1. Understanding temporal trends in HIV prevalence, incidence and ARV Dr Valerie Delpech Head of HIV surveillance Public Health England

2. How do we measure TasP at the population level? 2

3. Challenges of Test and Treat Efficacy versus effectiveness Individual versus public health benefit Feasibility and acceptability Ethics Resistance and toxicity Role of primary HIV infection in transmission MSM versus heterosexual epidemics Role of undiagnosed HIV in transmission Linkage to care and access to ART 3 3

4. ?Elimination or ?decrease in incidence /new HIV infections ?Elimination or ?reduction in AIDS deaths ?Impact on STIs How do we monitor our successes and failures? Hard measures – ‘surveillance’ data in key populations new diagnosis, AIDS and non AIDS deaths late diagnosis, linkage and retention in care, testing and treatment uptake, viral suppression – ‘continuum of care STI rates, behavioural data Estimates incidence, undiagnosed infections Should NOT be used as ‘substitute’ for surveillance What is successful Treatment as Prevention?

5. HIV Prevention Technologies Shown to Be Effective in Reducing HIV Incidence in Randomized Clinical Trials 5

6. Granich RM et al, Lancet 2009; 373: 48–57 HIV incidence 6 2000 2020 2040

7. British Columbia, Canada: Montaner et al (2010) 7

8. 8 Among approximately 77,600 persons living with diagnosed HIV infection in the UK 97% are linked to care after diagnosis within 3 months 95% are retained in care annually 92% of persons in need are on treatment (85% of all persons in care) 95% of persons on treatment achieve VL<200 copies/ml

9. 9Mortality and causes of death among women living with HIV in the UK in the era of HAART Annual new HIV and AIDS diagnoses and deaths: UK, 1981-2012 First test for HIV ART available

10. New HIV diagnoses in the UK by exposure category: 2003 - 2012 10

11. Uptake and HIV tests among MSM attending STI clinics, UK

12. CD 4 back-calculation method of annual HIV incidence in MSM: England & Wales 2001-2010 Birrell P.J. Gill O.N., Delpech V.C et al (2013). HIV incidence in men who have sex with men in England and Wales 2001–10: a nationwide population study. The LancetID-D-12-0107 - S1473-3099(12)70341-9

13. HIV in the United Kingdom: 2013 Back-calculation estimate of HIV incidence and prevalence of undiagnosed infection among MSM: UK, 2003-2012

14. SOPHIDMPES Treatment cascade of adults living with HIV: United Kingdom, 2012 14Treatment cascade of adults living with HIV: United Kingdom, 2011

15. UK Continuum of care ‘cascade’ DATA SOURCES Estimates of undiagnosed infections using Multi Parameter Evidence Synthesis Model Routine HIV surveillance data UA programmes in key pops Natsal – nationally representative sexual health survey Behavioural data in key pops ‘In care’ data consists of linked comprehensive national data new diagnoses CD4 and VL laboratory data Persons in HIV clinics - annual updates 15Presentation title - edit in Header and Footer

16. London Less than 1 1-2 >2 Prevalence of diagnosed HIV infection by region of residence among population aged 15-59 years: United Kingdom, 2011 16

17. People living with HIV by diagnostic and treatment status, and number with detectable viral load, UK, 2006-2012

18. HIV epidemic in the United Kingdom

19. First Year of HIV care is crucial late diagnoses link to care high uptake of ART high 1 yr mortality in late Dx

20. 20HIV in the United Kingdom: 2013 Late HIV diagnosis: Proportion* of adults diagnosed with a CD4 count <350 cells,UK, 2012

21. HIV and STI Department, Health Protection Agency - Colindale HIV and AIDS Reporting System ¹Prompt diagnosis: CD4 count ≥350 cells/mm³ within 91 days of diagnosis ²Late diagnosis: CD4 count <350 cells/mm³ within three months of diagnosis ³Percentage of patients known to have died within a year of diagnosis. Prompt 1 and late² HIV diagnosis in MSM with associated short-term mortality³: United Kingdom, 2002 - 2011

22. Exploration of the CD4 Data Warehouse – South Africa Simbarashe Takuva, Adrian Punen Aliison Brown, Valerie Delpech Centre for HIV and STIs, National Institute for Communicable Diseases, NHLS, Johannesburg. 22

23. PLHIV in South Africa: Spectrum estimate Persons in HIV Care using CD4 as marker 23

24. CD4 Count Distribution, SA 2004-2012 24 Source: CDW, 2013

25. HIV clinical dashboard Individual based clinical outcome data at the local level

26. HIV clinical dashboard: England Outcome nameMeasure England 2012 Late diagnosis% newly diagnosed patients with a CD4 count <350 cells/mm3 at diagnosis 47% 28% (CD4<200) Linkage to care% newly diagnosed patients with a CD4 count test done within 28 days of diagnosis 89% (97% in 3 months) Retention in care after diagnosis % newly diagnosed patients retained in HIV care one year after diagnosis 95% Retention in care of all patients % of all patients retained in HIV care in the following year 85% Immunological response % of all patients seen for HIV care with a CD4 count > 350 85% (95%>200) ART coverage% of patients in care on ARV 89 % Viral load suppression % of patients with an undetectable viral load (VL<50 copies/ml) one year after initiating treatment 88% (95%<200) Poster number: WEPE175

27. HIV Dashboard: Quality of care for newly-diagnosed by trust 27Poster number: WEPE175 135 trusts in England 5,808 newly-diagnosed adults in 2012 4,820 linked to HARS cohort record

28. Quality of care dashboard for all adults in care by Trust 28 Poster number: WEPE175

29. Conclusions and Public health relevance Successes (and failures) of public health policies including TasP can be measured using basic routine surveillance data for key risk groups and over time Accurate and comprehensive (representative) data and clear consistent methodologies are key for tracking progress HIV surveillance data should be linked to vital statistics death data CD4 data are extensively used to track the epidemic – late diagnosis, link to care, retention in care, back-calculation estimates, as well as evaluation of treatment guidelines, estimates of incidence and undiagnosed VL – provide insight into success of treatment programs and ongoing transmission Other markers are also important – STI and behavioural data Clinical dashboards at the local level in key populations provide accountability and can drive improvements 29Presentation title - edit in Header and Footer

30. NO ONE SHOULD DIE OF AIDS IN 2014 NO ONE ANYWHERE 30

31. We gratefully acknowledge all the persons living with HIV as well as clinicians, health advisors, nurses, microbiologists, public health practitioners, data managers and other colleagues who contribute to the surveillance of HIV and STIs in the UK. Thank-you