1. Sexual health in London & the South East: 2014 data
Josh Forde, Field Epidemiology Services (FES)
27 June 2016

2. STIs v HIV
Sexually transmitted infections (STIs) STIs are episodic, caused by a range of organisms and may be viral or bacterial Viral infections (e.g. HSV) generally remain infectious longer than bacterial infections (e.g. gonorrhoea) so bacterial infections need higher rates of partner change to persist in a population STIs include: syphilis - relatively small numbers of infections concentrated in high risk populations chlamydia - much higher prevalence in the general population, affects a younger age group than syphilis and tends to be asymptomatic, particularly in males HIV HIV is a chronic infection with a long latent period It is caused by a single virus which attacks CD4 cells in the immune system In the UK it is mostly, but not exclusively, sexually transmitted
Sexual health in London and the South East

3. London v the South East
London is a high density urban area. It has a high prevalence of both HIV and STIs such as gonorrhoea
The SE is much less urbanised and has a low prevalence of HIV and STIs, but contains high prevalence ‘hot spots’, particularly Brighton
Sexual health in London and the South East

4. HIV
Sexual health in London and the South East

5. New HIV diagnosis per 100,000 population aged 15 years or older by PHE centre of residence, 2014
London has a far higher new HIV diagnosis rate than any other part of England – 5 times that of the SE...
Source: Public Health England, HIV and Aids New Diagnosis Database (HANDD). The number of new diagnoses will depend on accessibility of testing as well as infection transmission.
Sexual health in London and the South East

6. New HIV diagnoses per 100,000 population aged 15 years or older – top 25 UTLAs of residence, London & the SE, 2014
However… the new HIV diagnosis rate for Brighton & Hove is not far below the overall rate for London (36.5)
Source: Public Health England, HIV and Aids New Diagnosis Database (HANDD). The number of new diagnoses will depend on accessibility of testing as well as infection transmission.
Sexual health in London and the South East

7. Diagnosed HIV prevalence per 1,000 residents aged 15-59 years by PHE Centre, 2014
The diagnosed prevalence of HIV in London is about 3 and a half times that of the SE
Source: Public Health England, Survey of Prevalent HIV Infections Diagnosed (SOPHID).
Sexual health in London and the South East

8. Diagnosed HIV prevalence per 1,000 residents aged 15-59 years by local authority, London, 2014
All but one London borough is above the 2 per 1,000 threshold for expanded HIV testing (Havering, shown in pale pink)
Source: Public Health England, Survey of Prevalent HIV Infections Diagnosed (SOPHID).
Sexual health in London and the South East

9. Diagnosed HIV prevalence per 1,000 residents aged 15-59 years by local authority, South East, 2014
Because the SE has a lower prevalence of HIV the ranges used for the map differ. The one London borough shaded pale pink on the London map would be bright pink using the categories here.
Most (but not all) SE UTLAs remain below the 2 per 1,000 threshold
Source: Public Health England, Survey of Prevalent HIV Infections Diagnosed (SOPHID).
Sexual health in London and the South East

10. UTLAs with highest and lowest % of late HIV diagnoses
Although London has higher rates of new HIV diagnoses, people in the SE are more likely to be diagnosed late
Sexual health in London and the South East

11. New HIV and AIDS diagnoses and deaths, London, 2005-2014
This trend chart is for London. Its SE equivalent would look similar but the red (new HIV diagnoses) line would show a steeper and less equivocal decline
Source: Public Health England, HIV and Aids New Diagnosis Database (HANDD). The number of new diagnoses will depend on accessibility of testing as well as infection transmission. *Numbers may rise as further reports are received. This will impact on interpretation of trends in more recent years.
Sexual health in London and the South East

12. New HIV diagnoses by probable exposure category (adjusted for missing information), London residents,
In London the decrease in new diagnoses seen in heterosexuals has been offset by an increase in new diagnoses in MSM. In the SE numbers of new diagnoses in MSM have remained stable.
Source: Public Health England, HIV and Aids New Diagnosis Database (HANDD). The number of new diagnoses will depend on accessibility of testing as well as infection transmission.
Sexual health in London and the South East

