on the grounds that they are too much of a burden on health services.
But the Terrence Higgins trust fears much of the debate on immigration and HIV is taking place to a backdrop of ignorance and false assumptions.
Last autumn it carried out an analysis of 60 migrants to Britain in touch with their services. It found that that three quarters of those surveyed had not been tested for HIV until nine months after they entered Britain - suggesting tabloid claims of immigrants coming to the UK in search for expensive NHS treatment are way off the mark.
Policy officer Lisa Power says the research, which has been passed to the Department of Health, also suggests claims of immigrants using asylum to access healthcare are also overstated. Just one in five immigrants in the survey were asylum seekers. A similar proportion came to Britain to study, or as a visitor, while 12 per cent were joining families already settled here.
She tells HSJ: 'If this research is borne out on a wider scale it will show it is just not effective to talk about testing people coming into this country - unless the government is prepared to test every visitor to the UK.'
The scale of the problem facing Britain is certainly large: Of around 50,000 people living with HIV in the UK, around one third are undiagnosed. Many of the undiagnosed are part of this African migrant group.
The government is aware that this is one of the thorniest problems it faces. For almost 12 months the Cabinet Office working group on imported infections has been mulling this over. As always, presentation is crucial and it is a particularly difficult issue for a Labour administration.
Which way does it go without courting accusations of racism and of pandering to prejudice from the left - and claims of being weak on asylum and immigration from the right, particularly at a time when leaks on immigration have already exposed holes in current procedures?
However, there is a growing awareness in government circles that the need for action is urgent.
Senior policy figures argue that it is the role of a modern left-ofcentre government to tackle these kind of sensitive issues head on.
Within this is a belief that it is better that an administration broadly sympathetic to the future of the UK's African community deals with the situation before it gets out of hand, and might be dealt with more harshly under a future Conservative government.
Then, of course, there is the ongoing consultation over the public health white paper. Included in the consultation was a series of questions about an individual's responsibility towards his fellow citizens. The first two dealt with passive smoking and anti-social behaviour. The third asked if the UK has 'got the balance right when it comes to considering the consequences of unprotected sex'.
This is not, say policy figures, a prelude to the government perching itself at the bottom of the nation's beds, but rather a desire to begin a debate around safe sex and personal responsibility. And, they say, nowhere is that debate more pressing than in the UK's African community.
Commission for Racial Equality chair Trevor Phillips wants affirmative action from the government and African communities and is lobbying health secretary John Reid to this end.
Last month he told a conference at the Terrence Higgins Trust of Africa HIV Prevention: 'The government must treat this as a health problem, not an immigration problem.
By all means provide the means for people to know their [HIV] status. But alongside this must go an all-out education campaign to ensure that African communities do the right thing. The NHS must consult existing ethnic minority service providers, faith and refugee groups on how to deliver sensitive and accessible services.'
National director for primary care Dr David Colin-Thomé says the problem of African HIV infection is focused on London and a large belt around the M25.
One of the biggest increases is in Bedfordshire, where 59 per cent of new infections are among Africans.
Luton Teaching PCT says that it is working with faith and community groups to encourage testing, early diagnosis and treatment. Dr Colin-Thomé says that rather than adopt a blanket strategy, 'local targeted initiatives and even specialised treatment centres might be an option'.
Dr Chris Taylor is a consultant in genito-urinary medicine at King's College Hospital covering Lambeth, Southwark and Lewisham, which has the highest rates of heterosexual HIV in England, possibly Europe, with more than one in 300 people living with the disease.
He says screening at point of entry would present massive practical and ethical problems.
'There are very high levels of HIV in Africa, south-east Asia and some parts of Europe.Who do you screen and what do you do with those who are positive? Send them home or keep them in isolation?'
Dr Taylor says his trust encourages testing and wants to help reduce some of the stigma around the disease. 'People do not present early.When they do they are very sick and present a significant burden for the health service. Even if you can stabilise them they might not be well enough to leave hospital for some time.'
He says King's has done excellent work on antenatal screening and help to cut levels of motherto-baby infection.
Dr Taylor acknowledges that significant pressure on beds is created by patients who have been adjudged illegal entrants by the government or whose asylum status is in question.
'In some cases if you have got someone who has been stabilised but who has got no legal recourse to social services we simply pay their air fare home to their families as it works out so much cheaper than having them in an acute bed. Numbers are difficult to judge - It is tens rather than hundreds a year in this situation.'
However, the Terrence Higgins Trust is opposed to the NHS behaving like an arm of the immigration services.
Policy officer Lisa Power says: 'The threat of sending people home can only discourage others from seeking help in the first place. If that happens, people stay highly infectious and continue to spread the disease. If people go home they know they will not get any healthcare.'
Elias Moyo, who preaches at Forest Gate Brethren in Christ Church in north-east London says the Faith Health Project works to encourage churches and community groups to spread the message of safer sex.
'We try to tell people that doctors and medicines are a gift from God. St Luke in the Bible was a physician, and they should use them. We also want to tell mothers who are HIV positive to use vouchers for formula milk rather than breast feed their babies and pass on the infection.'
Some fundamentalist Christian churches object to talking about condom use. The Reverend Moyo uses another approach: 'AIDS is seen as the leprosy of today.We always talk about using the right tools and knowledge to protect yourself.
'Some churches say that using a condom encourages promiscuity and that people should abstain.We talk about using 'preventive tools'.
You have to be careful with words.'
A Department of Health spokesman said no decisions have been taken about changing screening or treatment policies. 'The Cabinet Office working group on imported infections continue to act as a resource to ministers, providing evidence studies and advice.
No decisions on possible future steps have been taken.'
Dr Barry Evans, a consultant in communicable disease at the Health Protection Agency, and an expert on the epidemiology of HIV, sums up the dilemma.
'I am a liberal, with a small 'l', and have a social conscience. But we cannot go on with a cumulative 20 per cent year-on-year increase in [HIV] infections.
Some people will, of course, go back home to Africa; some people will die because they come to us when they are too ill. There has to be a solution that is consistent with human rights, international law and medical ethics.'
For now, the government appears to be relying on affected communities to find their own solutions with some support. But if they cannot, pressure on the government to take more interventionist action can only intensify.
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