Palliative Care

The role of the expert palliative care nurse is complex and unique. The nurse functions as an integral part of a Multidisciplinary team, providing expert skilled assessment and nursing care, supporting the patient and the family to make informed choices thereby encouraging the patient to continue to make autonomous decisions about their care towards the end of their life.

However, often the nurse will find herself dealing with difficult family dynamics with family members having differing expectations of the type of care that the patient should be receiving, staff conflict over treatment methods or strategies and high workloads. These issues can only compound the stresses on the Palliative Care Nurse and to cope with the many dilemmas she must be well armed.

The complex needs of the terminally ill patients and their families make the multidisciplinary team approach the most effective method of care Staff from a range of disciplines including medical, nursing, social work, dietitian, physiotherapist, pharmacist and others bring diverse and unique skills. As a team they provide an excellent sounding board for ethical dilemmas thereby –hopefully- enhancing ethical practice. (Latimer, 1998)

The Nurse in her role is required to act as patient advocate and ensure that the patient’s rights are respected. Unfortunately this advocacy is sometimes perceived negatively as a threat or implied criticism of medical care. Doctors need to listen to the nurses more accurate perspective of patient concerns. Consistency across the team leads to better outcomes for patients. Reinforcing the same information by both medical and nursing staff help to allay patient anxiety far more than conflicting views on such things as symptom control. (Jeffrey, 1995)

The members of the Multidisciplinary team sometimes make decisions regarding treatments, which they may perceive to be of the most benefit to the patient whilst in fact the patient, does not perceive the benefits in quite the same way. Nurses have more prolonged contact with the patient than most other members of the team due to the hands on patient care that they do. They often establish a close rapport with the patient and the family and are most likely to be aware of the patients likes, dislikes, hopes and dreams and are privy to often delicate and very private details of the patients life. The very fact that the nurse spends so much time with the patient makes them more likely to have knowledge of this kind of information. Doctor’s rounds in a Palliative Care Unit enable the doctor to spend perhaps 30minutes maximum per day in talking to the patient. In the community, appointments times with Doctors are restrictive and Home Visits limited. Patient Nurse dependency ratios in hospitals and palliative care units mean that Nurses are spending approximately four hours per day on one to one patient contact. Again, other team members are very limited in the amount of time they spend with patients due to the number of clients/patients they may have. A dietitian for example may spend 15 minutes with a patient twice during their six-week stay in a Palliative Care Unit or 30 minutes as an outpatient during the course of the Terminal illness. Social workers often spend long periods at a time with patients and/or their families in lengthy discussion however these discussions may only take place a couple of times over the period of the illness. Therefore the Nurse is far more likely to be aware of issues affecting patient care.

There can be many difficulties for the Nurse expert providing high quality care to palliative patients whilst respecting their right to autonomy in the setting of the Palliative Care Unit, the role of the Nurse is to painstakingly assess the needs of patient and family. These needs may be constantly changing and there is no room for the Palliative Care Nurse to become complacent in her patient care. Symptoms may be physical such as pain, nausea, and dyspnoea or psychosocial or spiritual. In identifying care needs the nurse must be able to determine who is the most appropriate team member to refer to provide optimum management of these needs. E.g. although the expert nurse will have counselling skills, she must be aware of her limitations and refer on where appropriate to counsellors, psychologist or social worker. Mount (1993) suggests that we must first attend to physical needs and that to do this we need a detailed knowledge of therapeutics. Skilled listening and attention to detail are paramount in Palliative Care. Our listening skills not only apply to what the patient is saying, but what they may be leaving unsaid. Nonverbal cues such as facial expressions and demeanour, the need to keep the door to their room open at all times or to constantly keeps the curtains drawn.

