Review of Research into the sexual health outcomes of UK based Black Africans. 

Staff also partnered with another community organisation, who were keen to engage Black African Communities on another matter of health, who were experiencing similar barriers to conducting this work.  

Five interviews with individuals were conducted, however individuals were reluctant to explore issues of sexual health in an in-depth manner. It did not feel that enough insight had been gathered to draw comparisons and conclusions. At this point the focus of the work changed to be a review of the current research and evidence relating to the black experience of sexual and reproductive health in the UK. This is a relatively small piece of work, touching on what saw as being the main themes from the research. We have used our experiences when engaging in this work, and those of the Fiveindividuals interviewed to draw conclusions as to the situation on the ground in Devon & Torbay.  

A report from the HIV Commission, published in 20205 found that as well as being disproportionately affected by high levels of HIV, the rate of late diagnosis is higher within this community,6 as 52.9% of Black African people are diagnosed at late stage of infection, compared to 40.1% of white people diagnosed. The potential reasons for this are described by Nyashanu et al as being ‘pillars of HIV stigma’. These include; marriage institution (limiting the power of women in sexual health matters); religion and religious leaders shaping a community’s response to HIV; cultural competency of Sexual Health Professionals; how the Black Sub Saharan African community are perceived due to reported HIV data; sexual health being a sensitive topic for BSSA communities, including around sexuality; men being less likely to ask for help, especially around sexual/mental health; and bullying on social media.   

An individual who took part in our interviews was a heterosexual male of Ghanian heritage in his early 30’s. He describedhow conversations with his parents and other family members contrasted with that of his white, British friends who, were more open in relation to sex and relationships. Not only was sex rarely mentioned amongst family members, but he acknowledged a level of discomfort and a need to change the subject when it did come up. He went on further to say that when he began to go to nightclubs in his early 20’s, he noticed an attitude of sexualisation from white women and a beliefhe would have a lot of sexual experience. This left him feeling unable to discuss sex or ask questions with his friends, as the perception was that he would have all the knowledge.  

These inequalities also extend to preventative HIV care, in particular relation to PrEP.  Coukan et al7 discuss the equity of access of PrEP within England, using PrEP to need ratio (PrEP users / New diagnoses), providing a key indicator of which populations are underserved. Black Africans had consistently the lowest PrEP to need ratio, with black African women being the lowest of all ethnic groups. The barriers to PrEP uptake identified by Coukan et al are described as including; lack of knowledge, not perceiving oneself at risk, HIV stigma and lack of access to a PrEP provider. Factors which can be logically linked to the barriers discussed by Nyashanu et al.8 Black African women are nearly twice as likely to be living with HIV compared to Black African men9, indicating the vitality of changing this lack of uptake of PrEP.  

Data provided by the UKHSA in a 2024 Department of Health report on PrEP10 found that where a PrEP need had been identified only 71.3% went on to access PrEP, suggesting there is work to be done in breaking down the barriers to uptake of HIV Prevention methods. It is important to take these barriers into consideration as we approach the roll out of new preventative methods such as Doxy PEP11 to avoid creating similar disparities in access and uptake. Equity must be central to this new line of prevention healthcare, or Black African communities will be left behind again. 12 

Research investigating women’s decisions around breastfeeding13 highlights further differences in aspects of sexual and reproductive health for Black African women. 36 women living with HIV in the UK (22 of whom were Black African) were interviewed about their experiences infant feeding. Despite WHO guidance supporting breastfeeding for women with undetectable viral loads, most participants opted for formula feeding. Their decisions were shaped by lots of factors, which included the influence of their healthcare provider. Some of the women struggled to access free formula milk from their clinics or HIV charities. The paper also describes fragmented communication between paediatric and HIV healthcare teams, in addition to conflicting information about the safety of breast feeding. One participant also felt she had been potentially racially stereotyped and denied the deeper conversation she wanted. There was sometimes a lack of knowledge around HIV and the latest guidelines. 

The complexities of healthcare for Black African populations in the Southwest is hindered by the lack of literature more generally14. The 2021 census15 shows that the Torbay Local authority has 0.3% population who identify as Black, Black British, Black Welsh, Caribbean or African (447 people). Data applying to Devon as a county, rather than a local authority area, also had a population of the same groups as 0.3% (2,474). These low numbers mean that the African population of the area will be small. This is likely one reason there is little research around Black Africans in Coastal and Rural Southwest. 

