In 2010, a New Zealand Ministry of Health request for proposals defined African communities in New Zealand as a population at high risk for HIV disease, and called for further investigation into these communities. Prior to the present study, however, very little was known about African communities in New Zealand and about Black Africans in particular including an estimate of the number resident in New Zealand, the prevalence of HIV in Black African communities, or the knowledge, attitudes, behaviours and beliefs (KABB) about HIV in these communities which contribute to the transmission and management of HIV, and the stigma associated with the disease. In response to these issues, the present research was proposed and funded. The mixed method research project was conducted in two phases: the first phase used existing data sources in order to estimate the number of Black African new settlers in New Zealand and the prevalence of HIV in these communities. The second phase was a quantitative survey amplified with qualitative data from focus groups to assess the KABB of Black African new settlers about HIV.A full report of the entire project, including a complete discussion of methods and findings, is beyond the scope of the present paper, and is available elsewhere.1 The purpose of this paper is not to report on the primary data, but rather to provide some key findings, analyses and conclusions from this unique dataset that are specifically relevant to New Zealand medical providers as they work with Black African new settlers. Specifically, we propose that while Black African new settlers demonstrate a high level of basic, objective knowledge of HIV transmission, there is an apparent disconnect between this objective knowledge and the informal, but perhaps more significant, discussions of this same topic which emerged in focus groups. This second kind of operational knowing is contextual, and is shaped more by religious and cultural expectations of acceptable behaviour, than by objective or factual knowledge about transmission.2,3 This space between what people know and what they believe is important for the development of effective, targeted public health interventions, and for addressing individual barriers to HIV education, testing and care.We recognise that discussions of race and ethnicity are fraught in both African and New Zealand contexts, and that definitions of who is African is a highly contested issue, even in African nations.4 Our decision to focus on Black Africans (as opposed to all African-born migrants) was based in part on a South African household study of HIV prevalence5 which showed that the highest prevalence of HIV was in Blacks relative to Whites and Coloured, and on the Mayisha II study in the UK,6 a model for the present study that simply assumed without explanation that African meant Black African .MethodsFrom the outset of the project, the research team worked closely with community advisers recruited nationally from Black African communities. The two advisory groups, made up respectively of community and religious leaders in Black African communities, and Black Africans living with HIV, were consulted regularly over the 18-month period of the project, and were given opportunities to review and comment on research instruments and the draft research reports before publication. Ethics approval for the study was given by an accredited academic human ethics committee.Phase I: Demographic estimatesSince Black African ethnicity was not captured by any existing New Zealand source, the first phase of the study used existing data sources, including census data on ethnicity, place of birth, language, and religion, as well as arrival and departure information, to develop an estimate of the New Zealand resident population of Black Africans at the end of 2011. In addition, laboratory and AIDS Epidemiology Group data were used, and HIV specialist provider information were canvassed for relevant HIV reports (even though these data are not reported by ethnicity) to develop an estimate of Black Africans living with HIV. This analysis led us to estimate that 12,500 Black African new settlers were living in New Zealand (or less than 0.3% of the total population), of whom an estimated 5% may be living with HIV.7 These first phase estimates served as a rough sampling frame for the second phase of the study.Phase 2: Methods and samplingThe second phase comprised two arms, both of which were inevitably samples of convenience, since probability sampling for these relatively small communities was neither practical nor necessary when purposively recruiting an homogenous group.8 The first arm was an anonymous quantitative self-completed survey (n=703, or approximately 5% of the estimated resident Black African population) distributed by Black African research staff at African community and sporting events, festivals, pageants, churches, and other events in the four centres with the largest concentrations of Black Africans as found in the first phase analysis: Auckland, Hamilton, Wellington and Christchurch. Participants were provided a copy of the survey and invited to complete it anonymously on the spot, or to return it at a later time via a Freepost envelope. Survey team members anecdotally estimate that less than 5% of people approached at these events declined to participate in the survey. Survey questions were adapted from the Mayisha II6 and Bass Line9 studies from the UK, and developed in collaboration with the two Black African community advisory groups. Responses to the knowledge section of the quantitative survey were framed to be consistent with the UK studies for comparison, and were worded as statements with response options I knew this, I didn t know this, I wasn t sure if this were true, and I don t understand this.The