13. Number of new HIV diagnoses by age group and gender (A) and probable exposure category in males (B), London residents, 2014
(A)
(B)
In both London and the SE, MSM are most at risk for new HIV diagnoses. Note also that HIV is more likely to be diagnosed in those aged between 25 and 44 years of age.
Source: Public Health England, HIV and Aids New Diagnosis Database (HANDD). The number of new diagnoses will depend on accessibility of testing as well as infection transmission.
Sexual health in London and the South East

14. Number of new HIV diagnoses by ethnic group (adjusted for missing information), London residents,
Apart from MSM, the other group most at risk of HIV are black African heterosexuals. Numbers of new diagnoses in this group have declined due to changes in migration patterns. The “All other ethnic groups” category is extremely heterogeneous.
Source: Public Health England, HIV and Aids New Diagnosis Database (HANDD). The number of new diagnoses will depend on accessibility of testing as well as infection transmission.
Sexual health in London and the South East

15. Number of new HIV diagnoses by world region of birth (adjusted for missing information), London residents,
Most black Africans diagnosed with HIV in the UK are African-born and have acquired their infection in their country of origin. This does not account by itself for the higher rates of late diagnoses seen in this group however. The “All other countries” category is extremely heterogeneous.
Source: Public Health England, HIV and Aids New Diagnosis Database (HANDD). The number of new diagnoses will depend on accessibility of testing as well as infection transmission.
Sexual health in London and the South East

16. Diagnosed HIV prevalence per 1,000 residents by ethnic group (aged 15-59 years), London, 2014
White people make up the largest group of people living with HIV in London. However rates are highest amongst black Africans. Some Asian ethnic groups have lower diagnosed prevalence rates than the white population.
Source: Public Health England, Survey of Prevalent HIV Infections Diagnosed (SOPHID).
Sexual health in London and the South East

17. Complex, diverse communities
The MSM community is diverse and a grouping such as ‘black African’ is a huge oversimplification. Black Africans of the early part of the UK HIV epidemic tended to be from countries in the east of the continent, such as Uganda. After 2000 the emphasis shifted to countries in South-eastern Africa, especially Zimbabwe and in more recent years we’ve seen decreasing numbers overall coupled with an increasing proportion who are West Africans from countries such as Nigeria. The chart below shows sub-region of birth for Africans diagnosed in London with HIV in 2004 and 2013.
Important…
initiatives that work well in the context of one community may not work so well in another
The background prevalence of HIV and awareness of the risk of HIV – varies widely between different countries.
Sexual health in London and the South East

18. Percentage of new HIV diagnoses that were diagnosed late by probable exposure category (A) and ethnic group (B), London residents, aged 15 years and over, *
(A)
(B)
MSM have higher new HIV diagnosis rates than other groups, but they’re also more likely to be diagnosed early. This reflects the fact that they tend to test more frequently and have higher levels of knowledge about HIV.
Source: Public Health England, HIV and AIDS New Diagnosis Database, CD4 Surveillance, Survey of Prevalent HIV Infections Diagnosed (SOPHID).
* Only includes new diagnoses for which CD4 count was reported within 91 days of diagnosis; late diagnosis defined as CD4 count <350 cells/mm3.
Sexual health in London and the South East

19. Number of residents living with diagnosed HIV and accessing care, London and the South East,
Effective treatment means that, once diagnosed, HIV+ people have normal or near-normal life expectancies. As infections continue to occur the number of people accessing HIV-related care increases.
Source: Public Health England, Survey of Prevalent HIV Infections Diagnosed (SOPHID).
Sexual health in London and the South East

20. Percentage of residents with diagnosed HIV and accessing care by age group, London, 2005 and 2014
The age profile of people living with diagnosed HIV is changing. As people reach their 50s they also becoming increasingly at risk of age-related illnesses.
Source: Public Health England, Survey of Prevalent HIV Infections Diagnosed (SOPHID).
Sexual health in London and the South East

21. The London HIV treatment cascade among adults living with HIV, 2014
UNAIDS recommends a “ ” strategy to control the HIV epidemic. In London we are just short of the first 90% (the proportion of those infected we are diagnosing) but we’re meeting the 90% on treatment and exceeding the 90% with an undetectable viral load.
ǂ The number of diagnosed from multi-parameter evidence synthesis data. * Viral load (VL) <200 copies/ml
Sexual health in London and the South East

