Research and analysis

Annual epidemiological spotlight on HIV in London: 2021 data

Updated 19 October 2023

Summary

This report aims to provide important intelligence about HIV in London. Further information can be found in the UK Health Security Agency (UKHSA) national HIV report (1).

In 2021, an estimated 38,100 people were living with HIV in London (95% credible interval (CrI) 37,500 to 38,900), which was 40% of all people living with HIV in England. This includes both diagnosed and undiagnosed people.

New diagnoses

In 2021, an estimated 883 London residents were newly diagnosed with HIV. This represents a decrease of 7% from 2020 and continues a longer-term declining trend since 2012 when 2,656 new diagnoses were reported (a 67% decrease).

A third of all new HIV diagnoses in England were in London residents (33%). The new diagnosis rate for London residents (10 per 100,000) was above that of England in 2021 (5 per 100,000) and London has by far the highest new diagnoses rate of any region.

In London in 2021, 22% (196 out of 883) of new diagnoses were in individuals previously diagnosed abroad. This represents a decline from 2018 when the proportion was 29%. These diagnoses are unlikely to reflect HIV transmission in the UK, and so would not be preventable by public health measures taken in the UK.

In 2021, 47% of all new diagnoses in London residents were in gay, bisexual and other men who have sex with men (GBMSM) (compared to 51% in 2020 and 57% in 2012). The number of GBMSM residents in London newly diagnosed with HIV (411, adjusted for missing information) was 16% lower than in 2020, and 73% lower than in 2012. Of the GBMSM newly diagnosed with HIV, 55% were white and 25% were UK-born. Countries of origin for non-UK-born GBMSM varied, with Brazil as the most common country of birth, but it should be borne in mind that this is a country with a large population. Other common countries of birth for this group included countries in the European Union such as Poland, Spain and Italy. The Philippines, China, Nigeria and India also featured, which are also populous countries.

Heterosexual contact was the largest transmission route for new diagnoses in London residents in 2021 (50%). HIV acquisition in African-born persons accounted for 58% of all heterosexually acquired cases in 2021 (n=168), compared to 61% (n=598) in 2012. There was a 5% increase in heterosexually acquired diagnoses from 2020 to 2021; however, the number diagnosed in 2021 was much lower than in 2012 (58% lower).

HIV acquisition in UK-born persons accounted for 13% of all heterosexually acquired cases in 2021. Aside from countries in sub-Sahara Africa, common counties of birth for those who acquired HIV through heterosexual sex included Jamaica and India, and regarding the European Union, Romania, Portugal and Italy. For both GBMSM and heterosexuals, most of the newly diagnosed who were born abroad appeared to have arrived in the UK at least 2 calendar years before their first UK HIV diagnosis.

Injecting drug use accounted for 1% of new diagnoses in London residents (n=7) and has declined from the 39 reported in 2012. There were 5 new diagnoses reported as due to mother-to-child transmission, a fall from the 30 reported for 2012 and from the 17 reported for 2019.

Despite making up a smaller number of the overall London population, black Africans represented 26% of all newly diagnosed London residents in 2021 (compared to 23% in 2020 and 27% in 2012) and the number of new diagnoses in this group, adjusted for missing information, rose slightly from 2020 to 2021 (8% increase). A small proportion of new diagnoses in 2021 were in black Caribbean residents (6%).

The number of new diagnoses was highest in males aged 25 to 34 years and females aged 35 to 44 years in 2021. For GBMSM, compared to 2020, in 2021 new diagnoses fell in all age groups; however, for heterosexuals, increases were seen in diagnoses in those aged 15 to 24 years and aged 55 to 64 years.

Late diagnoses

It is of particular concern that a large proportion of London residents first diagnosed with HIV in the UK were diagnosed late (39% from 2019 to 2021, compared to 43% in England), as defined by a CD4 count of less than 350 cells/mm³ at diagnosis.

In London, heterosexuals were more likely to be diagnosed late (58% of males, 54% of females) than GBMSM (24%). By ethnic group, black Africans were more likely to be diagnosed late than the white population (57% and 32% respectively). Among people who inject drugs, 37% were diagnosed late.