second arm was a series of focus groups (n=131 in 23 focus groups around the country) that were recorded, transcribed and analysed. Participants were recruited by Black African research staff from the same community events where surveys were distributed, and from Black African community groups, interest groups and churches. Some, but not all, focus group participants may also have completed a survey (because of anonymity there is no way to know this definitively). All groups but one were held in English, although in some groups summaries or simultaneous interpretations in relevant languages were provided if required. Once the focus group convened, participants were consented, asked to sign a confidentiality agreement and to choose a pseudonym for the purposes of the group. Great care was taken to ensure that participants were fully informed, voluntary, and their identities protected; these methods are fully elaborated elsewhere.10,11 Topic areas and specific questions were developed in collaboration with the project advisory groups, and included settlement experiences in New Zealand, attitudes about the appropriate age for sexual activity, same-sex sexual activity and relationships, multiple sexual partners, condom use, HIV testing, disclosure of HIV, HIV education and awareness, and African cultural understandings about HIV. At the end of the 90-minute group, participants were invited to complete anonymously a short demographic questionnaire, put it in an envelope and deposit it in a box as they left; only two participants submitted blank forms. Project staff from Black African communities facilitated groups of participants of their own genders so that men and women did not need to discuss intimate matters in front of opposite gender participants.ResultsFindings have been selected here in order to focus on survey and focus group similarities and differences on key KABB questions.SurveyThe survey included responses from 343 (48.8%) men and 351 (49.9%) women; 9 (0.1%) responded as other or did not state gender. Ages included 214 (30.4%) in the 16\u201324 year old group, 273 (38.8%) in age group 25\u201339, and 160 (22.7%) in the 40 and older group; 56 did not respond to the age question. Most respondents (65.8%) had a tertiary education, as we would expect from a new migrant group. Christianity was the religion of 571 (81.2%), and Islam of 94 (13.4%) respondents; the others were African traditional religions, Buddhist, other, none, or not stated, each comprising 2% or less.Respondents reported high levels of knowledge of HIV transmission (I knew this). For example, 90% of all respondents (n=605 of 674 responding) knew that HIV is never passed on through shaking hands or touching people, 88% (n=596 of 674) knew that Condoms reduce the risk of HIV transmission during sexual intercourse, and 73% (n=491 of 673) knew that HIV is never passed by mosquitos or other insects. Analysis by age groups found differences between younger (\u226424 years) and older (\u226525 years) demographic groups. Among older respondents, 92% (n=382 of 413) indicated that they knew that HIV is not contracted through touching, whereas only 85% (n=174 of 204) of younger respondents indicated the same. In older respondents, 79% (n=325 of 413) said that they knew that HIV is never passed by mosquitoes, but only 61% (n=123 of 203) of younger respondents reported the same knowledge. Both age groups indicated that they knew that condoms reduce the risk of HIV transmission (88% of younger respondents, n=178 of 203, and 89%, n=369 of 415, of older respondents knew this.) Traditional beliefs about HIV also play a role in attitudes to testing in a small number of people: 5% of survey respondents believed that witchcraft was a cause of AIDS (although 31% said they did not know if this was true), and 8% believed that a person would not join their ancestors if they died a dishonourable death from AIDS (27% did not know if this were true).Focus groupsThe focus groups comprised 76 males (58%) and 54 females (41%), and one did not specify gender; 31 (24%) identified as Muslim, 88 (66%) identified as Christian, and the rest reported no religion, other, or did not respond. Of focus group participants, 103 (78%) identified as heterosexual, two (1.5%) identified as homosexual, and 26 (20%) did not specify a provided option. Three participants (2%) identified as HIV positive, 101 (77%) identified as HIV negative, 16 (12%) said they did not know their HIV status, and 11 did not respond to the question about their HIV status. The mean time living in New Zealand was 7.5 years (SD=5.09).KnowledgeThere were different kinds of operational knowledge identified in the qualitative data. Some participants expressed the belief that religion and marriage each provided a kind of prophylactic effect against HIV transmission:\r\n If you are a religious person, you re not gonna get HIV because you going to the right way, how you gonna get the HIV unless by accident, like we say, injury? (male, Group 1, Auckland)\r\nThe presumption of fidelity within marriage, whether monogamous or plural marriage, was seen as a defense against HIV transmission:\r\n We only get married when we have sex, so it s not like you can have sex with different people that you don t know, like strangers, and you know your husband, he s healthy. (female, Group 2, Auckland)\r\nHowever, a substantial number of participants indicated that men and women were held to different standards with regards to sexual infidelity:\r\n Women are kind of more respected for having less partners, and men are more respected for having more partners. (female, Group 3, Auckland)\r\nWhile women are expected not to engage in sex outside of marriage, men are not held to such strict standards:\r\n In Africa, monogamous relationships are much worse