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South Asians with HIV in London: is it time to rethink sexual health service delivery to meet the needs of heterosexual ethnic minorities?
  1. G Sethi1,
  2. C J Lacey1,
  3. K A Fenton2,
  4. I G Williams2,
  5. E Fox3,
  6. C A Sabin4,
  7. A Shaw5,
  8. M Kapembwa5
  1. 1St Mary’s Hospital, London W2 1NY, UK
  2. 2Department of Sexually Transmitted Diseases, Royal Free and University, College Medical School, London WC1E 6AU, UK
  3. 3St George’s Hospital, London SW17 0RE, UK
  4. 4Department of Epidemiology and Population Sciences, Royal Free and University College Medical School, London, UK
  5. 5Northwick Park Hospital, Harrow HA1 3UJ, UK
  1. Correspondence to:
 Dr Gulshan Sethi
 Jefferiss Wing, St Mary’s Hospital, London W1 2NY, UK; gsethidoctors.org.uk

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Recent conservative estimates suggest that at the end of 2002, 4.8 million people were living with HIV/AIDS in south Asia including 4.58 million in India.1 In the United Kingdom there are estimated to be 1.5 million people of south Asian ethnicity. While the National Strategy for Sexual Health aims to improve health care in those who have HIV through earlier diagnosis,2 studies have shown that that other ethnic minority groups present with advanced disease and not through routine genitourinary medicine (GUM) screening.3,4 We studied the case notes of all adults self defining as of Indian, Pakistani, Bangladeshi, or Sri Lankan ethnicity diagnosed HIV positive from January 1985 to December 2002 attending four HIV treatment centres in London. Information was collected on demography, mode of first presentation, and clinical stage of HIV infection.

In all, 117 patients were identified, 30 women and 87 men. The number of new diagnoses among south Asians increased by more than threefold over the period 1996 to 2002 compared to earlier years (25 diagnoses before 1996, 90 diagnosed from 1996–2002).

The median age at diagnosis was 38 years (range 19–64 years) for men and 28 years (range 20–55 years) for women. Forty five patients (38%) had originated from Africa, 28 (24%) from India, and 18 (15%) from the United Kingdom. The majority were of Indian ethnicity (95/117; 81%) with the next largest ethnic group being Sri Lankan (12/117; 10%).

The primary mode of transmission was heterosexual sex (72/117; 62%) with transmission through sex between men accounting for a further 31% (36/117) of cases. Four infections were acquired through blood transfusion, two through injecting drug use, one from a needle stick injury, and in two cases risk behaviour could not be identified. The majority (39%, 45/117) of patients identified Africa as the probable place of infection with 28% and 15% probably infected in the United Kingdom and India, respectively.

There were substantial differences in the reasons for testing between individuals in the main risk groups. In particular, heterosexual men and women were both significantly less likely than homosexual men to be diagnosed via routine attendance at a GUM clinic (2% and 4%, compared to 44%, respectively, p = <0.001, Fisher’s exact test). Among heterosexuals, the main reason for testing in men was symptomatic HIV infection/AIDS (60% of men but only 26% of women), whereas women were more likely to be tested through partner notification of a known HIV+ sexual contact (44% v 7% in males) (table 1).

The median CD4 count at presentation overall was 300 (range 3–1104) cells ×106/l. However, male heterosexuals presented with significantly lower CD4 counts (median 178, range 3–1023 cells ×106/l) than either homosexual men (median 381, range 4–810 cells ×106/l; p = 0.01) or heterosexual women (median 377, range 10–1104; p = 0.02).

While there are methodological limitations with retrospective case note reviews and differing reporting categories used for Asian ethnicity, our data confirm national surveillance reports of increasing HIV infection among Britain’s south Asian communities.5 The four centres taking part in this study reported 90 cases from 1996–2002 representing one in three of all HIV positive south Asians reported in this time period. Despite the fact that the majority of these were not diagnosed through routine GUM screening the median CD4 count at presentation of heterosexual and homosexual men was consistent with national trends.6 Indeed, south Asian women presented higher CD4 counts than seen nationally, primarily attributable to effective partner notification. While south Asians still represent less than 5% of all reported HIV positive diagnoses in UK ethnic minority groups5 (Asians 334; black Africans 8848; black Caribbeans 844) numbers are likely to continue to increase in the future and methods for encouraging early presentation need to be developed in response to this.

Table 1

Characteristics of presentation of study population at time of HIV diagnosis (n = 117)

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