In order for patients to make choices they need to be accurately and appropriately informed, yet Vachon (1993) suggests that whilst caregivers sometimes decide not to tell patient and family what is likely to happen, at other times they may give too much negative information not allowing the patient and family to have any hope. Patients need to know at what stage their disease is and their prognosis in order to choose where to spend their remaining time. The ethical communication of information should be timely and desired by the patient, accurate and given in words understandable to the patient and family and conveyed in a “gentle, respectful and compassionate manner.” (Latimer, 1998) An example of such communication would be that when asked by my patient (speaking about his fungating tumour) “When will this thing on my neck stop leaking?” I need to gently but truthfully explain that it will most likely continue to leak blood and fluid until he dies but also that we will continue to contain the fluid and minimise the discomfort and attempt to disguise the drainage appliance as best we can. To not advise him of the eventuality of the fluid discharge continuing is to encourage him to have false hope and expectations and further disappointment when the discharge continues and probably worsens.

However, the nurse needs to recognise that some patients do not wish to have information relayed to them e.g. a patient who did not want to talk about her illness & future and continued to deny that her disease was terminal. “Don’t tell me that, I don’t want you to say those words!”

Yet respect for patient autonomy demands that patients be given honest answers to their questions. Without this, patients become more uncertain and unable to make decisions about their future.

Dying patients are by virtue of their physical and emotional situation, frail and vulnerable their treatment and management during this final phase of their life must be of a high standard both professionally and ethically. The Nurse and other members of the team should seek to do the best for the patient and their family. This includes respecting autonomy, through the provision of truthful information and helping them to set realistic goals while providing genuine attentive care during the full course of the illness.

Provision of symptom control hinges on accurate assessment. McCafferty and Beebe (1989) suggest that we don’t always make assessment easy by the fact that sometimes we don’t readily believe what the patient tells us or the patient may deny having pain or refuse pain relief although they may be hurting. The expert Nurse should remember that the person with the pain is the authority- they are the one who is living the experience and we must believe them if they tell us they have pain. It is all too easy to allow ones own values and beliefs to cloud our judgement Unfortunately I have seen it happen where a nurse usually not experienced in Palliative nursing will make a statement such as ” He says he has pain rated 8 out of 10 but he doesn’t look distressed” or “She was laughing and talking with her visitors 5 minutes ago and now she’s buzzing for pain relief”. Such comments display the Nurses ignorance and lack of understanding of pain. It seems apparent that they do not understand about adaptation or distraction or that laughter stimulates the relaxation response throughout the body systems by lowering blood pressure, deepening breathing and releasing endorphins.

Also of great importance is the need for the nurse to explore further if a patient denies pain despite indications that they are in fact suffering pain. There may various reasons for denial for example; sometimes our language when asking questions about the patient’s pain may be inappropriate. Some patients may not consider a dull constant ache as “pain” but an ache. Others may feel “sore”. Other words such as discomfort and pressure may be used instead of “Pain” We as nurses need to avoid misinterpretation by using such other words.

The Nurse needs to explore the issue of pain and help to identify the source. Location. Intensity, and Quality of the pain help to identify the source. Eg. Bone, visceral or nerve pain. Identifying the source aids in determining the appropriate treatment method. The expert Nurse will be aware that nerve pain will not respond as well to opiates and that neuroleptic agents need to employed. As suggested earlier, as Nurses spend the most time with the patients they are able to obtain the most information on the patients response to pain management plans, they are able to educate patients on the need to take regular analgaesia; and they can be the most influential in management of pain (Lindley, Dalton and Fields, 1990).

Of course we as nurses in Palliative Care need to be aware that not all pain will respond well to traditional or “orthodox treatments”. Seeing a patient in pain and trying all pharmacological methods without success is distressing for staff as well as the patient and it is then that nurses should further attempt to employ other methods such as relaxation, distraction and music. Studies have shown that that listening to music disrupts the chronic pain cycle. Laughter, Massage and relaxation therapies have also been shown to interrupt this chronic pain cycle (Owens & Ehrenreich, 1991) and massaging a dying patients back or feet with oil blends incorporating lavender instils in many cases a feeling of peace, contentment and lessening of pain. Heat and cold packs are also said to be beneficial in the treatment of chronic pain however heat applications are said to be contraindicated in patients with poor vascular supply and in malignancy. Most institutions have policies related to the use of thermal applications.

