Can we reach UNAIDS targets and will this lead to the elimination of HIV in the UK? Dr Valerie Delpech Head of national HIV surveillance

Contents of today’s talk Highlights from our annual report 2014  All of the information is in on the PHE website somewhere UNAIDS targets 2

HIV in the United Kingdom

People living with HIV in the UK in 2013 HIV diagnoses, AIDS & deaths 6,000 new HIV diagnoses 42% diagnosed late 319 reports of AIDS 577 all cause deaths Accessing HIV care 81,512 living with diagnosed HIV infection 87% receiving ART of whom 95% virally suppressed Total living with HIV ( ,800) PLHIV (20,300-33,800) unaware

People living with HIV Diagnosed and undiagnosed

People accessing HIV care

New diagnoses

16 New HIV diagnoses and number of persons accessing HIV care in the United Kingdom: 2014

18

19 New HIV diagnoses and number of persons accessing HIV care in the United Kingdom: 2014

Late diagnosis & deaths

Number of new HIV diagnoses Proportion with CD4 <350 cells, UK

MSM with diagnosed HIV, United Kingdom 24

HIV Testing

Self-reported high risk sexual behaviour among MSM by HIV status, GMSHS (2 nd July 2013)

HIV tests ordered on-line 4 th generation dried blood spot 3 rd generation oral swab Samples posted to laboratory Individual informed of result Negatives by text Positives by phone and letter Referral to HIV service recommended HIV Self-Sampling Services

Results from 2 nd phase support  5 months of operation (Nov 13 – March 14), these two services have delivered: −12,485 test requests −6,593 returned (53%) −92 new diagnoses (1.4% positivity)  Major issues highlighted from pilot phases −High volumes that can be managed through the internet −Different to clinic populations (younger and more rural) −Used by those at high risk due to testing and sexual behaviour −Good linkage to care −High user satisfaction 31

Self-reported HIV testing history 32 n= % 41% 25% MSM Black African Heterosexuals

Self-reported HIV testing behaviour among MSM, GMSHS (2 nd July 2013)

Quality of HIV care - late diagnosis - link to care - one year mortality post diagnosis

Positive Voices Study – Preliminary results (n=700 PLHIV in the UK)

Link to care: proportion* of adults with a CD4 count within 1 and 3 months of diagnosis: UK, 2013

Continuum of care Reaching

UNAIDS targets by % PLHIV know their status 90% of diagnosed on sustainable ART 90% of treated have a durable viral suppression  ‘ This would result in the end of AIDS and make HIV transmission rare by 2030’

Are the UNAIDS goals achievable? And if they were would it result in the end of AIDS? and a near elimination of HIV? 43

Treatment as Prevention Granich RM et al, Lancet 2009; 373: 48– 57 MTCT and breastfeeding Cohort of couples Swiss statement Ecological RCT HPTN052 Modelling PARTNER study Real world (26%-96%)

People in HIV care in Presentation title - edit in Header and Footer 81,512 living with diagnosed HIV infection 97% linked to care within 3 months >95% retained in care annually 92% in need of treatment are on treatment (87% of all diagnosed) 95% on treatment achieve VL<200 copies/ml

46 Presentation title - edit in Header and Footer Continuum of Care People living with HIV, United Kingdom, 2013

Estimated number persons living with HIV infection (diagnosed and undiagnosed), UK

People living with HIV by diagnostic and treatment status, and number with detectable viral load, UK,

Phillips et al – Plos One 2013 Incidence of HIV per 100 MSM-year, UK

Counter – factual scenario No condom use Phillips et al PLOS One 2013 No condom use (a)ART at diagnosis from 2000 (A) Cessation of all condoms in 2000 would have resulted in a 400% increase in incidence

Increased testing Uptake of TasP 52

ECDC. Monitoring implementation of the Dublin Declaration on Partnership to Fight HIV/AIDS in Europe and Central Asia: 2012 Progress Report. Stockholm: ECDC; Availability of ART for undocumented migrants 2012

Proportion of patients with VL <200 copies 12 months after ART initiation, by CD4 at ART start, UK

Proportion MSM in the UK Potential increases in testing: probability of diagnosis by time from infection, Phillips, PLOS One 2014 Years from infection base test rate (Current situation) test rate + test rate ++

Number of new infections per year Year HIV incidence among MSM, Phillips PLOS One 2014 test rate ++ ART 350 base test rate ART at diagnosis test rate + ART at diagnosis test rate ++ ART at diagnosis test rate + ART at 350 base test rate ART at % CI given for two lines to illustrate uncertainty over mean effect

High HIV transmission among MSM in the UK Role primary infection likely to be substantive 30%- 60% of all infections Testing rates remain too low High rates of STIs and other co-infections Condom uptake remains too low – serosorting is not safe Changing social networks with wide use of apps to find casual partners Increase in chemsex Failure of partner notification policies Low uptake of TasP 58

Whole system approach

Promote sexual health among LGBT communities across the lifecourse Tackling homophobia and bullying Education in Schools Increase use of high-quality, coordinated educational, clinical, and other preventive services Increase knowledge, communication, and respectful attitudes regarding sexual health and drug and alcohol use Promoting opportunities to discuss role of pleasure, satisfaction and ability to use drugs 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 60 Source: Douglas JM Jr, Fenton KA. Public Health Rep Mar-Apr;128 Suppl 1:1-4

Community engagement Stigma and discrimination remains major barrier to testing, link and retention in care and prevention efforts Need greater engagement of PLHIV and affected communities at every level Tailored messages for individuals recognising diverse nature of community Supporting peer-led initiatives and outreach programs Sustained funding for NGOs Provision of integrated and welcoming, non judging services in partnership with NGOs 61Presentation title - edit in Header and Footer

Conclusions 62

Conclusions HIV epidemic is contained in the United Kingdom Reaching may be possible Whole system approach is required with greater investment in primary prevention Expand and target testing with novel diagnostics must be scale up. Greater emphasis on combination of identifying persons in primary infection+ early treatment/TasP + intense partner notification The challenge is identifying persons in early infection (eg recall of high risk STI attendees, home sampling and testing, use of apps etc) Prevention strategies including condom use, PREP, reduced partners, treatment of STIs, and improvements in sexual wellbeing, mental health and non-harmful use of drugs and alcohol remain critical in the control of HIV and other STIs epidemic. Greater engagement and involvement of community at all levels 66 Presentation title - edit in Header and Footer