hiv in the united kingdom: setting the scene dr valerie delpech hiv and aids reporting section...

HIV in the United Kingdom: Setting the scene

Dr Valerie DelpechHIV and AIDS Reporting SectionCentre for Infectious Disease Surveillance and Control (CIDSC) Public Health EnglandLondon, United Kingdom

HIV: the story in 2014• People living with HIV can expect a near normal life expectancy and very

good health outcomes if diagnosed in early stage of infection

• As a result of 30 years of prevention efforts, HIV in the UK remains relatively uncommon with an overall prevalence of 1.5 per 1,000 population (1.0 in women and 2.1 in men).

• An estimated 98,400 (93,500-104,300) people were living with HIV by the end of 2012

• Late diagnoses and high undiagnosed infections remain the biggest challenge

• Around 21,900 (22% [18%-27%]) of persons with HIV remain unaware of their infection.

• Of the 6360 persons diagnosed for the first time in 2012, 47% were diagnosed late

2 Presentation title - edit in Header and Footer

3 HIV in the United Kingdom: 2013

• No one should die of AIDS in the UK. Yet 390 persons died of AIDS in 2012

• Despite cont. declines, death rates among persons with HIV are 3 X that of general population

HIV: the story in 2014 cont


• A total of 77,610 people (770 children and 76,840 adults) received HIV care in 2012

• 1 in 4 adults living with diagnosed HIV are aged over 50 years.

• 97% linked to HIV care within 3 months of diagnosis with no differences by age, gender, ethnicity, sexual orientation, sex and area of residence. (195 persons were NOT)

• 95% of the 76,840 diagnosed adults are retained in care annually (3,850 were NOT)

• 89% receive antiretroviral therapy (8,500 were NOT), 92% of those with a CD4 <350

• 95% of persons on treatment achieve a VL<200copies/ml (3,400 did NOT)

• In England, key clinical indicators are monitored locally through the HIV Clinical Dashboard to maintain high standards of HIV care.

HIV: the story in 2014 cont

SOPHIDMPES

Treatment continuum of adults living with HIV: United Kingdom, 2012

5 Treatment cascade of adults living with HIV: United Kingdom, 2011

HIV infected (n=98,400) HIV diagnosed Retained in care On treatment Undectable VL0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%100%

79%

73%

69%

62%

A concentrated epidemic


A concentrated epidemicEstimated number of people living diagnosed

and undiagnosed HIV, 2012

Black Africans


Black Africans

• Black-Africans are the second largest group affected by HIV with 38 per 1,000 living with the infection (26 in men and 51 in women).

• 23% of the 31,800 (29,700-34,600) black-Africans living with HIV, remained unaware of their infection.

• Despite an overall decline over the past five years, an estimated 1,000 black-Africans diagnosed annually probably acquired HIV in the UK.

• High rates of late diagnoses

• Testing rates remain too low. Approximately 100,000 HIV tests (40,000 in STI clinics, 30,000 antenatal clinics and 30,000 in primary and secondary care settings)

HIV in the UK, 2012

New HIV diagnoses among black Africans born in Africa: UK, 2003 – 2012


Geographical trends of new HIV diagnoses among people who acquired their infection heterosexually:

UK, 2003-2012

Persons of black ethnicity living with HIV by probable route of exposure, UK: 2012

2%

31%

67%

n = 24,305

Black Africans

Black Caribbeans

Other black groups

MSM

Natsal III

MSM

• MSM remain the group most affected by HIV with 47 per 1,000 living with the infection (18% unaware= 8,000 men).

• An estimated 2,400 (1,600-4,100) MSM acquire HIV infection each year.

• New diagnoses continued to rise and reached an all time high of 3,250 in 2012. This reflects both an increase in HIV testing and on-going transmission.

• Compounded by high rates of STIs and ongoing risk of HCV

• Circumstantial evidence of an association between drug use and elevated STIs (other than HIV)

• HIV positive men have higher rates of risky behaviour and other STIs.

14

Gay and other MSM bear disproportionate burden of the HIV epidemic in virtually every country that reports reliable HIV data

15 Source: Beyrer, Baral, van Griensven, Goodreau, Chariyalertsak, Wirtz, Brookmeyer, The Lancet, 2012


Geographical trends of new HIV diagnoses among MSM by PHE region and country:

UK, 2003-2012

2006 2007 2008 2009 2010 2011 20120

5000

10000

15000

20000

25000

30000

35000

40000

45000

Number of MSM living with HIV by diagnostic and treatment stats, number infectious (VL>50copies/mL) and estimated number of incident infec-

tions, UK, 2006-12

Estimated undiagnosed* Diagnosed untreatedDiagnosed treated Number infectious (Vl >50 copies/mL)**Estimated number of incident infections***

* MPES model, Presanis et al** Assuming undiagnosed had same proportion with VL >50 copies/mL as those newly diagnosed and untreated*** Birrell, data for England and Wales only, pers comm

HIV the story in 2014

• New set of biomedical prevention tool available with focus on TasP & Prep

• TasP alone is unlikely to be sufficient to reduce HIV transmission in the UK since it is estimated that two-thirds of HIV positive people with detectable viral loads are unaware of their infection.

