Africans and HIV in the UK: an epidemiological perspective May 2006 Valerie Delpech On behalf of the HIV Reporting Section with special thanks to Julia Abernethy HIV & STI Department, Health Protection Agency Centre for Infections

What I will cover…  Global trends  UK trends  Focus on black Africans  Diagnosed  Seen for care  Undiagnosed  Implications

Global picture

Global estimates for adults and children end 2005 People living with HIV New HIV infections in 2005 Deaths due to AIDS in million [36.7 – 45.3 million] 4.9 million [4.3 – 6.6 million] 3.1 million [2.8 – 3.6 million]

Adults and children estimated to be living with HIV as of end 2005 Total: 40.3 (36.7 – 45.3) million Western & Central Europe [ – ] North Africa & Middle East [ – 1.4 million] Sub-Saharan Africa 25.8 million [23.8 – 28.9 million] Eastern Europe & Central Asia 1.6 million [ – 2.3 million] South & South-East Asia 7.4 million [4.5 – 11.0 million] Oceania [ – ] North America 1.2 million [ – 1.8 million] Caribbean [ – ] Latin America 1.8 million [1.4 – 2.4 million] East Asia [ – 1.4 million] 1.3 million on ARV

Estimated adult and child deaths from AIDS during 2005 Total: 3.1 (2.8 – 3.6) million Western & Central Europe [<15 000] North Africa & Middle East [ – ] Sub-Saharan Africa 2.4 million [2.1 – 2.7 million] Eastern Europe & Central Asia [ – ] East Asia [ – ] South & South-East Asia [ – ] Oceania3600 [1700 – 8200] North America [9000 – ] Caribbean [ – ] Latin America [ – ]

Estimated number of adults and children newly infected with HIV during 2005 Total: 4.9 (4.3 – 6.6 ) million Western & Central Europe [ – ] North Africa & Middle East [ – ] Sub-Saharan Africa 3.2 million [2.8 – 3.9 million] Eastern Europe & Central Asia [ – ] East Asia [ – ] South & South-East Asia [ – 2.4 million] Oceania8200 [2400 – ] North America [ – ] Caribbean [ – ] Latin America [ – ] Total: 4.8 (4.2 – 6.3) million

About new HIV infections a day in 2005  More than 95% are in low and middle income countries  Almost 2000 are in children under 15 years of age  About 6000 are in persons aged years  About 50% are women

20% − 39% 10% − 20% 5% − 10% 1% − 5% 0% − 1% trend data unavailable outside region HIV prevalence in adults in sub-Saharan Africa, end 2003 UNAIDS levels Low: < 5% in any sub-population. Concentrated: 5% in at least one sub-population but < 1% in pregnant women. Generalised: > 1% in pregnant women

HIV prevalence in adults in sub-Saharan Africa, 1988− % − 39% 10% − 20% 5% − 10% 1% − 5% 0% − 1% trend data unavailable outside region

‘ 91 ‘ 92 ‘ 93 ‘ 94 ‘ 95 ‘ 96 ‘ 97 ‘ 98 ‘ 99 ‘ 01 Source: Department of Health, Republic of South Africa HIV prevalence among pregnant women in South Africa, 1990 to 2001 HIV prevalence (%) 01 July 2002 slide number SSA-11

Has global incidence peaked? Declines in HIV prevalence in some countries Uganda, Urban Kenya and Haiti, Zimbabwe, Botswana, South Africa, Malawi ? Due to behaviour change ? Blood safety interventions ? AIDS deaths Caution: Incidence versus prevalence

Prevalence in years old first time testers in Kampala, Uganda: Source: Uganda National AIDS Programme Males Females HIV Prevalence (%) 01 July 2002 slide number SSA-13

UK picture

HIV diagnoses and deaths by year, UK Widespread introduction of HAART

HIV diagnoses by exposure category Source: HIV/AIDS diagnoses reports to end of March 2006, UK

HIV diagnoses acquired through heterosexual contact by sub-category Source: HIV/AIDS diagnoses reports to end of March 2006, UK >75%

HIV infections where the probable country of infection was a named country in Africa – heterosexual men and women UN geographical areas 1 Numbers will rise for recent years, as further reports are received. Data source: HIV/AIDS reports. Reports received by the end of September

Number of UK diagnoses & HIV prevalence in selected African countries Probable country of infection Number HIV among heterosexuals in UK ( ) UNAIDS Adult prevalence (15-49 yrs) in 2003 Zimbabwe % South Africa % Uganda 12354% Zambia 80817% Nigeria 7595% Malawi 64914% Kenya 5667% Congo Zaire 4375% Ghana 4123% Cameroon 2927% *Total HIV infections acquired in Africa =