because\u2026you ll find that\u2026men sleep with women and then they have children with them and then they leave them\u2026And then they go to another. (female, Group 4, Auckland)\r\nOne participant noted:\r\n [In New Zealand] if [men] have more than one or two partners it s usually like an affair and it s all hidden. In Africa if they do that they, like you have four wives, it s out in the open, you marry four women, which is kinda gross, but you did, and everyone knows it. (female, Group 4, Auckland)\r\nParticipants catastrophised relatively small risks: participants felt there was little they could do to avoid infection. Examples include rationalising not using condoms, and accidental contact infection:\r\n The condom can explode and then they get the disease. (female, Group 5, Auckland) You have an accident, someone has blood and then you touch it, then that s it, you get [HIV]. (male, Group 1, Hamilton)\r\nMany participants expressed a reluctance to use condoms within committed relationships, saying that using this kind of protection implied a lack of trust of the partner. Cultural and religious norms also factored into condom use:\r\n The focal point of marriage is having children\u2026They can t see the point of why are you getting married if you don t want kids. (female, Group 8, Wellington)\r\nWhen asked about condoms, most participants understood them as a form of contraception, but their use for STI and in particular HIV risk reduction was a secondary or conflicted consideration for most:\r\n I know for a fact that Catholics are completely against contraception unless it s a case of\u2026medical condition, unless it s going to kill you and then you need to have contraception. But I know that they don t like people using contraceptions which kind of makes it\u2026contradict with the fact that we don t want the spread of HIV and the solution to it is contraception. (female, Group 4, Auckland)\r\nThere was also a sense that exposure to HIV necessarily meant that a person was immediately infected with HIV, and any subsequent protection was unnecessary:\r\n When a couple, one of the couple have HIV, by the time it will be known that means that they both have it. (female, Group 7, Auckland)\r\nStigmaSome participants suggested a need for protecting themselves against people with HIV, even when there was low or no risk:\r\n Just don t share anything [with] them like drink-wise, it s just for safety. (female, Group 6, Auckland)\r\nSome participants expressed concerns that individuals living with HIV were consciously and deliberately attempting to infect others:\r\n I hear when they found they got HIV they took their blood and\u2026if the women are cutting the onion and the salad and making the salad, she might add her blood to that food. (female, Group 2, Auckland)\r\nThis fear of people living with HIV manifested itself in other ways, including social and physical isolation of seropositive individuals:\r\n If I in case see that person I will take to the hospital, somewhere they can keep [them isolated], so nobody will see that person. (female, Group 2, Auckland)\r\nProvider responseA complex relationship between Black Africans and HIV testing emerged. While some were enthusiastic about testing, particularly at the beginning of a new relationship, others expressed concern about the stigma attached to the act of testing or seeking information about HIV:\r\n There s HIV centres you can go to, but if you go there, even if you re going with someone, people will think you have it. (female, Group 8, Wellington) Because of the stigma\u2026no one can easily go there. And again, people are scared of just being diagnosed because we come from a mindset it s a death sentence. (female, Group 8, Wellington)\r\nMany focus group participants expressed high levels of discomfort about associating with men who have sex with men (MSM), and in accessing HIV information and resources through perceived gay organisations. Approaching gay organisations for information amplifies the already considerable levels of stigma around HIV in African communities. However, one participant noted:\r\n It s time we started looking at it in a different way cos we are coming under the gay community, which is not common in our community. (female, Group 8, Wellington)\r\nDiscussionWhat is knowledge?The quantitative data in this study confirms findings in other studies6,9 that there is a high level of basic knowledge about HIV transmission in Black African new settlers, particularly in older respondents who may have learned this information in their home countries. The disparities by age in knowledge about transmission are of some concern, given that Black African communities include larger proportions of young people relative to other ethnic groups, and clearly more targeted education is required. Many of these young people will have been born in New Zealand, or arrived at a very young age, and will have been exposed to HIV education only in New Zealand, if at all. These findings are consistent with those of the Bass Line study, which demonstrated that basic knowledge of HIV was lowest in the youngest members of Black African communities in the UK.9 From a medical and epidemiological standpoint, however, these survey findings are generally encouraging.However, what this study suggests is that the survey findings alone present only a partial and insufficient portrait of the operational knowledge that is used in daily life by members of these communities to affiliate with cultural and religious norms, a problem that the focus group data help to elucidate. Black African new settlers experience and knowledge of HIV is shaped not only by objective information and transmission facts, but also by multifarious social and cultural forces. A belief in supernatural causes of HIV, for