Increases have been seen in the percentage of Londoners diagnosed late who were aged 55 years and over (from 10% of late diagnoses in 2012 to 24% in 2021), while the percentage of those aged 15 to 24 years remained stable (7% of late diagnoses in 2021 compared to 6% in 2012).

Compared to the 2015 to 2017 period, the proportion of those newly diagnosed between 2019 and 2021 who were diagnosed late has significantly increased overall (from 29.9% to 38.6%), and also in GBMSM (from 17.0% to 24.2%).

People living with diagnosed HIV

The 36,767 people living with diagnosed HIV in London in 2021 was 2% higher than 2020 and 13% higher than 2012. This increase may be partly due to the effectiveness of HIV treatment, which has reduced the number of deaths from HIV.

The diagnosed prevalence rate of HIV in London in 2021 was 5 per 1,000 residents aged 15 to 59 years. This was more than double the 2 per 1,000 observed in England as a whole. Thirty-two local authorities in London had a diagnosed HIV prevalence of more than 2 per 1,000 population aged 15 to 59 years in 2021, which is the threshold for expanded HIV testing. The only local authority in London with a diagnosed prevalence below this level was Kingston upon Thames (1.9).

The 2 most common probable routes of transmission for London residents living with diagnosed HIV in 2021 were sex between men (52%) and sex between men and women (45%).

Those living with diagnosed HIV are an ageing cohort. In 2021, 38% of those living with diagnosed HIV in London were aged between 35 and 49 years, and 49% were aged 50 years and over (up from 25% in 2012). Males represented 71% of London residents living with diagnosed HIV in 2021 and females represented 29%.

In 2021, 46% of London residents living with diagnosed HIV were white and 31% were black African. However, due to the different sizes of the white and black African populations, the rate per 1,000 population aged 15 to 59 years was much higher in black Africans (15 per 1,000) than in the white population (3 per 1,000).

Continuum of HIV care

For London residents diagnosed in 2021, the proportion starting treatment within 91 days of diagnosis for the period 2019 to 2021 was 81%. This compares to 84% for England.

In London in 2021, 98% of HIV diagnosed residents were receiving antiretroviral treatment (ART). Of these, 99% were virally suppressed (viral load less than 200 copies/mL of blood). This compares to 99% in England as a whole receiving ART and 99% of these virally suppressed.

A considerable number of people with diagnosed HIV were not retained in care. There were 1,809 people with diagnosed HIV who had not been seen for care in the 15 months to the end of 2021, but who had been seen for care in the 12 months prior to that and who had not been reported as having died.

People living with undiagnosed HIV

In 2021, it is estimated that 3.5% (credible interval (CrI) 2.6% to 4.9%) of people living with HIV in London were undiagnosed. This equates to an estimated 1,332 (CrI 983 to 1,910) undiagnosed people.

Of those living with HIV in London, it is estimated that 3% (Crl 1% to 5%) of GBMSM are undiagnosed (500 men, Crl 300 to 900) and 4% (Crl 3% to 7%) of heterosexuals (700 people, CrI 500 to 1,200), including 340 black Africans. In London, the proportion undiagnosed varied by exposure group with the highest proportion undiagnosed among people living with HIV who inject drugs (7%, CrI 1% to 22%), non-black African heterosexual women (6%, 4% to 9%), and non-black African heterosexual men (5%, 3% to 15%).

HIV testing

A total of 362,571 Londoners were tested in sexual health services (SHSs) in 2021, representing a rise of 12% from 2020. However, this followed a 25% fall in testing between 2019 and 2020, and therefore the number tested in 2021 remained 16% lower than in 2019.

Testing among heterosexual men in 2021 was 32% lower than in 2019 and testing among heterosexual and bisexual women who have sex with men (termed women who have sex with men) in 2021 was 16% lower. Testing in GBMSM in 2021 slightly exceeded that seen in 2019 (1% increase) and was 30% higher than in 2017. Correspondingly, the HIV positivity in GBMSM has steadily declined since 2017 from 0.87% to 0.25% in 2021 (2).