As most nurses working with palliative patients will know, bowel management is of MAJOR importance! The Narcotics we administer to alleviate the symptom of pain have the side effect of causing the symptom of constipation. Vigilant monitoring of a patients bowel status is essential but it is of great importance that patients are not quizzed about their bowel actions in front of visitors or during meal times. Privately and quietly please! Cameron (1992) describes the types of constipation, these being primary and secondary due to pathology or iatrogenic. The goal of bowel management should be the prevention of constipation rather than treatment of constipation and appropriate assessment, regular administration of aperients, appropriate diet and fluids and provision of conditions favourable to bowel evacuation should all be part of the nurses management plan and patient education is paramount here for without the knowledge that opioids will contribute to constipation but that regular aperients will counteract this symptom, the patient is unable to make informed choices about his symptom control.

Nausea and vomiting are other symptoms the nurse can provide valuable assistance in controlling again through adequate assessment and intervention. The nurse needs to be aware of possible causes of nausea and vomiting such as hypercalcaemia, disseminated carcinoma, renal failure and vestibular stimulation particularly in patients with primary brain tumours or secondary cancer deposits. Constipation and radiotherapy, urinary tract infection and chemotherapy- the causes are many and varied. Hogan (1990) suggests that an understanding of the various pharmacological and non-pharmacological interventions is the foundation of symptom control but that the nurse’s commitment to alleviate the symptoms is the most important variable. Simple techniques like minimising cooking smells, presenting small meals and ensuring offensive odours such as foul linen bags from the vicinity can all be employed in conjunction with pharmacological methods to minimise nausea and vomiting. Successful management requires an understanding of the cause of the symptoms.

Other symptoms that may prove troublesome for the terminally ill patient include oral thrush and stomatitis, diarrhoea, lethargy and insomnia. Dyspnoea can be the cause of great distress and the expert nurse will be aware of the need to employ techniques to minimise discomfort. These may include reducing exertion by the patient, positioning them to allow maximum comfort when breathing and improving air circulation by use of fans or open windows. Humidification by methods such as nebulised saline may also be helpful. Pharmacological methods such as morphine either orally, subcutaneously or as a nebulised solution have also been found to decrease the perception of breathlessness (Chater, 1991) and anxiolitics such as Lorazepam s/l are quite helpful. Reassurance and providing a calm environment are also helpful techniques to employ. Distressed relatives around the bedside can further increase the patients respiratory distress and it is at such times that the nurse needs to take them aside and explain to them what is happening and how they can help by remaining calm and distracting the patient or helping them to relax.

For the terminally ill patient, being in control is vital and the nurse must appreciate that the patient though suffering an illness from which he will eventually die must be allowed to keep his self respect. This self respect can be eroded enough by the nature of the disease its symptoms and suffering, sorrow and emotional pain. There are times when we as nurses see patients admitted to hospital who have already had their autonomy undermined. Whilst it may have been their wish to stay at home longer or until the end, families may feel the burden of care is too great and that they can no longer cope. This is usually when a new symptom presents that the family feel unable to manage. Nurses in the community may sometimes be able to prevent this situation arising by offering a more frequent or higher level of care supported by a Palliative Care Service, education of the family about the patients symptoms and how to help manage them. Sometimes admission is not what the patient wishes but the service is unable to provide appropriate management in the home. There is then an onus upon those providing the care to look at all options to enable the patient to achieve his goal of returning home. To be autonomous means to have choice and control in our own lives yet we must accept that total autonomy is hardly ever possible. Sometimes there are circumstances in which it is not possible to challenge on the patients behalf- times when the patient may wish to have their autonomy eroded. There are times when the patient may not want our advocacy and times when we may not be able to give it- for example controversial ethical issues such as euthanasia. (Coyle, 1992).

