HIV in the United Kingdom: Setting the scene Dr Valerie Delpech HIV and AIDS Reporting Section Centre for Infectious Disease Surveillance and Control (CIDSC) Public Health England London, 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 Presentation title - edit in Header and Footer

HIV: the story in 2014 cont 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 in the United Kingdom: 2013

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 in the United Kingdom: 2013

Treatment continuum of adults living with HIV: United Kingdom, 2012 MPES SOPHID I couldn’t see which numbers to add so I have added the boxes so it animates and can change the numbers later. Treatment cascade of adults living with HIV: United Kingdom, 2011

A concentrated epidemic

A concentrated epidemic Estimated number of people living diagnosed and undiagnosed HIV, 2012 By the end of 2012, an estimated 98,400 (95% credible interval [CI] 93,500-104,300) people were living with HIV in the UK; approximately one in five (21,900, 22% [18%- 27%]) of whom were undiagnosed and unaware of their infection. HIV in the United Kingdom: 2013

Black Africans

HIV in the UK, 2012 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 United Kingdom: 2013

New HIV diagnoses among black Africans born in Africa: UK, 2003 – 2012 UPDATED: I have included unadjusted figures here. ‘Other Africa’ includes codes – ‘Unknown African country’. ‘Southern Eastern (n=1 only), ‘Africa Other’ and ‘Multiple African Countries’. UN geographical area used. Despite the general decline in new diagnoses among African born individuals since 2003, West African born individuals are accounting for an increasing proportion of new diagnoses – increased testing initiatives among this group? Migration patterns among this and other groups? Real increase in new infections?

Geographical trends of new HIV diagnoses among people who acquired their infection heterosexually: UK, 2003-2012 In 2012, the number of new diagnoses among heterosexuals was highest in London (1,020); this was followed by the PHE regions Midlands and the East of England with 590 diagnoses, and the North and South of England with similar numbers of 400 and 370 new diagnoses respectively. In Scotland, Wales and Northern Ireland the number of new diagnoses were lower at 110, 50 and 40. HIV in the United Kingdom: 2013

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

Gay and other MSM bear disproportionate burden of the HIV epidemic in virtually every country that reports reliable HIV data 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 In 2012, London (1,450) had the highest number of new diagnoses among MSM followed by the PHE regions: North of England 470, South of England 410 and the Midlands and East of England 370. Scotland, Wales and Northern Ireland had 140, 50 and 60 diagnoses in 2012 respectively. HIV in the United Kingdom: 2013

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. Presentation title - edit in Header and Footer

HIV testing Natsal III

HIV testing 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 in the United Kingdom: 2013

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 Presentation title - edit in Header and Footer

Prevention is better than cure

HIV Synthesis transmission model of HIV in MSM Phillips et al HIV 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 All people: Age, longer term condomless anal sex partner, number of short-term condomless anal sex partners People with HIV: CD4 count, viral load, ART drugs, adherence, resistance, risk of AIDS / death. We decided to extend our model to a dynamic one, which included the transmission of HIV and that reflected the epidemic in heterosexuals in southern Africa. So this time our model simulates a cohort of around 50,000 single individuals aged over 15 and we assume that in 1985, when the epidemic is supposed to be started, a few subjects with a high level of risky sex are HIV+. As in the progression model, each individual has a set of fixed variables and a set of variables updated every 3 months. But now we need to model factors which characterize the risk behaviour: - Probability of having a partner of a certain age - Long term partnership status, if the individual has a long term partner, he/she has unprotected sex with in each 3 months - the number of short-term partners he/she engaged in unprotected sex with Methods and fit to HIV natural history and effect of ART extensively documented in Phillips et al, PLOS One 2013 23 23

Counter – factual scenarios, Phillips PLOS One 2013 No condom use ART at diagnosis from 2000 Increased testing rates Higher testing and ART at diagnosis (d) (A) NOTE Cessation of all condoms in 2000 would have resulted in a 400% increase in incidence

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

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 The most deprived areas in England also have the highest HIV prevalence; this is particularly evident in London where diagnosed HIV prevalence is as high as 7.0 per 1,000 in the most deprived areas and less than 2.4 per 1,000 in the least deprived areas. Living with HIV can be associated with an individual’s ability to work, financial difficulties and social challenges such as residential status. The wider social determinants of health should be addressed in order to reduce these inequalities and furthermore, reduce transmission among these populations. HIV in the United Kingdom: 2013

Strategy for MSM Promote 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 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 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 Presentation title - edit in Header and Footer

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: 2013