22. STIs
Sexual health in London and the South East

23. New STI diagnosis per 100,000 population by PHE centre of residence, 2014
As with HIV, London has by far the highest rate of New STIs in England. By contrast, the South East has the lowest rate in the country.
Source: Public Health England, GUMCAD and CTAD.
Sexual health in London and the South East

24. Map of new STI rates per 100,000 residents by upper tier local authority in London: 2014
The map for New STIs for London is similar to that for new HIV diagnoses with the highest rates being seen in inner London boroughs, particularly those such as Lambeth which have large MSM populations.
Source: Public Health England, GUMCAD and CTAD
Sexual health in London and the South East

25. Map of new STI rates per 100,000 residents by upper tier local authority in the South East: 2014
For New STIs the shading of the maps is the same for London and the South East, so you can see the difference in diagnosis rates quite clearly.
Note that again there are urban hotspots within the South East that have much higher rates, particularly Brighton which has a rate comparable to an inner London borough.
Source: Public Health England, GUMCAD and CTAD
Sexual health in London and the South East

26. Diagnosis rates of the five main STIs: London residents, 2010-2014
Chlamydia is the most prevalent STI in London and in the South East (and in England). It particularly affects younger people, which is why the National Chlamydia Screening Programme targets year olds.
Any increase in gonorrhoea diagnoses may be due to the increased use of highly sensitive nucleic acid amplification tests (NAATs) and additional screening of extra-genital sites in MSM.
Any decrease in genital wart diagnoses may be due to a moderately protective effect of HPV-16/18 vaccination.
Any increase in genital herpes diagnoses may be due to the use of more sensitive NAATs.
Increases or decreases may also reflect changes in testing practices.
Due to changes in 2012 to the surveillance of chlamydia, comparisons to previous years are not robust.
Source: Public Health England, GUMCAD, CTAD, NCSP and laboratory chlamydia data.
Sexual health in London and the South East

27. Percentage change in new STI diagnoses. London and South East residents
Due to changes in 2012 to the surveillance of chlamydia diagnosed outside GUM, comparisons for chlamydia and for new STIs before and after 2012 are not robust and, therefore, have not been presented.
Both London and the South East have seen large rises in the numbers of syphilis and gonorrhoea diagnoses. These are markers for high risk sexual behaviours.
Source: Public Health England, GUMCAD, CTAD, NCSP and laboratory chlamydia data. .
Sexual health in London and the South East

28. Rate of new STIs per 100,000 residents by age group in London, 2014
Women tend to be younger than men at diagnosis.
This age pyramid is for New STIs overall, but different age/gender distributions are seen for different STIs with syphilis for example having an older and male-dominated distribution.
Source: Public Health England, GUMCAD and CTAD.
Sexual health in London and the South East

29. Rates by ethnicity per 100,000 population of London residents diagnosed with a new STI: 2014
Black Caribbeans have much higher rates of New STIs than other ethnic groups. Black Africans have higher rates than the white ethnic group but they are not as at risk as they are for HIV.
Source: Public Health England, GUMCAD and CTAD.
Sexual health in London and the South East

30. Diagnoses of the five main STIs among men who have sex with men (MSM) in GUM clinics: London residents,
As with HIV, the rises in New STI diagnoses are associated with large increases in diagnoses in MSM. London has saw a 54% increase in syphilis diagnoses in MSM and a 31% increase in gonorrhoea diagnoses between 2013 and For the South East the equivalent percentages were even higher: 67% and 36%.
The most common STI in MSM is gonorrhoea
GUMCAD started in Reporting of sexual orientation is less likely to be complete for earlier years, so rises seen may be partly artefactual.
Any increase in gonorrhoea diagnoses may be due to the increased use of highly sensitive nucleic acid amplification tests (NAATs) and additional screening of extra-genital sites in MSM.
Any decrease in genital wart diagnoses may be due to a moderately protective effect of HPV-16/18 vaccination.
Any increase in genital herpes diagnoses may be due to the use of more sensitive NAATs.
Any increase or decrease may reflect changes in testing.
Source: Public Health England, GUMCAD .
Sexual health in London and the South East