The nurse may sometimes develop feelings of helplessness and insecurity because of her unrealistic expectations of herself. The complex role we play in management of the terminally ill sometimes may lead the nurse to think she should be all things to all people — the doctors ‘handmaiden’ the patients advocate, the families sounding board. Sometimes nurses can become over involved, infringing on the autonomy of the patient and the family (Scanlon, 1989) and must be aware of when to withdraw. At times when caring for a patient with uncontrollable physical or emotional pain the nurse may feel herself to be a failure. Add to this the likelihood of inadequate resources and staffing, staff conflict and role conflict and there is a pretty good recipe for stress. Abraham and Shandley (1992) list five main sources of work stress. These being: 1. Work overload, 2. Difficulties relating to other staff, 3. Difficulties involved in nursing critically ill patients 4.concerns over patient treatment and 5. Nursing patients who fail to improve.

This again emphasises the fact that nurses specialising in palliative care are likely to suffer high levels of stress.

CONCLUSION

To help cope with these high demands and continue to maintain the delicate balance between what the patients want and what the health professionals think the patient needs, nurses need to arm themselves with expert knowledge of symptom control, and be well aware of ethical issues related to palliative care. Nurses also need to maintain open active communication with their peers and other members of the facility. We must also realize that even if we do not influence a situation or supply an answer to all needs and if our patients do not maintain total autonomy, it is enough that we have been with them, supporting them as best we can in their journey to the end of their life.

Bibliography:

Today the epidemic HIV/AIDS has become a universal issue demanding attention of all public sectors. The HIV infection has developed as a major public health importance in the whole world with its increasing prevalence rate. The human immunodeficiency virus (HIV) is a retrovirus which affects the immune system of the body and destroys all its functions where an acquired immunodeficiency syndrome (AIDS) is the most advance phase of HIV infection (World health organisation, 2010). Globally around 60 million people are affected since the start of this epidemic HIV and till now around 20 million people are died due to infection of this virus (UNAIDS, 2005). In the year 2007, it was estimated that around 33.2 million people were living with HIV in the world (UNAIDS, 2007). Similarly in United Kingdom, the prevalence of HIV infected people was 77,400 in 2007 (Health Protection Agency, 2008). The London city continues to be the UK’s HIV/AIDS hot spot with leading numbers of HIV cases as compared to UK. In London, the population of Black Africans are most rapidly increasing in terms of HIV infection and forming the second largest group of HIV/AIDS service users (Erwin and peters, 1999). This essay will try to investigate and analyse the causes of increasing prevalence of HIV infection in Black African people in London Borough of Lewisham. The essay will briefly examine the epidemiology of HIV infection in Lewisham particularly with focusing on Black African ethnicity. This essay will also focus on socio economic determinants of HIV prevalence in Black African community in London borough of Lewisham. With the help of this research the factors influencing HIV/AIDS in Black African population in Lewisham would be studied. This will be an attempt to analyse the strategies and interventions of the issue regarding global, national and mainly the local perspectives. It focuses on black African communities because they are disproportionately affected by HIV infection compared to other minority ethnic groups.

The HIV infection is mainly transmitted through unprotected sexual intercourse which can be anal or vaginal. It may also be transmitted through the transfusion of HIV contaminated blood to the healthy individual. Sharing needles has become a most common reason for the spread of this epidemic. It may also be transmitted through the mother having HIV to her child. Breast feeding is also one of the factors which can help to spread the HIV (World Health Organisation, 2010). Still in many areas like developing countries, people are unknown to HIV/AIDS. The illiteracy and poverty are the main causative factors for the spread of epidemic HIV in the world. Being an epidemic, migration is the most common cause for increasing the prevalence of HIV. Sex workers also play a leading role in the spread of HIV because the infection is sexually transmitted. London city has the maximum proportion of population from minority ethnic groups migrated from all over the world. Among these different ethnic groups, Black Africans are one of the fastest growing immigrants in London. East London is one of the poorest areas in London city with having lowest expectation of life, highest unemployment rate and poor housing with low level of education (Elford et al, 2006).

