1. HIV and STI Department, Health Protection Agency - Colindale HIV and AIDS Reporting System The threshold for an ART secondary prevention effect on HIV transmission among MSM has not been reached despite high treatment uptake Alison Brown, Valerie Delpech, Anne Presanis, Gary Murphy and Noel Gill.

2. HIV and STI Department, Health Protection Agency - Colindale HIV and AIDS Reporting System Background : Viral load established as key predictor for HIV transmission; ART effective at individual level From promise to programmes: the challenge of the treatment cascade In the UK: MSM HIV prevalence 5% and sustained number of HIV diagnoses HIV care provided free of charge Nearly all diagnosed MSM are in HIV care 82% of MSM in HIV care receive treatment

3. HIV and STI Department, Health Protection Agency - Colindale HIV and AIDS Reporting System Aims: Assess the impact of high ART coverage on HIV transmission among MSM through: Community viral load Number/proportion of population who are infective (viral load >1500 copies) Markers of HIV incidence

4. HIV and STI Department, Health Protection Agency - Colindale HIV and AIDS Reporting System Methods: Observational study of HIV-infected MSM in the UK, 2006-2010 Comprehensive, national surveillance data and modelling techniques determined: Number HIV+ MSM (diagnosed and undiagnosed) ART coverage Number & proportion of HIV-infected MSM who were infective (viral load >1500 copies/mL) HIV incidence indicators and the estimated number of infective MSM

5. HIV and STI Department, Health Protection Agency - Colindale HIV and AIDS Reporting System Number of HIV positive MSM,and proportion diagnosed and treated UK: 2006-10

6. HIV and STI Department, Health Protection Agency - Colindale HIV and AIDS Reporting System Number of HIV positive MSM,and proportion diagnosed and treated UK: 2006-10

7. HIV and STI Department, Health Protection Agency - Colindale HIV and AIDS Reporting System Number of HIV-infected MSM, and proportion infective (VL>1500 copies) by diagnostic and treatment status, UK: 2010

8. HIV and STI Department, Health Protection Agency - Colindale HIV and AIDS Reporting System Distribution of infective MSM * among HIV-infected MSM, UK: 2010

9. HIV and STI Department, Health Protection Agency - Colindale HIV and AIDS Reporting System Annual HIV incidence in MSM, England & Wales: 2001-2010 (Birrell et al.)

10. HIV and STI Department, Health Protection Agency - Colindale HIV and AIDS Reporting System Annual HIV incidence in MSM, England & Wales: 2001-2010 (Birrell et al.) Also, between 2006-2010: - Number of new diagnoses increased - Median age & CD4 count at diagnosis stable - 25% of MSM newly diagnosed were recently infected (2009-10)

11. HIV and STI Department, Health Protection Agency - Colindale HIV and AIDS Reporting System Why is HIV transmission continuing? And… in 2010 only 15-25% of MSM had an HIV test

12. HIV and STI Department, Health Protection Agency - Colindale HIV and AIDS Reporting System Why is HIV transmission continuing? And… in 2010 only 15-25% of MSM had an HIV test

13. HIV and STI Department, Health Protection Agency - Colindale HIV and AIDS Reporting System Conclusions: UK access to HIV testing and treatment is excellent Despite very high ART coverage, HIV transmission has not decreased among MSM HIV incidence probably would have been much higher without extensive ART coverage Undiagnosed probable source of most new infections Higher rates of testing are required to reduce late diagnoses Primary prevention remains key – Safer sex campaigns and behavioural interventions – Role of partner notification needs expanding