instance, and the accompanying fatalism may be one reason why some participants do not see the value of HIV testing. Cultural and religious expectations impact participants perceptions of their actual risks for HIV infection,2 and the willingness to adopt what have become standard prevention technologies, (But I know that they don t like people using contraceptions which\u2026contradict with the fact that we don t want the spread of HIV. Group 4).Public conformity to these community expectations promotes a sense of immunity if the individual adheres to accepted norms and standards of acceptable behaviour (If you are a religious person, you re not gonna get HIV because you going to the right way Group 1). The dissonance between beliefs that are publicly stated, and what is done in private, has been considered elsewhere.12 However, publicly stated, and perhaps privately held, beliefs may limit open and honest communication with medical providers about perceived risk behaviour, and the acceptance of accurate information relating to HIV.14,15The pervasive impact of stigmaBlack African migrants also face intersectional stigma, stigma from non-African New Zealanders because they are Black, stigma because they are new settlers, and stigma that associates African identity with HIV.15 This stigma has an impact on the willingness of Black Africans to seek out HIV education, testing, and treatment. The very act of volunteering for testing for HIV, or even seeking out prevention information, suggests that the individual has risk behaviours (such as having sex before marriage, or multiple sexual partners, or a man who is having sex with another man), which are stigmatised in public Black African discourse. In Black African contexts, even the relatively neutral term man who has sex with a man may evoke stigma and create barriers.16 If a medical provider recommends HIV testing, the implicit message is that the provider thinks the individual is engaging in behaviours that put them at risk, behaviours that would violate powerful cultural norms (\"There s HIV centres you can go to, but if you go there even if you re going with someone, people will think you have it.\" Group 8). This may lead to denial of such behaviours. Resistance to associating with men who have sex with men (MSM) may lead Black Africans to avoid accessing HIV resources through gay-identified organisations (we are coming under the gay community which is not common in our community Group 8), which remain key sources for education about HIV. Other factors, such as attitudes about HIV, perceived risk behaviours, racism, and the need to be perceived as model new settlers by denying the existence of risk behaviours, also make decisions to seek testing and treatment more fraught.Provider responsesHow, then, can medical providers engage with Black African new settlers around HIV? Community recommendations to researchers include normalising routine HIV education, counselling and testing at health care providers, and contextualising HIV along with other chronic, life-threatening health issues in Black African communities such as cancer and diabetes. These recommendations also note that routine HIV testing should be linked to increased education in health and dental care providers, including support staff, in order to decrease the stigma that surrounds HIV and Black African new settlers in New Zealand.LimitationsThere are many possible limitations to this study, including the absence of a clearly defined sampling frame; purposive homogenous sampling included only people who are socially engaged with African community events, and excluded people who spoke no or very limited English. There is also an underrepresentation of Muslims in our survey participants. We know from many sources, including our HIV positive community advisors, that Black Africans who are HIV positive or who are MSM are very reluctant to disclose in any public way, and are quite likely to say don t know in response to these questions. We are also mindful of the possibility of social desirability bias, the need for respondents and participants to be model migrants in both survey and focus groups, and thereby provide responses they believe researchers want to hear. We have attempted to address some of these limitations through the two-arm approach and the extensive use of our two advisory groups, but clearly much more research is required to understand the multifarious forces that shape the HIV knowledges of Black African new settlers in New Zealand.ConclusionHealthcare professionals rarely have time to interrogate notions of knowledge and truth, and usually take what patients say at face value. They will not be entirely incorrect. Familiar questions and algorithms, however, may not capture all the required information, since different cultures have different ways of communicating, and attribute different meanings and values to experiences and knowledge. What Black Africans disclose, particularly to non-Africans, may not reveal all of what they think, understand, or believe, because much of that knowledge and belief is implicit. Our findings suggest that face value knowledge assessments are not sufficient, and that a contextual approach to understanding what people know is essential, not only for HIV, but for the delivery of all health care education and interventions to Black African new settlers. In order to discover what Black Africans know about HIV, healthcare professionals will want to ask questions designed to elicit meaning and understanding, shaped by Black African religious and cultural expectations of acceptable behaviour. Understanding this space between what people know and what they believe will assist in the development of effective interventions and address individual barriers to HIV education, testing and care.\r\n