In England, late diagnosis of HIV remains a major problem among black Africans. In 2007, about 42 per cent of black Africans diagnosed with HIV were diagnosed late. The evidence shows that late diagnosis of HIV increases more risk of early mortality. The research also conclude some reasons for late diagnosis of HIV in Black African community such as, fear of testing positive for HIV, some of them have a misconception that testing positive would lead to deportation, fear of breaking up the social relationships after testing positive, unknown of testing centres due to lack of information, having fear that life or business pattern will change because of testing positive. Most of Black Africans felt that they had no reason to think they had HIV. Due to HIV related stigma and discrimination Black Africans as compared to White community are the least likely to disclose their HIV status to their partners, family members, employers or friends. Cultural and religious diversity among African community are the main causes of increase in prevalence of HIV. The evidence indicates that long time stay in England also has an impact on the sexual health of black Africans. Many black African migrates are facing insecure residency status problem. This causes unemployment and mental problems to the community and due to this they are forced into sexual risks, such as prostitution which increases high risk to HIV infection (Race Equality Foundation, 2009).

Language barrier is one of the main causes for the increase in prevalence of HIV in Black people. Ineffective communication between people and health care professional causes poor service of the health care. Spirituality is also an important factor in the health and well-being of older Black African people and must also be considered when deciding on methods of engagement (Race Equality Foundation, 2010).

In England, It has proved that there are more same-sex relationships than reported among black Africans (Race Equality Foundation, 2009). There is growing evidence to show that African men who have sex with men (MSM) living in the UK are deeply affected by HIV. The article from Audrey Prost, related to sexually transmitted diseases (STIs) highlights the fact that homosexually active men from Black African communities in UK are disproportionately vulnerable to STIs compared to white people community. According to a study conducted by Hickson and his colleagues in 2001, a higher proportion of black African MSM (18%) was living with HIV compared with white MSM with 10% (Aidsportal, 2007).

African gay/bisexual men, regardless of their HIV status, are considered ‘hard to reach’ and reluctant to talk. Various reports indicate that homophobia, both at large and within the black African community may be preventing African men from engaging with HIV prevention initiatives and even discussing their sexual identity with anyone. The racism and homophobia are being very offensive part in Black gay community because Black people have always excluded, harassed, imprisoned and killed often solely because they have black skin where Gay men are also harassed, beaten and killed because they are gay. This explains how difficult it can be being black and gay. In UK, there are some evidences of research studies which are related to Black Caribbean MSM and their problems regarding social lives but there is no evidence of equivalent research which has been has been carried out with African men in UK. Therefore more research is needed urgently for understanding the sexual lifestyles of African MSM, their problems regarding social lives and the best ways to reach them with HIV prevention policies and interventions (Aidsportal, 2007).

Commission for Equality and Human Rights (CEHR) presents a real opportunity to address the multiple forms of discrimination faced by Black/African gay men, including racism, homophobia, sexism etc.

In London the well established determinants of health care costs for people living with HIV/AIDS such as disease stage and transmission category, socio-economic factors like employment and the support of a living-in partner drastically reduced community services expenses (Kupek et al, 1999). The social responses of fear, stigma, denial and discrimination have accompanied the epidemic HIV/AIDS where the discrimination has increased enormously with maximum anxiety and prejudice against the community who are commonly affected with HIV/AIDS (UNAIDS, 2000).

The HIV/AIDS can be treated by some modern therapies but it cannot be cured. The highly active antiretroviral therapy (HAART) is a therapy which uniformly slower down the rate of disease development towards AIDS or the death. In London it is consistently showed that, the Black African people living with HIV are more likely to present with advanced stage of disease, and are therefore less likely to access and get advantage from this therapy. Because of this consequence there is a high mortality rate related to AIDS among the White community but in Black African community it has not yet seen remarkably (Boyd et al, 2005). The main reason for this occurrence is an unawareness of the highly active antiretroviral therapy (HAART) among the Black African community. The information and knowledge regarding demographic characteristics and the stage of HIV in various communities can give important insights like which community should be targeted to provide more intensive educational campaigns to develop the uptake of HIV testing.