Black Africans

HIV diagnoses among black Africans Over 3500 diagnoses per year (approx total)  Almost 2/3 are women  About 1/3 have been in the UK less than 2 years  90% acquired heterosexually, majority in Africa  7% through sex between men (?sigma)  around 100 children (<15 years) 97% infected MTCT  >10% present late (with AIDS symptoms)  TB most important AIDS defining illness

Diagnoses of HIV infection in black Africans by age and sex Source: HIV/AIDS diagnoses reports to end of March 2006, UK

Diagnoses of HIV infection in black African women diagnosed through antenatal care Source: HIV/AIDS diagnoses reports to end of March 2006, UK

Diagnoses of HIV infection in black Africans acquired through heterosexual contact within the UK, by partner's probable world region of infection Source: HIV/AIDS diagnoses reports to end of March 2006, UK

Late diagnoses of HIV among black and minority ethnic adults, with and without TB Source: HIV/AIDS diagnoses reports, UK

People seen for HIV care

HIV-infected individuals accessing treatment and care services by ethnic group, 2004 Source: SOPHID N= 42,182 38%

Black and minority ethnic individuals diagnosed as HIV-infected accessing treatment and care services by exposure category Source: SOPHID

Data source: SOPHID Rates of diagnosed HIV-infected adults (15+) seen for HIV-related care in the UK, by SHA of residence

Percentage of ethnic groups diagnosed as HIV-infected: 2004 Source: SOPHID and ONS Black AfricanBlack Caribbean Indian/Pakistani/ Bangladeshi White Number aged diagnosed as HIV-infected (SOPHID) Population, aged (Census 2001) Percentage aged living with diagnosed HIV 4.4%0.3%0.03%0.07%

HIV prevalence among women giving birth by world region of birth Source: Unlinked anonymous testing of newborn infant blood spots

HIV prevalence among women giving birth by African region of birth Source: Unlinked anonymous testing of newborn infant blood spots

Diagnosed HIV-infected adults (15+) seen for HIV-related care by level of anti-retroviral therapy (ART) Data source: SOPHID

Undiagnosed infection

Undiagnosed HIV infections One in 3 persons living with HIV are undiagnosed (approx people) - Persons unaware are at increased risk of:  presenting late/ AIDS  preventable death  transmitting HIV to sexual partners - varies with different groups

Prevalence previously undiagnosed 1 HIV infection among UK-born heterosexuals attending sentinel GUM clinics 1 Previously undiagnosed HIV infection includes those diagnosed at the clinic visit as well as those who remained unaware of their infection Data source: Unlinked Anonymous prevalence monitoring, United Kingdom

Prevalence of previously undiagnosed 1 HIV infection among heterosexuals attending sentinel GUM clinics 1 Previously undiagnosed HIV infection includes those diagnosed at the clinic attendance and those remaining undiagnosed. Data source: Unlinked Anonymous prevalence monitoring, England, Wales and Northern Ireland

Estimates 1 of prevalent HIV infections in adults aged 15-59, 2004 Exposure CategoryNumber diagnosedNumber undiagnosedTotal Sex between men (16 900, ) 9100 (6600, ) (23 900, ) Injecting drug use 1300 (1300, 1400) 600 (500, 800) 2000 (1800, 2100) Heterosexuals (19 300, ) 9800 (7600, ) (27 600, ) Men 7400 (7100, 7600) 4700 (3600, 6700) (10 900, ) African born Non-African born Women (12 100, ) 5100 (3900, 6700) (16 500, ) African born Non-African born Grand total (37 500, ) (16 100, ) (54 700, ) 1 Multi-parameter Evidence Synthesis method - Goubar A et al. 2005, United Kingdom

Black and ethnic minority populations Conclusions  rapid increase in the numbers of infections acquired through heterosexual contact diagnosed in the UK  three-quarters were probably acquired in Africa – reflects focus of pandemic in sub-Saharan Africa  large proportion of undiagnosed individuals (>4000)  disproportionate high number of late diagnoses and deaths

Black and ethnic minority populations Need to ensure:  Access to confidential HIV testing  Targeted health promotion to encourage testing, reduce stigma, encourage early presentation  Access to safer sex and other sexual health skills  condom negotiation, disclosure of status  Support to those living with diagnosed infection  Effective treatment access and care

Acknowledgements The continuing collaboration of clinicians, nurses, microbiologists, health advisors and data managers who contribute to HIV surveillance in the UK is gratefully acknowledged. Without their generosity, time and effort, the current level of understanding of the epidemic could not have been attained. May 2006

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