In 2010, a New Zealand Ministry of Health request for proposals defined African communities in New Zealand as a population at high risk for HIV disease, and called for further investigation into these communities. Prior to the present study, however, very little was known about African communities in New Zealand and about Black Africans in particular including an estimate of the number resident in New Zealand, the prevalence of HIV in Black African communities, or the knowledge, attitudes, behaviours and beliefs (KABB) about HIV in these communities which contribute to the transmission and management of HIV, and the stigma associated with the disease. In response to these issues, the present research was proposed and funded. The mixed method research project was conducted in two phases: the first phase used existing data sources in order to estimate the number of Black African new settlers in New Zealand and the prevalence of HIV in these communities. The second phase was a quantitative survey amplified with qualitative data from focus groups to assess the KABB of Black African new settlers about HIV.A full report of the entire project, including a complete discussion of methods and findings, is beyond the scope of the present paper, and is available elsewhere.1 The purpose of this paper is not to report on the primary data, but rather to provide some key findings, analyses and conclusions from this unique dataset that are specifically relevant to New Zealand medical providers as they work with Black African new settlers. Specifically, we propose that while Black African new settlers demonstrate a high level of basic, objective knowledge of HIV transmission, there is an apparent disconnect between this objective knowledge and the informal, but perhaps more significant, discussions of this same topic which emerged in focus groups. This second kind of operational knowing is contextual, and is shaped more by religious and cultural expectations of acceptable behaviour, than by objective or factual knowledge about transmission.2,3 This space between what people know and what they believe is important for the development of effective, targeted public health interventions, and for addressing individual barriers to HIV education, testing and care.We recognise that discussions of race and ethnicity are fraught in both African and New Zealand contexts, and that definitions of who is African is a highly contested issue, even in African nations.4 Our decision to focus on Black Africans (as opposed to all African-born migrants) was based in part on a South African household study of HIV prevalence5 which showed that the highest prevalence of HIV was in Blacks relative to Whites and Coloured, and on the Mayisha II study in the UK,6 a model for the present study that simply assumed without explanation that African meant Black African .MethodsFrom the outset of the project, the research team worked closely with community advisers recruited nationally from Black African communities. The two advisory groups, made up respectively of community and religious leaders in Black African communities, and Black Africans living with HIV, were consulted regularly over the 18-month period of the project, and were given opportunities to review and comment on research instruments and the draft research reports before publication. Ethics approval for the study was given by an accredited academic human ethics committee.Phase I: Demographic estimatesSince Black African ethnicity was not captured by any existing New Zealand source, the first phase of the study used existing data sources, including census data on ethnicity, place of birth, language, and religion, as well as arrival and departure information, to develop an estimate of the New Zealand resident population of Black Africans at the end of 2011. In addition, laboratory and AIDS Epidemiology Group data were used, and HIV specialist provider information were canvassed for relevant HIV reports (even though these data are not reported by ethnicity) to develop an estimate of Black Africans living with HIV. This analysis led us to estimate that 12,500 Black African new settlers were living in New Zealand (or less than 0.3% of the total population), of whom an estimated 5% may be living with HIV.7 These first phase estimates served as a rough sampling frame for the second phase of the study.Phase 2: Methods and samplingThe second phase comprised two arms, both of which were inevitably samples of convenience, since probability sampling for these relatively small communities was neither practical nor necessary when purposively recruiting an homogenous group.8 The first arm was an anonymous quantitative self-completed survey (n=703, or approximately 5% of the estimated resident Black African population) distributed by Black African research staff at African community and sporting events, festivals, pageants, churches, and other events in the four centres with the largest concentrations of Black Africans as found in the first phase analysis: Auckland, Hamilton, Wellington and Christchurch. Participants were provided a copy of the survey and invited to complete it anonymously on the spot, or to return it at a later time via a Freepost envelope. Survey team members anecdotally estimate that less than 5% of people approached at these events declined to participate in the survey. Survey questions were adapted from the Mayisha II6 and Bass Line9 studies from the UK, and developed in collaboration with the two Black African community advisory groups. Responses to the knowledge section of the quantitative survey were framed to be consistent with the UK studies for comparison, and were worded as statements with response options I knew this, I didn t know this, I wasn t sure if this were true, and I don t understand this.The