The World Health Organisation, UNAIDS and AVERT are the globally leading health organisations which work together and with the government for the prevention of HIV/AIDS. These organisations regularly keep an updates of the prevalence of epidemic HIV/AIDS globally, on national level as well as on the local level. Though these organisations are trying to provide maximum services for HIV infected people, it is proved that, globally only less than one individual in five who are at risk of HIV had access to basic prevention services for HIV (UNAIDS, 2005). As mentioned earlier, the prevalence of HIV is much in African regions. The governments of African countries should act decisively against the increase of HIV infections in the country. In South Africa the government has approved the long-awaited provision of free antiretroviral drugs in public hospitals. The South Africa is the only country in Africa whose government is still obtuse, dilatory and negligent about rolling out treatment (AVERT, 2010). To fight against an epidemic HIV worldwide, the World Health Organisation and other national and international health organisations celebrates ‘World AIDS Day’ every year on first December. The theme was established by World Health Organisation in 1988. Worldwide it provides national AIDS programs, faith organisations, community organisations, and individuals with an opportunity to raise awareness and focus attention on the global AIDS epidemic (U.S. Department of Health and Human Services, 2010).

In England, the HIV related framework of services has been developed for African communities. This framework is developed to fulfil the vision of NHS plan and meet the standards and goals set out in the National Strategy. This service framework helps NHS staff offering HIV prevention and sexual health promotion advice to African communities. The Department of Health has proposed an ASTOR framework to deal with the diverse black community with different needs. It is a standardised planning tool which can be very helpful to deal with the Black African HIV infected patients. The benefits of ASTORs are for both service commissioners and providers (Department of Health, 2005). To reduce the prevalence of HIV infection in Black African community, the government of England have planned some strategies such as, Reducing the number of people living with undiagnosed HIV with maximum access to testing HIV, improving the health of people living with HIV by providing an antiretroviral therapy to them, preventing the onward transmission of HIV by addressing knowledge and awareness to the infected people (Elam et al, 2006).

The African HIV Policy Network (AHPN) is a national umbrella organisation which deals with providing the information of national policies on HIV and sexual health that have implicated for African communities (African HIV Policy Network, 2008). In England the National African HIV prevention Programme (NAHIP) also works effectively delivering prevention interventions for African people living in England. In 1997, the department of health set up a first group of national projects targeted for African community to reduce the prevalence of HIV infection in England. In 2008 the Department of Health instigated a review of the two national HIV Prevention programmes, NAHIP and CHAPS which highlighted the strengths and weaknesses of both programmes and discussed the challenges regarding increasing prevalence in black Africans. In mid 2009, the RBE Consultancy was commissioned to consult with stakeholders in order to develop the NAHIP Strategic Plan 2010 – 2012. There is a provision of African AIDS Helpline which will become an intervention within NIHIP and the African community. The structure of the plan of NIHIP for 2010-2012 mainly include, the Implementation of the African HIV Prevention Handbook, Putting the Knowledge, The Will and The Power into Practice, relationships with evaluation and development. The aim of AHPN plan is taking into account the needs of African communities and more specifically incorporates Africans living with HIV into local delivery plans where the NIHIP aims to maintain the flow of the previous structure, provide a link for Sub-Contracted Agencies in case of grievances, reduce the length of time between HIV infection and diagnosis, reduce the number of condom failure events by increasing correct use of condoms, increase post-exposure prophylaxis in people who are sexually exposed to HIV (NAHIP, 2010).

The Department of Health (2005) planned some interventions to decrease the prevalence of HIV in African communities such as,

One to one counselling.

Telephone help lines.

Provision of sperm washing services.

Clinical services to prevent mother-to-child transmission.

To maximise the contact with the target group Department of Health made some settings which include, religious groups of African community or churches, African restaurants and embassies etc (Department of Health, 2005).

The most prominent initiatives of NIHIP are the ‘Do It Right – Africans Making Healthy Choices’ campaign providing information on sexual health, condoms, and where to access help to the targeted group. The ‘Beyond Condoms’ campaign of NIHIP promotes debate among African communities about a wide range of issues regarding sexual health and ‘building a safer sex culture’. To avoid the language and religious barriers the campaign literature is available in five different languages with targeting different religious groups (AVERT, 2010).