From 2019 to 2021, the percentage of testing delivered by internet services has increased from 26% (18,705 out of 70,716) to 51% (36,244 out of 71,534) in GBMSM in London. Similar expansions in the role of internet testing can be seen for women who have sex with men but were not as pronounced for heterosexual men.

HIV testing coverage at specialist SHSs in London was 54%, which compares favourably to 46% across England. HIV testing coverage in specialist SHSs in London is much higher in men (72%) than women (41%), and highest in GBMSM (82%). Some HIV tests are performed in settings other than at specialist SHSs. These include tests done through online consultations. It is not currently possible to include these in the HIV testing coverage measure. There are 2 reasons for this. Firstly, online and other non-specialist SHSs are not mandated by the British Association of Sexual Health and HIV (BASHH) to offer an HIV test to everyone. Secondly, they may not code and report the outcome of an HIV test in their GUMCAD STI Surveillance System (GUMCAD) submissions.

Pre-exposure prophylaxis

HIV PrEP is the use of ART agents by people who do not have HIV prior to a potential exposure to HIV to prevent acquisition. In total, 33,944 Londoners began or continued to take PrEP in 2021. Of these, 81% (27,393) were GBMSM.

In 2021, 14% of HIV-negative London residents accessing SHSs in England were defined as having a PrEP need, among whom 79% initiated or continued PrEP. Of those with PrEP need, 84% had this need identified at a clinical consultation. Among GBMSM, the group with greatest need, these proportions were 75%, 80% and 85%.

Public health implications

Although the number of new diagnoses of HIV has been declining in London, the high rates of HIV seen in London compared to other areas of England is an important reminder of the importance of strengthening combination prevention. This includes condom use, expanded HIV testing, prompt and continued use of ART and wider availability and uptake of PrEP and post-exposure prophylaxis (PEP).

The data also highlights the continued health inequalities relating to HIV experienced by particular populations, especially GBMSM and black Africans, and HIV prevention and health care needs to address the greater needs of these groups.

The 2022 to 2025 HIV Action Plan (3, 4, 5), jointly developed by the Office for Health Improvement and Disparities (OHID) and UKHSA, has an aim to reduce HIV transmission by 80%, and HIV related and preventable deaths and AIDS by 50% between 2019 and 2025. This can only be achieved by:

• ensuring equitable access and uptake of HIV prevention
• scaling up HIV testing in line with national guidelines
• optimising rapid access to treatment and retention in care
• improving the quality of life for people living with HIV
• addressing stigma

There are important initiatives in place that aim to reduce the impact of HIV in London. The London HIV Prevention Programme (LHPP) is a London-wide sexual health promotion initiative funded by London boroughs aiming to increase HIV testing and promoting prevention choices for Londoners (6). HIV Prevention England delivers a nationally coordinated programme of HIV prevention work (7). Fast Track Cities, a partnership of organisations, including the Mayor of London, UKHSA, London councils and the HIV voluntary sector and community, is committed by 2030 to ending new HIV acquisition in the capital, putting a stop to HIV-related stigma and discrimination, stopping preventable deaths from HIV-related causes and working to improve the health, quality of life and wellbeing of people living with HIV (8).

Consistent use of PrEP can be an efficacious and effective intervention to prevent HIV acquisition. Between October 2017 and July 2020, PrEP was available in England through the Impact Trial (1), which recruited 24,268 participants. The rollout of routine PrEP commissioning began in England in the autumn of 2020 with SHSs responsible for the delivery of PrEP to those at higher risk of acquiring HIV. Despite PrEP being routinely available, awareness, accessibility and uptake is variable for different population groups, for example, the uptake is lower among heterosexuals, and this needs to be addressed.

