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Editor,—We have surveyed the regular HIV infected attenders in the Leicester genitourinary medicine (GUM) HIV cohort; there are currently 60 men and 16 women. Twenty five per cent are black African and 13% are of Indian/Pakistani/Bangladeshi stock, while 62% are white. This amounts to 19 of 8258 black Africans in the Leicestershire total county population (which includes Leicester central district) being HIV positive. Forty seven of 771 181 white people and 10 of 77 537 Asians in the Leicestershire total county population were also HIV positive (Leicester City Council, from 1991 census figures, 2000, personal communication).
For acquisition of HIV related to ethnicity, the results are as displayed in table 1.
In 1997, of those with heterosexually transmitted HIV1 in the United Kingdom, 3.3% were black Caribbeans, 49% were black African, with 33% being white, and 2.3% were Asian.
In 1999, the Communicable Disease Report2 stated that, of female HIV infected people in England and Wales, 32% were white people and 49.5% were black Africans, and 2.7% were black Caribbeans, and 1.3% were south Asians.
Compared with the latter England and Wales figures, Leicester appears to have a moderate underrepresentation of black Africans with HIV, and a moderate overrepresentation of Asians in its cohort. This latter figure is to be expected because Leicester's Asian population is 23.7% of the total population of the city (Leicester City Council, 1991 census figures, 2000, personal communication). However, the Asian figure is not that high pro rata, possibly because cultural factors prohibit sex outside marriage.
Quinn et al3 have shown recently that viral load is the chief predictor of the risk of heterosexual transmission of HIV-1, and that transmission is rare among people with levels of less than 1500 copies of HIV-1 RNA per ml.
It may be that HAART (highly active antiretroviral therapy) for HIV infected people has caused transmission to be low in the United Kingdom but, as Cohen says, such a theory has not been proved.4
The viral subtype dominant in parts of Africa (clade C), has unique properties that favour sexual transmission.5 Other factors that make Africans more susceptible to HIV than those who live in more developed countries include lack of host factors that reduce infection risk; the plasma HIV-1 RNA level in seropositive people being higher in sub-Saharan Africans; the lack of mutations in the gene for chemokine receptor 5; circumcision status, with most men in Africa being uncircumcised; and the high prevalence of ulcerative sexually transmitted diseases.4 Some of these factors will operate for Asian patients born in Africa.
Thus, ethnicity and country of acquisition of HIV in Leicester as elsewhere, is a reflection of interwoven, genetic, environmental and behavioural, political, and geographical factors.4 Therefore, we cannot just examine nationality in isolation when considering HIV epidemiology. Travellers from Britain to Thailand, the Philippines, India, and Africa especially should be forewarned of the risks of sex and healthcare needle exposure and/or blood transfusions in all travel medicine consultations.
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