• Earlier treatment must be combined with a substantial increase in the frequency of HIV testing among groups most affected.


HIV testing

Natsal III


• Late diagnosis has declined over the past decade but remains high in 2012 (47% overall, 34% in MSM and 58% in heterosexuals)

• 64 of 326 (20%) local authorities across England had a prevalence of diagnosed HIV infection of ≥2 per 1,000 population (aged 15-59 years), the threshold for expanded testing (BHIVA 2008 & NICE 2010 guidelines)

• In 2014, there is little evidence of expanded HIV testing taking place in high prevalence areas

HIV testing

HIV testing in STI clinics

• Testing rates have improved in STI clinics with 900,000 tests in 2012

• But remain too low in higher risk groups: 70,000 among MSM and 40,000 in black Africans

• 49% of MSM were diagnosed at their first HIV test at that STI clinic


Prevention is better than cure

All people: Age, longer term condomless anal sex partner, number of short-term condomless anal sex partnersPeople with HIV: CD4 count, viral load, ART drugs, adherence, resistance, risk of AIDS / death.

Phillips et alHIV Synthesis transmission model of HIV in MSM

Simulation model - each time the model program is run it creates a ‘dataset’ of the lifetime experiences of a 1 in 10 sample of adult MSM in UK

Methods and fit to HIV natural history and effect of ART extensively documented in Phillips et al, PLOS One 2013

Counter – factual scenarios, Phillips PLOS One 2013

No condom use(a)ART at diagnosis from 2000(b)Increased testing rates(c) Higher testing and ART at

diagnosis(A)

(d)

NOTE(A) Cessation of all condoms in 2000 would have resulted in a 400% increase in incidence

24

Scaling HIV testing

• HIV testing is a gateway for more tailored approach, and access to, behavioral and biomedical interventions

• Key challenge will be optimising HIV testing programmes• Increase HIV testing frequency by providing acceptable options

• Test whose at high risk, but currently not testing

• Use new testing options to leverage networks

• Use internet-based technologies

• Integrate HIV testing into routine care in range of health care settings

25

Whole system approach

Evidence that particularly sexual risk taking behaviour can only be addressed by tackling syndemic factors including depression, substance use, violence, sexual stigma, homophobia and homelessness

26


Prevalence of diagnosed HIV infection among adults aged 15-59 years by residential deprivation:

England, 2012

Strategy for MSMPromote sexual health across the lifecourse

• Tackling homophobia and bullying

• Increase use of high-quality, coordinated educational, clinical, and other preventive services

• Increase knowledge, communication, and respectful attitudes regarding sexual health

• Promoting opportunities to discuss role of pleasure, satisfaction and ability to have the best sex with the least harm

• Increase healthy, responsible, and respectful sexual behaviors and relationships

• Decrease adverse health outcomes, including HIV/STDs, viral hepatitis, and sexual violence

28 Source: Douglas JM Jr, Fenton KA. Public Health Rep. 2013 Mar-Apr;128 Suppl 1:1-4

Enhancing MSM HIV Prevention Comprehensive Clinical Care

• Work with providers to address stigma, discrimination, homophobia and provide comprehensive care• culturally competent health care that addresses health needs• As major sources of information and vital services, health

providers play a key role, and must be trained to provide supportive, non-judgmental care

• Well-trained clinicians who understand realities and contexts• Use provider engagement can to enable healthier lifestyles

29 Adapted from Mayer et al 2012

Conclusions• HIV is here to stay but no one should die of AIDS

• We have a unique opportunity to refocus prevention and testing efforts

• Re-investing a small amount of the savings from switch to generics into prevention and testing strategies will within a few years prevent thousands of HIV infections and save lives



Acknowledgements

We gratefully acknowledge the continuing collaboration of clinicians,

microbiologists, immunologists, public health practitioners,

occupational health doctors and nurses and other colleagues who

contribute to the surveillance of HIV and STIs in the UK.

Also members of the UK Collaborative Group for HIV and STI

surveillance (listed in surveillance report)

hiv in the united kingdom: setting the scene dr valerie delpech hiv and aids reporting section...

Documents

diagnosed hiv

hiv care

general population hiv

united kingdom slide

diagnosed adults

scene dr valerie delpech

footer slide

cont slide