second arm was a series of focus groups (n=131 in 23 focus groups around the country) that were recorded, transcribed and analysed. Participants were recruited by Black African research staff from the same community events where surveys were distributed, and from Black African community groups, interest groups and churches. Some, but not all, focus group participants may also have completed a survey (because of anonymity there is no way to know this definitively). All groups but one were held in English, although in some groups summaries or simultaneous interpretations in relevant languages were provided if required. Once the focus group convened, participants were consented, asked to sign a confidentiality agreement and to choose a pseudonym for the purposes of the group. Great care was taken to ensure that participants were fully informed, voluntary, and their identities protected; these methods are fully elaborated elsewhere.10,11 Topic areas and specific questions were developed in collaboration with the project advisory groups, and included settlement experiences in New Zealand, attitudes about the appropriate age for sexual activity, same-sex sexual activity and relationships, multiple sexual partners, condom use, HIV testing, disclosure of HIV, HIV education and awareness, and African cultural understandings about HIV. At the end of the 90-minute group, participants were invited to complete anonymously a short demographic questionnaire, put it in an envelope and deposit it in a box as they left; only two participants submitted blank forms. Project staff from Black African communities facilitated groups of participants of their own genders so that men and women did not need to discuss intimate matters in front of opposite gender participants.ResultsFindings have been selected here in order to focus on survey and focus group similarities and differences on key KABB questions.SurveyThe survey included responses from 343 (48.8%) men and 351 (49.9%) women; 9 (0.1%) responded as other or did not state gender. Ages included 214 (30.4%) in the 16\u201324 year old group, 273 (38.8%) in age group 25\u201339, and 160 (22.7%) in the 40 and older group; 56 did not respond to the age question. Most respondents (65.8%) had a tertiary education, as we would expect from a new migrant group. Christianity was the religion of 571 (81.2%), and Islam of 94 (13.4%) respondents; the others were African traditional religions, Buddhist, other, none, or not stated, each comprising 2% or less.Respondents reported high levels of knowledge of HIV transmission (I knew this). For example, 90% of all respondents (n=605 of 674 responding) knew that HIV is never passed on through shaking hands or touching people, 88% (n=596 of 674) knew that Condoms reduce the risk of HIV transmission during sexual intercourse, and 73% (n=491 of 673) knew that HIV is never passed by mosquitos or other insects. Analysis by age groups found differences between younger (\u226424 years) and older (\u226525 years) demographic groups. Among older respondents, 92% (n=382 of 413) indicated that they knew that HIV is not contracted through touching, whereas only 85% (n=174 of 204) of younger respondents indicated the same. In older respondents, 79% (n=325 of 413) said that they knew that HIV is never passed by mosquitoes, but only 61% (n=123 of 203) of younger respondents reported the same knowledge. Both age groups indicated that they knew that condoms reduce the risk of HIV transmission (88% of younger respondents, n=178 of 203, and 89%, n=369 of 415, of older respondents knew this.) Traditional beliefs about HIV also play a role in attitudes to testing in a small number of people: 5% of survey respondents believed that witchcraft was a cause of AIDS (although 31% said they did not know if this was true), and 8% believed that a person would not join their ancestors if they died a dishonourable death from AIDS (27% did not know if this were true).Focus groupsThe focus groups comprised 76 males (58%) and 54 females (41%), and one did not specify gender; 31 (24%) identified as Muslim, 88 (66%) identified as Christian, and the rest reported no religion, other, or did not respond. Of focus group participants, 103 (78%) identified as heterosexual, two (1.5%) identified as homosexual, and 26 (20%) did not specify a provided option. Three participants (2%) identified as HIV positive, 101 (77%) identified as HIV negative, 16 (12%) said they did not know their HIV status, and 11 did not respond to the question about their HIV status. The mean time living in New Zealand was 7.5 years (SD=5.09).KnowledgeThere were different kinds of operational knowledge identified in the qualitative data. Some participants expressed the belief that religion and marriage each provided a kind of prophylactic effect against HIV transmission:\r\n If you are a religious person, you re not gonna get HIV because you going to the right way, how you gonna get the HIV unless by accident, like we say, injury? (male, Group 1, Auckland)\r\nThe presumption of fidelity within marriage, whether monogamous or plural marriage, was seen as a defense against HIV transmission:\r\n We only get married when we have sex, so it s not like you can have sex with different people that you don t know, like strangers, and you know your husband, he s healthy. (female, Group 2, Auckland)\r\nHowever, a substantial number of participants indicated that men and women were held to different standards with regards to sexual infidelity:\r\n Women are kind of more respected for having less partners, and men are more respected for having more partners. (female, Group 3, Auckland)\r\nWhile women are expected not to engage in sex outside of marriage, men are not held to such strict standards:\r\n In Africa, monogamous relationships are much worse