31. Shigella Bacteria Faecal-oral spread
Apart from the main STIs there are some other infections that affect the MSM community in particular. Shigella is an example. It is not traditionally thought of as an STI, but in recent years there have been outbreaks among MSM.
Bacteria
Faecal-oral spread
Historically, adults infected abroad
More recently – transmission during sexual activity
Case interviews S. flexneri 3a
++ sexual partners
Condomless sex
Chemsex
Majority HIV +ve
Sex parties
Sexual health in London and the South East

32. LGV – 67% in London Sexual health in London and the South East
LGV is a previously rare form of chlamydia which began to be reported among MSM in the Netherlands in An ongoing outbreak in the UK, particularly London, Brighton and Manchester followed.
LGV – 67% in London
Sexual health in London and the South East

33. Chemsex Associated with UAI with casual partners
The emergence of ‘chemsex’, recreational drug use in sexual settings, among MSM is of particular concern as it is associated with unprotected anal intercourse with casual partners. Like many high risk sexual behaviours a minority of MSM are involved but the dense sexual networks they belong to increases the risk of STI and HIV transmission.
Chemsex
Associated with UAI with casual partners
Specialist clinics seeing more patients with problems with these drugs
x7 higher in LGB than in general population
Use higher in MSM in London than elsewhere
Use in the last 4 weeks
3.4% crystal meth
6.6% GHB/GBL
6.3% mephedrone
Only a minority of MSM inject
Higher in HIV positive men
‘Chemsex’ involves the use of drugs in sexual settings and is being increasingly recognised as a problem, particularly within the MSM community and within that community particularly in London. It is associated with UAI – that’s unprotected anal intercourse – with casual partners.
Sexual health in London and the South East

34. Serosorting and MSM
Serosorting = trying to choose a partner with the same HIV status as yourself, Idea - that if you’re both negative or both positive you don’t have to worry about one of you infecting the other. Problems – Very hard to be sure that you’re both negative (when were you last tested? What about the window period?) The fact that you both have the same HIV status doesn’t mean that the same is true in respect of STIs
Most MSM do try to manage their risk, however strategies such as serosorting have problems of their own. Consistent condom use remains the most important way of preventing infections.
Sexual health in London and the South East

35. Contact with health services
More positively, studies show that MSM are engaged with sexual health services and more likely to test.
Contact with health services
MSM are engaged with sexual health services
87% confident of how to access HIV testing
HIV testing uptake higher in MSM than heterosexuals
80% had HIV test at some point
Half had HIV test in the last year
HIV testing in GUM is increasing – 11% from
Self sampling – feasible, acceptable and effective
Reached by HIV prevention programmes
Reached 81% including 40% received info in the last 7 days
On a more positive note, MSM are engaged with sexual health services. They express confidence in knowing how to access testing and are increasingly good at getting themselves tested.
Sexual health in London and the South East

36. Understanding at-risk BME populations – the example of HIV and black Africans
African Health & Sex Survey (Sigma Research 2014): 1/10 of respondents had been diagnosed with HIV, while >1/3 had never tested for HIV Nearly 3/4 not aware of the high prevalence of HIV among black African people living in England >2/5 not aware that effective treatment of HIV can significantly reduce the likelihood of onward transmission >1/3 were not aware that HIV medication is freely available
However BME populations may be less confident and less knowledgeable when it comes to accessing services. The African Health & Sex Survey carried out by Sigma Research recently indicated that more than third of respondents had never been tested for HIV and more than 2/5 were unaware of the impact that treatment can have on reducing the risk of onward transmission.
Knowledge and access to sexual health services remains a problem for at risk BME communities however.
Sexual health in London and the South East

37. Acknowledgments
The HIV and GUM clinics who report the data The HIV & STI department at the Centre for Infectious Disease Surveillance and Control (CIDSC) Field Epidemiology Services South East and London (FES SEaL) colleagues EMIS 2010 Sigma Research Everyone else involved in HIV and STI surveillance and research
Sexual health in London and the South East