HIV testing, including online, is freely available in the UK and remains pivotal for reducing HIV transmission. It decreases the number of people living with HIV who are unaware of their HIV status and is also critical in reducing late diagnosis. Late diagnosis is the most significant predictor of premature mortality among people with HIV (3), with those first diagnosed late in the UK 11 times more likely to die within a year of their diagnosis, compared to those who were diagnosed promptly (1). The proportion of people newly diagnosed with HIV in London who were diagnosed late has been increasing in recent years.

The COVID-19 pandemic impacted HIV testing and this disruption may partly explain the rise in the proportion diagnosed late in London, although this had already been showing signs of rising prior to the pandemic. After an increasing trend for testing pre-pandemic, testing fell markedly in London in 2020 and in 2021 had not recovered to pre-pandemic levels in heterosexual men and heterosexual and bisexual women who have sex with men.

Heterosexuals in London have a lower HIV testing uptake in specialist SHS and are more likely to be diagnosed late (especially black Africans) and national data suggests that internet testing is disproportionately accessed by GBMSM (9). Therefore, efforts need to be taken to redress this inequity, accompanied by increased access to testing in other settings (3). From 2022, London emergency departments began to offer opt-out HIV testing and it is expected this will contribute to earlier diagnosis and access to care. There must also be full implementation of HIV testing among people presenting with indicator conditions. Partner notification following diagnosis also remains a highly effective way to detect undiagnosed HIV. Given the high proportion of people newly diagnosed with HIV who are born outside the UK, testing in those born in countries where HIV is common should be increased.

Symptoms due to HIV and AIDS may not appear for many years, and people who are unaware of their HIV status may not feel themselves to be at risk. Prevention messages should reinforce that anyone can acquire HIV regardless of age, gender, ethnicity, sexuality or religion, and it is essential to challenge assumptions about who is at risk of HIV. As well as increasing awareness of HIV, efforts to reduce stigma and other socio-cultural barriers like racism and homophobia that prevent people from testing and seeking long-term care should be strengthened.

Free and effective ART has transformed HIV from a fatal illness into a chronic, manageable condition. People living with HIV in the UK can now expect to live into old age if diagnosed promptly. It is now widely understood that effective HIV treatment results in an ‘undetectable’ viral load which protects individuals living with HIV from passing on the virus to others. The important message is that ‘Undetectable = Untransmittable’ or ‘U=U’. People with HIV who maintain an undetectable viral load for at least 6 months do not transmit HIV.

HIV treatment and care provision continued to have high coverage and effectiveness in 2021, with high proportions of those diagnosed with viral suppression. However, there are a few areas that warrant further attention. Compared to England as a whole, a lower proportion of those newly diagnosed in London were reported as being started on treatment within 91 days. In addition, there are a considerable number of people diagnosed with HIV who are not retained in care. Finally, national data indicates that people exposed by vertical transmission and injecting drug use continue to display significantly lower levels of viral suppression (1) These points highlight the need for interventions to maintain and re-engage people in care, thereby increasing the number of people on treatment with undetectable levels of virus to reduce the potential for onward transmission.

The population of people living with diagnosed HIV is growing older, so it remains important that HIV and other services continue to evolve to meet the needs of older people living with HIV including the management of comorbidities and other complex health conditions. Challenging and eradicating HIV stigma in the wider health and social care system remains an important factor in improving lives.

As rates of other infections transmitted sexually such as gonorrhoea, syphilis, lymphogranuloma venereum, hepatitis C and Shigella have been shown to be higher in GBMSM who are living with HIV, it is important that they are specifically made aware of the risks of these infections and how to prevent them.

While there has been considerable progress towards ending HIV transmission in the UK, the interim ambitions of the HIV Action Plan were adversely impacted by COVID-19. To ensure the goals are reached, several prevention areas need to be prioritised which include the following:

• PrEP access for all
• scaling up of partner notification
• increasing HIV testing among heterosexual men and women
• improving retention to care
• monitoring inequalities in all aspects of HIV prevention and care

The further ambition to achieve zero new HIV infections, AIDS and HIV-related deaths in England by 2030 will require significant improvement in diagnoses and retention in care, especially for heterosexuals and black Africans.

