Vulnerability to HIV infection: an investigation of HIV/AIDS-related knowledge, attitudes and practices in the Brazilian expatriate population in England

According to the 90-90-90 UNAIDS report (2014), we could end the Human Immunodeficiency Virus (HIV) epidemic globally by 2030, and bring HIV incidence to rare occurrences. In order for that to happen, every country will have to step up their efforts in relation to HIV prevention and treatment. Including HIV education, condom distribution, behaviour change, voluntary male circumcision, availability of HIV counselling and testing, and a human rights approach with key populations (Fast-Track Report, UNAIDS 2014). In England, Black, Asian and Minority Ethnic (BAME) groups are disproportionately affected by HIV. Many of these BAME communities are under researched and very little is known about their prevention needs. The Brazilian expatriate population, for instance, according to Public Health England, has a higher than expected HIV prevalence. In this PhD thesis I identify some of the HIV prevention needs of the Brazilian expatriate population in England, through a survey of 1018 participants, as well as 30 in-depth interviews, assessing their HIV/AIDS-related knowledge, attitudes and practices. The overall research question of the thesis is to find out how are the HIV/AIDS-related knowledge, attitudes and practices of the Brazilian expatriate population in England impacting on their vulnerability to HIV infection. My key findings suggest that many members of the Brazilian expatriate population in England speak limited English and are therefore unable to follow sexual health campaigns in that language. Also, because of immigration constraints, they have limited access to GPs and other health services (including genitourinary clinics), which is where they similarly would like to learn about sexual health. The consequence is that they are not aware of current knowledge of HIV prevention and treatments in England, including Pre-Exposure Prophylaxis (PrEP) and Post-Exposure Prophylaxis (PEP). In fact, when compared with Brazilians back in Brazil, the sample surveyed in England knew slightly less about HIV and Sexually Transmitted Infections (STIs) in almost all indicators of correct knowledge of HIV transmission. This situation, coupled with increased unprotected sexual intercourse, illicit drug use, and resorting to sex work because of poverty is increasing their vulnerability to HIV infection. My key recommendations are that a target sexual health campaign is created using the Vulnerability to HIV Infection framework (i.e.: “Information/education, health and social services, and a supportive social environment”), from AIDS in the World (1992), aiming at the Brazilian expatriate population in England. This has to be in Brazilian Portuguese. This should promote greater access to health services in England for the Brazilian expatriate population, including to genitourinary clinics. Also, increased sexual health outreach in the community with free HIV/STIs counselling and testing, and free condoms are needed, with services equipped with at least one care-worker, nurse or doctor that speaks Portuguese, or easily available language-line services. A sexual health campaign in Brazilian Portuguese using community London-based media (especially Leros Magazine, Brazilian newspapers, Facebook and WhatsApp), and educational leaflets, is also needed. Lastly, I want to make a recommendation to the Brazilian Ministry of Health to create an awareness campaign in Brazil regarding the risks of HIV/STIs that can occour during migration, for prospective travellers to High Income Countries, including the risks of illicit drug use and sex work. This thesis contributes to knowledge gaps regarding the HIV prevention needs of a vulnerable population in England, with a high HIV prevalence. The information generated in this research can assist public health professionals, policy makers and programme managers in identifying key gaps in local and national responses to HIV/AIDS within BAME communities, enabling more effective planning and interventions to halt the spread of HIV