A vision for an anti-racist sexual wellbeing system


The focus of sexual, reproductive and HIV healthcare and wellbeing systems needs to be tackling health inequalities. This means ensuring that all people of Black heritage have what they need to attain their highest level of health. 

This approach necessitates:

  • Breaking down siloes and seeing people’s health in a holistic and integrated way. 
  • The entire health and social care system resolving to tackle the drivers of HIV and sexual reproductive health inequities such as racism, misogyny, homophobia, biphobia, transphobia and other systemic forms of discrimination. 
  • Interrogating and reforming research practices in HIV and sexual reproductive health by understanding and reflecting on the impact of historical, sociocultural, political and economic contexts that influence the lived experiences of community members.
  • Broadening referral networks into sexual and reproductive health, including working with Black-led organisations. 
  • Accessible screening and treatment for sexually transmitted infections (STIs). 
  • More opportunities to prevent HIV, including normalised HIV testing across the NHS, access to appropriate safer sex materials and better access to PrEP (pre-exposure prophylaxis) and PEP/PEPSE (post-exposure prophylaxis) treatment options.
  • Offering sexual reproductive health support that is more than the absence of disease. This needs to include: comprehensive Relationship and Sex Education (RSE); improved maternal and infant healthcare; access to abortion service; and robust referral pathways into sexual and gender-based violence, cancer, cervical screening and counselling services.
  • Central government adequately funding to enable this system to effectively work with communities proactively as opposed to reactively.

The current situation


HIV and poor sexual health disproportionately impacts those experiencing health inequalities, racism and discrimination due to a variety of socioeconomic factors. One prime example is those who have a vulnerable migrant status.

There is further impact to those of Black heritage with intersecting identities such as gender, those living in poverty, those with disabilities and LGBTQI+ individuals. 

Despite advances in technology and treatment options, people face barriers to access HIV and sexual and reproductive health care. 

People of Black heritage are four times more likely than the population at large to experience an STI. Yet funding for sexual health services have been reduced by over £1 billion since 2014. This has meant a significant reduction of vital services, key innovations and Black-led community-based responses to poor sexual health. 

30% of those receiving treatment for HIV in England are Black people of African heritage, despite being less than 2% of the UK population. 

In HIV, there are grounds for hope. The numbers of undiagnosed Black people of African heritage living with HIV is falling – with around 1,400 people remaining undiagnosed. However, late diagnosis continues to be stubbornly high, risking poor health and long stays in hospital. 

While HIV testing initiatives have been successful among Black people in the UK, we know Black women are the most likely to access sexual health clinics and not be offered a HIV test and the most likely to turn down a HIV test when they are offered one. This compounds the problem that knowledge about breakthrough HIV prevention methods such as the PrEP pill are incredibly low; unsurprisingly uptake among Black heterosexuals is incredibly small – this needs to change. 

Of those diagnosed with HIV, Black people of African and Caribbean heritage are among the group most likely to be lost to care, and therefore don't have their HIV under control. This risks the virus attacking their immune system and onward transmission of HIV to sexual partners. 

In South London, the Elton John AIDS Foundation piloted ways to find those lost to their HIV clinic. Of the 253 people re-engage to care, half (48%) were women, 60.5% were Black and 58.6% acquired HIV through heterosexual contact. Most worryingly, 6 out of 10 (58.6%) when found, had late-stage HIV and were at real risk of poor health. We know what works; we need to see it rolled out countrywide.

Required system improvements 


Investment in improved in HIV and sexual reproductive health services is vital. This new resource must be directed to tackle health inequalities and spent in collaboration with Black-led or co-produced services and organisations.

To see better outcomes for people of Black heritage, we need to see:

1. PrEP in primary care

The drug, which keeps people who test HIV negative unable to acquire the virus, has very low levels of awareness among people of Black heritage in the UK, and by definition, even lower uptake rates. Changing this means making the PrEP pill available in the places where Black people, especially Black women, are already using the NHS – for example, GPs and community pharmacies. 

2. Opt-out testing outside London

As the virus goes uncontrolled in someone’s system, generally, those living with undiagnosed HIV are using the NHS. However, the system is not seeing the untreated virus, nor its impact.

Every patient accessing accident and emergency departments (A&E), or otherwise getting their blood taken in hospital, should be given an HIV test unless they opt-out. Opt-out HIV testing has been funded in every London, Blackpool, Brighton and Manchester hospital. Despite NICE and BHIVA clinical guidance, there are about 40 hospitals in the 30 local authorities classed as high prevalence HIV areas where HIV testing is not routine in A&Es. 

3. Return/retention of care

The numbers of those lost to HIV post-diagnosis is regrettably increasing, with a 20% jump in the latest available figures (2019 to 2020). From those returned to care from the EJAF opt-out testing, this group is disproportionately women and Black people of African heritage.

4. Make testing easier and more accessible 

All postal HIV and STI testing services need to be linked into ‘click and collect’ services to allow people to pick up a test close to home but not at home. Where this has been trialled, we have seen an increasing interest and popularity among people of Black African heritage.

5. Action on anti-biotic resistance 

People of Black African heritage are more likely to experience gonorrhoea, and there is some real and urgent concern about antibiotic-resistant strains of this STI. Where is the work to develop new antibiotics? 

6. Investment in improved sexual health services

When the Sexual and Reproductive Health Strategy/Action Plan is published, it should be accompanied by new funds. Those funds should be deployed to reducing health inequalities and supporting Black-led innovations and community services.

Being the anti-racist organisation we need to be


Our new strategy is to tackle these institutionalised structural inequalities. We're currently investing in research to highlight the unmet need in sexual health services and compound inequities.

We're fully committed in our new strategy to ensuring that our workforce reflects the communities that we serve. We know we have still have a lot more to do, but this is change we are committing to, through action.