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Towards elimination of HIV transmission, AIDS and HIV-related deaths in the UK
Following publication, in October this year, of Official Statistics on HIV in the UK to the end of 2016 , Public Health England has published two companion reports [2,3,4] that provide full analysis of that data and commentary on achievements made to date in controlling the epidemic.
The first report, Towards the Elimination of HIV transmission, AIDS and HIV-related Deaths , provides further analysis and public health interpretation of the new data. The second, HIV Testing in England , provides an overview of national HIV testing activity and how it relates to NICE HIV testing guidance . This article summarises the key findings and implications from both reports.
An 18% overall decline in HIV diagnoses in the UK, between 2015 and 2016, was particularly marked among gay, bisexual and other men who have sex with men: in this group, new HIV diagnoses decreased 21%, from 3,570 in 2015 to 2,810 in 2016. The UK is one of the first countries to witness such a substantial decline in HIV diagnoses in gay, bisexual and other men who have sex with men [see note 1] . The decline was focussed in five London clinics, which had delivered high levels of HIV testing, including frequent testing of men at high risk of HIV, together with accelerated initiation of anti-retroviral therapy (ART) at HIV diagnosis . This represents the most significant development in the UK HIV epidemic in 20 years, since effective ART became widely available.
The observed decline in new HIV diagnoses in gay and bisexual men is linked to reduced transmission of HIV. The estimated annual number of new infections acquired in gay and bisexual men has declined year on year from a peak of 2,800 in 2012 [see note 2] to 1,700 in 2016 [see note 3]. Additionally, over the past decade, the number of gay and bisexual men diagnosed late (CD4 count <350 cells per cubic millimetre within 91 days of diagnosis) has reduced by 25%, from 1,200 in 2007 to 900 in 2016.
Decline among ethnic groups
There has also been a continued decline in new HIV diagnoses among black African heterosexual men and women (4,060 in 2007 to 2,110 in 2016). This decline is due to changing patterns of migration, with fewer people from high HIV prevalence countries coming to the UK. The number of black African men diagnosed with a late HIV diagnosis declined by 74% from 700 in 2007 to 170 in 2016. The decline was 82% among black African women: from 1,100 to 200.
Mortality rate comparable to general population
For the first time, the overall mortality rate among those diagnosed promptly (1.22 deaths per 1,000 15-69 year-olds) was comparable to that of the general population (1.39 deaths per thousand 15-59 year-olds). However, those diagnosed late remain at high risk of death in the first year of diagnosis (26.1 deaths per thousand 15-59 year-olds diagnosed late).
UNAIDS targets met in London
These recent successes have coincided with another achievement: in London, all of the UNAIDS targets  have now been met with 90% of people living with HIV infection diagnosed, 97% of people diagnosed receiving treatment and 97% of people receiving treatment being virally suppressed. The equivalent figures for the whole of England were 88%, 96% and 97% respectively.
Increased testing in gay and bisexual men
Combination prevention is working. HIV testing, including frequent testing among those most at risk of HIV, reduces the number of people unaware of HIV infection and the time with which people live with undiagnosed infection and provides the opportunity for prompt HIV treatment. HIV testing among gay and bisexual men has increased steadily over the last five years, and 104,478 gay and bisexual men were tested in sexual health services (SHS) in 2016. HIV test positivity rates among gay and bisexual men have fallen during this time, with a 29% drop in the last year (from 1.7% to 1.2%), in line with the decline in HIV diagnoses.
Despite these promising data, significant challenges remain. Guidelines indicate gay and bisexual men should test every three months if having sex without condoms with new or casual partners. However, 77% of gay and bisexual men diagnosed with HIV at a SHS had not had a test in the previous year; and only 36% of those testing in 2016 had been tested at least once in the previous year.
Number of late diagnoses remains high
The number and proportion of diagnoses made at a late stage of HIV infection remain high, particularly among heterosexual men and women. In 2016, 69% of black African men and women attending SHS were tested for HIV, and increasing numbers of black African men and women are declining HIV tests when offered. For heterosexual men and women, further expansion of HIV testing in line with NICE guidelines  will help bring down the number of AIDS diagnoses and HIV-related deaths further.
To reduce late HIV diagnoses, NICE quality standards include HIV testing in general practice and hospitals, and testing in the presence of HIV indicator conditions. HIV test positivity rates in general practice in high (0.5%) and extremely high (0.4%) diagnosed HIV prevalence areas, and those tested in A&E and other secondary care settings (0.6%), now exceed those seen in SHS. In 2016, 93% of people notified with tuberculosis were tested for HIV. Despite a high positivity rate (3.9%), the number of people known to have tested at an SHS as a result of partner notification remains low (2,211 in 2016).
Time to ART reduced
Following HIV diagnosis, ART is now so effective that those who are treated can attain an undetectable viral load (<200 copies) resulting in untransmissible levels of virus, even if having sex without condoms. The time from HIV diagnosis to starting ART has reduced; in 2016, 76% of people started ART within 90 days of diagnosis, compared to 33% in 2007.
With progressive strengthening of combination prevention (including condom use, expanded HIV testing, prompt ART and availability of PrEP), HIV transmission, AIDS and HIV-related deaths could be eliminated in the UK. The recent encouraging changes are dependent upon sustained prevention efforts. Combination prevention needs to be replicated for all those at risk of acquiring of HIV, whoever they are and wherever they live.
Note 1. “Gay, bisexual and other men who have sex with men” are hereafter referred to as “gay and bisexual men”. This group was previously referred to as “men who have sex with men” (MSM).
Note 2. 95% credible interval: 2,300-3,200.
Note 3. 95% credible interval: 900-2,700.
- PHE (3 October 2017). HIV: annual data tables
- PHE (15 November 2017). Towards elimination of HIV transmission, AIDS and HIV-related deaths in the UK: 2017 report.
- PHE (15 November 2017). HIV testing in England: 2017 report.
- “PHE publishes elimination of HIV and HIV testing reports 2017”, (PHE press release, 15 November 2017).
- NICE (2017). HIV testing: encouraging uptake. Quality Standard QS157.
- ECDC (2016). HIV/AIDS surveillance in Europe 2015.
- Bown AE, Mohammed H, Ogaz D, Kirwan PD, Yung M, Nash SG, et al (2017). Fall in new HIV diagnoses among men who have sex with men (MSM) at selected London sexual health clinics since early 2015: testing or treatment or pre-exposure prophylaxis (PrEP)? Euro Surveill. 22(25).
- UNAIDS (2014). 90-90-90: an ambitious treatment target to help end the AIDS epidemic.
Infection reports in this issue of HPR
The following reports are published in this issue of HPR.