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We read with interest the paper by Dougan et al1 regarding the epidemiology of HIV infection in black Caribbean adults in England, Wales, and Northern Ireland.
In our clinic setting, a district general hospital in north west London with a large black population (fig 1), diagnosis of HIV in black Caribbeans represents 8.6% (30/347) of all cases compared with 3.3% reported by Dougan et al.1 Of these; 83% (25/30) are of Jamaican origin, 13/30 (43%) male heterosexual, 14/30 (47%) female heterosexual. Men who have sex with men (MSM) accounted for 3/30 (10%) cases. A further 3/347 (0.86%) patients (all white) have unprotected sex with black Caribbeans as their risk factor for HIV acquisition. In 1999–2003, black Caribbean women accounted for 5/59 (8.47 %) of antenatal HIV diagnosis.
Ethnic breakdown of genitourinary medicine clinic attendees February 2004 (total n = 815).
Twenty seven of 30 (90%) of our black Caribbean patients have been diagnosed in the past 5 years (1999–2003) (fig 2), thus indicating the increasing magnitude of the problem.
HIV diagnosis in black Caribbeans (total n = 30).
We have noticed the trend in increasing HIV diagnosis in black Caribbeans over the past 5 years. This has impacted on our local service provision. Since the year 2000, black Caribbeans have been referred to the health advisers for pretest discussion and are asked to attend in person for results in recognition of their higher risk for HIV infection. Clearly, this has implications on health advising and clinic resources.
The national target for uptake of HIV testing in first attendees at genitourinary medicine (GUM) clinics is 40% by 2005; in the final quarter of 2003 we had achieved an uptake of 61% male and 58% female. The uptake of HIV testing in self proclaimed Afro-Caribbeans was 48% female and 47% male.
Ethnicity data as they currently stand are likely to underestimate the size of the problem in the black Caribbean population. As was highlighted, country of birth is not synonymous with ethnicity. However, ethnicity and country of birth may share risk factors. Certainly, there is a distinct grey area in self defined black British and black Caribbean designations in our clinic attendees. These issues urgently need identification and research.
As Dougan et al alluded to there are strong familial, cultural, and travel links with the Caribbean. Differential condom use may vary in the United Kingdom versus the Caribbean, fuelling potential transmission.
Efforts are required to improve ethnicity reporting. At new diagnosis, on confirmatory antibody test, details of country of birth and ethnicity should be recorded.
Dougan et al suggest that assortive sexual mixing1,2 may have an impact on limiting the spread of heterosexual HIV transmission. It seems likely that while prevalence remains relatively low this remains feasible; however, experience with bacterial sexually transmitted infections does not bode well for this to continue.
The number of undiagnosed HIV infection in black Caribbeans remains alarming.1 Dougan et al demonstrate that from 1997 to 2001, 73% of black Caribbean heterosexual males who were HIV positive via unlinked anonymous serology left the GUM clinic without a diagnosis. There are numerous challenges to GUM services to improve this. The presence of a bacterial STI should prompt further encouragement to undertake HIV testing.
A central challenge is how to improve access to GUM services and uptake of HIV testing. As Low3 in her editorial points out we must not allow misguided political correctness to impinge on the identification of those at highest risk. As with all minority groups, barriers, both perceived and real, can be overcome with imaginative approaches such as use of media, school/college based education programmes, saliva based, and “opt out” approach to testing. Radical innovations and improvements in current standards of care are urgently required to better understand the current situation and predict future trends.