There is, however, some data on the health outcomes of people in coastal areas. Coastal areas have a higher burden of ill health for nearly all non-communicable diseases, likely due to economic and socioeconomic deprivation, lack of opportunity and low educational capital16 Work by Murray et al17 acknowledges the complex picture of poverty in coastal areas and highlights worse health outcomes for those living in deprived communities in England.  

An enquiry by the joint committee of human rights18 emphasised how Black Africans’ experience of HIV is affected by ‘high levels of poverty, unemployment and poor housing… present(ing) barriers to community-led mobilisation and action which could support better prevention initiatives‘. They emphasise the importance of addressing these structural inequalities to address healthcare outcomes. This report also notes that a barrier to care is the charge for healthcare. While HIV care is free in the UK, the committee notes that many people with HIV have comorbidities which can push them away from healthcare. 

It is important to note that the Black African experience will not be unified. Within the communities, health care experience/seeking behaviours will be affected by age, gender, migration history, cultural background, and community engagement/opportunities.  

This complexity was inherent in an interview conducted with a heterosexual, male in his 20’s at St Petrocs homeless drop-in based in Exeter. He acknowledged his heritage as being Black African, however he said he struggled with this description as he did not identify with their way of thinking. He said he was from a large family, where there was an expectation that he would go on to get married and have lots of children. His words were that, ‘despite the colour of his skin, he identified as being white British.’ This points to the issues it can present when using race as a way of working with individuals around positive health outcomes.  

Over the last year the UK has seen an increase in Black African individuals coming to the UK to work within the field of health and social care. Their needs and experiences would be very different to a Black African who has been based in the UK for several years. Navigating an unfamiliar health service, struggling with interpretation or concerns over how a health concern could impact on their ability to work and, therefore, remain in the UK, all of which can be push factorsaway from accessing care. International students, migrant workers, first generation Black British may face barriers also, including racism or cultural stigma within healthcare, especially with SRH. 

Research has identified key themes leading to poor sexual health, and wider general health, outcomes for Black African GBMSM. Davis states how ‘Participants described feeling racially profiled and overlooked by healthcare providers, leading to a reluctance to engage with services they perceived as ‘not for them.’19 These feelings were further compounded by experiences of trying to access sexual health or specialist HIV services. Those interviewed by Davis reported experiences of mistrust, judgement, and stigma from providers, which delayed access to testing, PrEP, or treatment. 

The intersectionality of being Black and Queer/Gay brings its own challenges. Individuals report experiencing stigma in relation to racism and homophobia alongside the fear of familial or religious rejection. Leading to a reluctance to being open with health care professionals. 20 and placing a burden on mental health.  

This discussion has emphasised the importance of the human and social factors to improving sexual healthcare for Black African people in the UK, especially with regards to HIV prevention, diagnosis and ongoing care. The Eddystone Trust are keen to overcome barriers to ensure equity of access and service for everyone. Having reviewed the literature around this subject, there are tangible steps that can be taken that we believe will lead to the engagement of members of this community, leading to improved sexual health outcomes.   

Peer support is important to the wellbeing of Black Africans living with HIV.21 Figures within the community can influence health behaviours. The success of MSM championing PrEP22 and high uptake within this community, suggests that finding people withing the Black African community to talk about PrEP may boost uptake. The goal should be to support people to communicate their needs, feel able to access healthcare, and to reduce stigma around HIV and sexual health.23  The Eddystone Trust has existing relationships with organisations such as The Olive Project, who work with Black women, who we will partner with to deliver workshops to community leaders and motivated members of the community. The purpose of the workshops will be to provide them with the knowledge they need to discuss HIV and sexual health with those around them and empower them to engage with messages of HIV prevention.  

As we approach the roll-out of Doxy-PEP, Eddystone are keen to co-produce resources that will ensure those that need to hear these messages will do so. The starting point for this co-production work will be engaging and motivating members of the community to attend workshops.  

Nadarzynski et al24 demonstrate that chatbot-assisted self-assessment tools can effectively increase motivation for STI screening among ethnic minority groups (n = 548, with 66% identifying as Black). The chatbot increased motivation for STI screening, with caveat that post chat behaviour was not monitored. This could help overcome language barriers, shame or stigma, and help motivate people to test. A chatbot, for use on the Eddystone website, is currently in development. The chatbot will be used to respond to sexual health queries, which when used in conjunction with Eddystone’s other digital services (PrEP referral form, online testing) is hoped will be a supportive step towards removing barriers for those experiencing them.   