because\u2026you ll find that\u2026men sleep with women and then they have children with them and then they leave them\u2026And then they go to another. (female, Group 4, Auckland)\r\nOne participant noted:\r\n [In New Zealand] if [men] have more than one or two partners it s usually like an affair and it s all hidden. In Africa if they do that they, like you have four wives, it s out in the open, you marry four women, which is kinda gross, but you did, and everyone knows it. (female, Group 4, Auckland)\r\nParticipants catastrophised relatively small risks: participants felt there was little they could do to avoid infection. Examples include rationalising not using condoms, and accidental contact infection:\r\n The condom can explode and then they get the disease. (female, Group 5, Auckland) You have an accident, someone has blood and then you touch it, then that s it, you get [HIV]. (male, Group 1, Hamilton)\r\nMany participants expressed a reluctance to use condoms within committed relationships, saying that using this kind of protection implied a lack of trust of the partner. Cultural and religious norms also factored into condom use:\r\n The focal point of marriage is having children\u2026They can t see the point of why are you getting married if you don t want kids. (female, Group 8, Wellington)\r\nWhen asked about condoms, most participants understood them as a form of contraception, but their use for STI and in particular HIV risk reduction was a secondary or conflicted consideration for most:\r\n I know for a fact that Catholics are completely against contraception unless it s a case of\u2026medical condition, unless it s going to kill you and then you need to have contraception. But I know that they don t like people using contraceptions which kind of makes it\u2026contradict with the fact that we don t want the spread of HIV and the solution to it is contraception. (female, Group 4, Auckland)\r\nThere was also a sense that exposure to HIV necessarily meant that a person was immediately infected with HIV, and any subsequent protection was unnecessary:\r\n When a couple, one of the couple have HIV, by the time it will be known that means that they both have it. (female, Group 7, Auckland)\r\nStigmaSome participants suggested a need for protecting themselves against people with HIV, even when there was low or no risk:\r\n Just don t share anything [with] them like drink-wise, it s just for safety. (female, Group 6, Auckland)\r\nSome participants expressed concerns that individuals living with HIV were consciously and deliberately attempting to infect others:\r\n I hear when they found they got HIV they took their blood and\u2026if the women are cutting the onion and the salad and making the salad, she might add her blood to that food. (female, Group 2, Auckland)\r\nThis fear of people living with HIV manifested itself in other ways, including social and physical isolation of seropositive individuals:\r\n If I in case see that person I will take to the hospital, somewhere they can keep [them isolated], so nobody will see that person. (female, Group 2, Auckland)\r\nProvider responseA complex relationship between Black Africans and HIV testing emerged. While some were enthusiastic about testing, particularly at the beginning of a new relationship, others expressed concern about the stigma attached to the act of testing or seeking information about HIV:\r\n There s HIV centres you can go to, but if you go there, even if you re going with someone, people will think you have it. (female, Group 8, Wellington) Because of the stigma\u2026no one can easily go there. And again, people are scared of just being diagnosed because we come from a mindset it s a death sentence. (female, Group 8, Wellington)\r\nMany focus group participants expressed high levels of discomfort about associating with men who have sex with men (MSM), and in accessing HIV information and resources through perceived gay organisations. Approaching gay organisations for information amplifies the already considerable levels of stigma around HIV in African communities. However, one participant noted:\r\n It s time we started looking at it in a different way cos we are coming under the gay community, which is not common in our community. (female, Group 8, Wellington)\r\nDiscussionWhat is knowledge?The quantitative data in this study confirms findings in other studies6,9 that there is a high level of basic knowledge about HIV transmission in Black African new settlers, particularly in older respondents who may have learned this information in their home countries. The disparities by age in knowledge about transmission are of some concern, given that Black African communities include larger proportions of young people relative to other ethnic groups, and clearly more targeted education is required. Many of these young people will have been born in New Zealand, or arrived at a very young age, and will have been exposed to HIV education only in New Zealand, if at all. These findings are consistent with those of the Bass Line study, which demonstrated that basic knowledge of HIV was lowest in the youngest members of Black African communities in the UK.9 From a medical and epidemiological standpoint, however, these survey findings are generally encouraging.However, what this study suggests is that the survey findings alone present only a partial and insufficient portrait of the operational knowledge that is used in daily life by members of these communities to affiliate with cultural and religious norms, a problem that the focus group data help to elucidate. Black African new settlers experience and knowledge of HIV is shaped not only by objective information and transmission facts, but also by multifarious social and cultural forces. A belief in supernatural causes of HIV, for