The London Borough of Lewisham has large number of black African community with infected by HIV. Each year the NHS of Lewisham treats over 1,200 people for HIV infection. In this borough, around 57% of people are infected through heterosexual sex and 35% are infected through sex between men. The NHS Lewisham is trying to fight against increase in HIV prevalence by implementing different strategies. In 2009, the NHS set a theme for World AIDS Day entitled ‘Universal Access and Human Rights’. In the whole borough, the HIV testing is currently available through all GPs on request and four rapid-access HIV testing clinics around the borough. With implementing a new theme for HIV the NHS is piloting a new approach to HIV testing (NHS Lewisham, 2009). To avoid different barriers against HIV treatment the NHS has set 5 spoke providers on the weekly and monthly basis in which Metro is for weekly gay men group and FAWA provides French speaking African monthly group. This can help African community who are infected with HIV (NHS Lewisham, 2009).

In London Borough of Lewisham, the service providers for the black African people living with HIV are commissioned through the South London HIV Partnership (SLHP). The HIV services for black African communities commissioned by SLHP are as follows:

African Culture Promotion: Prevention work with African communities.

SHAKA: Prevention work with Caribbian and African communities.

NPL: Prevention work with African communities.

LSL African Health Forum: Prevention work with African communities.

THT & GMFA: Care and support services for gay men.

Terrence Higgins Trust: Counselling (NHS Lewisham, 2009).

Although Lewisham carries maximum number of HIV patients with black African ethnicity, still there are no specific strategies or policies targeting only for black Africans HIV patients in London Borough of Lewisham. According to the research carried out, the black Africans continue to present with more advanced HIV disease than whites or black Caribbeans. This community is still lacking for the early diagnosis as compared to other ethnic groups. The future strategies should be designed to promote the uptake of HIV testing among black Africans. The future strategies should address the multiple barriers to testing, including misperception of risk, stigma and discrimination and ready access to testing. This study suggests that although being on a high risk group for HIV infection the black Africans generally do not suspect their status. This community delay their uptake for HIV clinic care and test and statutory, voluntary support services. But still after diagnosis they are similar to their white counterparts. The black African community lack informal support networks. This study highlights a desperate need for health promotion work for the black African communities in London Borough of Lewisham, to increase awareness of the benefits of testing HIV and simultaneously to reduce the stigma and discrimination related to HIV/AIDS. These are some barriers which have been illustrated in this study related to HIV testing. The attitudes and practices of NHS and other health care providers, perceptions of patients living with HIV, and official, managerial and economical factors would be very important aspects for the effectiveness of HIV testing and counselling for black African community but yet there is lack of structured information regarding these barriers. The overall barriers described are associated with low-risk perception, access to the health services, reluctance to address HIV, fear and worries and scarcity of economical and properly trained human resources.

To conclude the overall study some suggestions would be helpful for the future strategies of health care services. The strategy or the policy should be made which can help strengthen work between the voluntary and statutory sector since the black African community would find it easier to approach their community organisations. The statutory sector should also approach the community directly by reaching them and to hear their personal views. Every newly established structure of the policy should be placed in each sector which will enable the people to attend easily. Considering the examples of the black African gay people, where it is perhaps easier for them to deal with HIV as they have, no baggage of family, these people are generally from the indigenous community therefore there is no immigration status problem, these people are stigmatised but also influential and empowered. If a HIV patient is admitted in hospital, try monitoring him and when he is about to discharged the hospital ask him to contribute some thoughts once back in the community. Proactive engagement with the black African community would effect in unequal access to services and care with raising the confidence in their own voluntary organisation that the information about their status is held in confidence and will not be breached. A health care service should have culturally competent staff and involves families in the communication process which can be effective and successful.

It is also a responsibility of all members of the society. The society should act well with the minority groups living with HIV. They should not be stigmatised by the general people. Being a good human everyone should avoid racism with minority communities like black Africans and the gay people. Remember, the ‘Black African’ community who have HIV/AIDS are not the problem but the ‘society’ is.

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