Sources: 

Asthana, S., & Gibson, A. (2022). Averting a public health crisis in England's coastal communities: a call for public health research and policy. Journal of public health (Oxford, England), 44(3), 642–650. https://doi.org/10.1093/pubmed/fdab130 

Coukan, F., Sullivan, A., Mitchell, H., Jaffer, S., Williams, A., Saunders, J., Atchison, C., & Ward, H. (2024). Impact of national commissioning of pre-exposure prophylaxis (PrEP) on equity of access in England: a PrEP-to-need ratio investigation. Sexually transmitted infections, 100(3), 166–172. https://doi.org/10.1136/sextrans-2023-055989 

Garcia-Iglesias, J., Ledin, C., Gilmore, J., Kohli, M., Smith, E., Weil, B., & Ventura Garcia, L. (2025). DoxyPEP: thinking towards implementation. The Lancet. Infectious diseases, 25(4), e191–e192. https://doi.org/10.1016/S1473-3099(25)00077-5 

HIV Commission (2020) How England will end new cases of HIV: Final report & recommendations. Available at: https://cliniq.org.uk/wp-content/uploads/2020/12/HIV-Commission-Full-Report_online_final_pages-2.pdf 

Jones, N. (2022) ‘Breaking barriers: Working with women of African and Caribbean heritage to break HIV stigma’, Terrence Higgins Trust. Available at: https://www.tht.org.uk/news/breaking-barriers-working-women-african-and-caribbean-heritage-break-hiv-stigma 

Kasadha, B., Hinton, L., Tariq, S., Nyatsanza, F., Namiba, A., Freeman-Romilly, N., & Rai, T. (2024). How women living with HIV in the UK manage infant-feeding decisions and vertical transmission risk - a qualitative study. BMC public health, 24(1), 2130. https://doi.org/10.1186/s12889-024-19581-9 

Murray, E. T., Keating, A., Cameron, C., Benchekroun, R., Whewall, S., Booker, C., & Jivraj, S. (2024). Residence in coastal communities in adolescence and health in young adulthood: An 11-year follow-up of English UKHLS youth questionnaire respondents. Health & place, 87, 103239. https://doi.org/10.1016/j.healthplace.2024.103239 

Nadarzynski, T., Knights, N., Husbands, D., Graham, C.A., Llewellyn, C.D., Buchanan, T., Montgomery, I., Khlafa, N., Tichackova, J., Odeyemi, R., Johnson, S., Jesuthas, N., Tahia, S. and Ridge, D.T. (2024) ‘The impact of ChatbotAssistedSelf Assessment (CASA) on intentions for sexual health screening in people from minoritised ethnic groups at risk of sexually transmitted infections’, Sexual Health, 21, article SH24058. doi: 10.1071/SH2405 

Namiba, A., Nyirenda, C., Sachikonye, M., Mbewe, R. and Sseruma, W. (2023) ‘Stories from the heart: Celebrating African contribution to the UK HIV response’, Terrence Higgins Trust. Available at: https://www.tht.org.uk/news/stories-heart-celebrating-african-contribution-uk-hiv-response 

Nyashanu, M., Ekpenyong, M.S., Chireshe, R., Serrant, L. and Mudzimu, E.R. (2024) 'Chapter 1: The Social Construction of HIV Stigma Among Black Sub-Saharan African Communities and its Impact on Sexual Health-Seeking Behaviour in the United Kingdom', in Emerging Perspectives on Society, Health, and Economics in Sub-Saharan Africa. London: Ethics International Press. Available at: https://books.google.co.uk/books?hl=en&lr=&id=kms2EQAAQBAJ&oi=fnd&pg=PA1&dq=info:ftISVJJKuZ0J:scholar.google.com&ots=DPSduTbhEK&sig=aLn9ETP5XXzcL0LI8-XH19RbtAs&redir_esc=y#v=onepage&q&f=false24 

Office for National Statistics (2021) ‘Census 2021 local authority report: Health in Devon, South West region and England’. Available at: https://www.nomisweb.co.uk/sources/census_2021/report?compare=E06000027,E12000009,E92000001 

Office for National Statistics (2024) 'HIV: Infection with late diagnosis (latest)', Ethnicity Facts and Figures. Available at: https://www.ethnicity-facts-figures.service.gov.uk/health/physical-health/hiv-infection-with-late-diagnosis/latest/ 

UK Parliament Health and Social Care Committee (2021). Black people, racism and human rights – Inquiry by the Joint Committee on Human Rights. Available at: https:// .parliament.uk/writtenevidence/11594/pdf/