instance, and the accompanying fatalism may be one reason why some participants do not see the value of HIV testing. Cultural and religious expectations impact participants perceptions of their actual risks for HIV infection,2 and the willingness to adopt what have become standard prevention technologies, (But I know that they don t like people using contraceptions which\u2026contradict with the fact that we don t want the spread of HIV. Group 4).Public conformity to these community expectations promotes a sense of immunity if the individual adheres to accepted norms and standards of acceptable behaviour (If you are a religious person, you re not gonna get HIV because you going to the right way Group 1). The dissonance between beliefs that are publicly stated, and what is done in private, has been considered elsewhere.12 However, publicly stated, and perhaps privately held, beliefs may limit open and honest communication with medical providers about perceived risk behaviour, and the acceptance of accurate information relating to HIV.14,15The pervasive impact of stigmaBlack African migrants also face intersectional stigma, stigma from non-African New Zealanders because they are Black, stigma because they are new settlers, and stigma that associates African identity with HIV.15 This stigma has an impact on the willingness of Black Africans to seek out HIV education, testing, and treatment. The very act of volunteering for testing for HIV, or even seeking out prevention information, suggests that the individual has risk behaviours (such as having sex before marriage, or multiple sexual partners, or a man who is having sex with another man), which are stigmatised in public Black African discourse. In Black African contexts, even the relatively neutral term man who has sex with a man may evoke stigma and create barriers.16 If a medical provider recommends HIV testing, the implicit message is that the provider thinks the individual is engaging in behaviours that put them at risk, behaviours that would violate powerful cultural norms (\"There s HIV centres you can go to, but if you go there even if you re going with someone, people will think you have it.\" Group 8). This may lead to denial of such behaviours. Resistance to associating with men who have sex with men (MSM) may lead Black Africans to avoid accessing HIV resources through gay-identified organisations (we are coming under the gay community which is not common in our community Group 8), which remain key sources for education about HIV. Other factors, such as attitudes about HIV, perceived risk behaviours, racism, and the need to be perceived as model new settlers by denying the existence of risk behaviours, also make decisions to seek testing and treatment more fraught.Provider responsesHow, then, can medical providers engage with Black African new settlers around HIV? Community recommendations to researchers include normalising routine HIV education, counselling and testing at health care providers, and contextualising HIV along with other chronic, life-threatening health issues in Black African communities such as cancer and diabetes. These recommendations also note that routine HIV testing should be linked to increased education in health and dental care providers, including support staff, in order to decrease the stigma that surrounds HIV and Black African new settlers in New Zealand.LimitationsThere are many possible limitations to this study, including the absence of a clearly defined sampling frame; purposive homogenous sampling included only people who are socially engaged with African community events, and excluded people who spoke no or very limited English. There is also an underrepresentation of Muslims in our survey participants. We know from many sources, including our HIV positive community advisors, that Black Africans who are HIV positive or who are MSM are very reluctant to disclose in any public way, and are quite likely to say don t know in response to these questions. We are also mindful of the possibility of social desirability bias, the need for respondents and participants to be model migrants in both survey and focus groups, and thereby provide responses they believe researchers want to hear. We have attempted to address some of these limitations through the two-arm approach and the extensive use of our two advisory groups, but clearly much more research is required to understand the multifarious forces that shape the HIV knowledges of Black African new settlers in New Zealand.ConclusionHealthcare professionals rarely have time to interrogate notions of knowledge and truth, and usually take what patients say at face value. They will not be entirely incorrect. Familiar questions and algorithms, however, may not capture all the required information, since different cultures have different ways of communicating, and attribute different meanings and values to experiences and knowledge. What Black Africans disclose, particularly to non-Africans, may not reveal all of what they think, understand, or believe, because much of that knowledge and belief is implicit. Our findings suggest that face value knowledge assessments are not sufficient, and that a contextual approach to understanding what people know is essential, not only for HIV, but for the delivery of all health care education and interventions to Black African new settlers. In order to discover what Black Africans know about HIV, healthcare professionals will want to ask questions designed to elicit meaning and understanding, shaped by Black African religious and cultural expectations of acceptable behaviour. Understanding this space between what people know and what they believe will assist in the development of effective interventions and address individual barriers to HIV education, testing and care.\r\n