Main STI prevention messages

Commissioners and providers of SHSs have an important role in communicating messages about safer sexual behaviours and how to access services.

Important prevention messages

Using condoms consistently and correctly protects against HIV and other STIs such as chlamydia, gonorrhoea, and syphilis and can also be used to prevent unplanned pregnancy.

Regular screening for STIs and HIV is essential to maintain good sexual health. Everyone should have an STI screen, including an HIV test, on at least an annual basis, if having condomless sex with new or casual partners.

In addition:

• women, and other people with a womb and ovaries under the age of 25 years who are sexually active should have a chlamydia test annually and on change of sexual partner
• GBMSM should have tests for HIV and STIs annually or every 3 months, if having condomless sex with new or casual partners

HIV PrEP is available for free from specialist SHSs and can be used to reduce an individual’s risk of acquiring HIV. HIV PEP can be used to reduce the risk of acquiring HIV following some sexual exposures. PEP is available for free from most specialist SHSs and most emergency departments.

People living with diagnosed HIV who are on treatment and have an undetectable viral load are unable to pass on the infection to others during sex. This is known as ‘Undetectable = Untransmittable’ or ‘U=U’.

Vaccination against human papillomavirus (HPV), hepatitis A and hepatitis B will protect against disease caused by these viruses and prevent the spread of these infections. GBMSM can obtain the hepatitis A and hepatitis B vaccines from specialist SHSs, and these vaccines are also available for other people at high risk of exposure to the viruses. GBMSM aged up to and including 45 years can obtain the HPV vaccine from specialist SHSs.

Specialist SHS are free and confidential and offer testing and treatment for HIV and STIs, condoms, vaccination, HIV PrEP and PEP. Clinic-based services are commissioned for residents of all areas in England, and online self-sampling for HIV and STIs is widely available.

Information and advice about sexual health including how to access services is available at Sexwise, NHS.UK and from the national sexual health helpline on 0300 123 7123.

Charts, tables and maps

Figure 1. New HIV diagnoses per 100,000 population (all ages) by UKHSA region of residence, 2021

Data source: UKHSA, HIV and AIDS New Diagnoses and Deaths (HANDD).

The number of new diagnoses will depend on accessibility of testing as well as transmission.

Figure 1 is a column chart showing new HIV diagnosis rates by English region for the year 2021. Rates are by 100,000 population and are not age-restricted. The overall England rate (4.8) is represented as a line.

The chart shows that London not only has the highest new HIV diagnosis rate of all English regions (9.8) but that its rate is more than twice that of the region with the next highest rate (the North West with 4.4).

Figure 2. New HIV diagnoses per 100,000 population (all ages) by local authority of residence, London residents, 2021

Data source: UKHSA, HANDD.

The number of new diagnoses will depend on accessibility of testing as well as transmission.

Figure 2 is a column chart showing new HIV diagnosis rates by London local authority for the year 2021. Local authorities are shown in descending order in relation to their new HIV diagnosis rate. Rates are per 100,000 population and are not age-restricted. The overall London rate (9.8) is represented as a line.

The chart shows that new HIV diagnosis rates tend to be higher in inner London local authorities with more diverse populations such as Southwark, which has the highest rate (22), Lambeth (19) and Westminster (19). The lowest rates are found in 3 local authorities in outer South West London which include Sutton (1), Richmond upon Thames (3) and Kingston upon Thames (3).

Figure 3. New HIV diagnoses and deaths, London, 2012 to 2021 [note 1]

Data source: UKHSA, HANDD.

The number of new diagnoses will depend on accessibility of testing as well as infection and transmission.

[note 1] Numbers may rise as we receive more reports and more information. This will impact on interpretation of trends in more recent years. New HIV diagnoses are shown by UK region of residence at diagnosis. Deaths are also shown by UK region of residence at diagnosis which in some instances may not be the same as UK region of death. Deaths in people living with HIV may not be related to HIV in all cases and this is likely to become increasingly true as people on treatment reach older ages. Charts in previous years’ reports showed deaths by region of death, rather than region of death at diagnosis, and so the trend for deaths cannot be compared directly with that seen in earlier reports. Region of residence at diagnosis has been used for deaths due to better data quality.

Figure 3 is a line chart showing the trend in number of new HIV diagnoses and deaths in HIV-diagnosed London residents between the years 2012 (2,656 new HIV diagnoses) and 2021 (883).

The new HIV diagnosis line shows the number of diagnoses broadly static between 2012 and 2015, then falling between that year and 2017, before reaching another plateau which lasted until 2019. There was a large fall in the COVID-19 pandemic year 2020. In 2021, the first half of which was also affected by pandemic related restrictions, diagnoses remained at the level seen in 2020.

Deaths began to rise in 2017. However, this coincides with improved ascertainment of deaths as a result of the National HIV Mortality Review. Additional deaths due to COVID-19 were also reported during the pandemic.

Figure 4. New HIV diagnoses by whether person had been previously diagnosed abroad

Data source: UKHSA, HANDD.

Figure 4 is a line chart. It displays the trend in new HIV diagnoses in London residents between 2017 and 2021 by whether the person had been previously diagnosed abroad or not. This has become an issue of increasing importance as the number of new HIV diagnoses has fallen. The chart shows that the proportion of London residents newly diagnosed with HIV who were previously diagnosed abroad has fallen over the 10-year period from 28% in 2012 (486 new HIV diagnoses) to 22% in 2021 (196).

Figure 5a. New HIV diagnoses by probable route of acquiring HIV (adjusted for missing route information), London residents, 2012 to 2021 [note 1]

Source: UKHSA, HANDD.
*NPDA = not previously diagnosed abroad.

See [note 1] above.

The number of new diagnoses will depend on accessibility of testing as well as transmission. Numbers may rise as further reports are received and more information is obtained. This is more likely to affect more recent years, particularly 2021.

Figure 5a is a line chart showing the trend in new HIV diagnoses by probable transmission route, grouped as sex between men, sex between men and women and other acquisition routes from 2012 to 2021. HIV exposure categories are arranged in a risk hierarchy. This hierarchy reflects what we know about transmission risk and the prevalence of HIV in different communities. If people have multiple exposures, they are allocated to the group highest in the risk hierarchy. As an example, a woman who reported sex with men and with women would be allocated to the sex between men and women group. For each group an additional dashed line shows the trend when people known to have been previously diagnosed abroad are excluded.

New HIV diagnoses have declined in all groups over the 10-year period, but the decline has been most pronounced in those probably acquiring HIV via sex between men (a decline of 73%). The number of new HIV diagnoses in this group fell from 1,510 in 2012 to 411 in 2021 (or from 1,426 to 301 if those previously diagnosed abroad are excluded). The impact of excluding those previously diagnosed abroad tends to be largest for this group.

For those probably acquiring HIV via sex between men and women, the number of new HIV diagnoses fell from 1,061 in 2012 to 444 in 2021 (or from 982 to 366 if those previously diagnosed abroad are excluded).

The number of people probably acquiring HIV from non-sexual routes remained low over the 10-year period, declining from 85 in 2012 to 29 in 2021 (or from 74 to 19 if those previously diagnosed are excluded).

Figure 5b. New HIV diagnoses: detailed ‘other’ route of acquiring HIV (not adjusted for missing information), London residents, 2012 to 2021

Data source: UKHSA, HANDD.

Figure 5b is a line chart which provides more detail about the acquired HIV routes grouped into ‘other routes of acquiring HIV’ in figure 4a. The group is broken down into subcategories including intravenous drug use, vertical (mother to child) transmission and other transmission routes which include transmission via blood or tissue. The chart displays data for 2012 to 2021.

The chart shows that the number of new HIV diagnoses in London residents whose probable route of acquiring HIV belonged to any of these categories remained low throughout the 10-year period and declined during it.

The most common ‘other’ HIV transmission route category in 2012 was intravenous drug use with 39 new HIV diagnoses. By 2021 the number of new HIV diagnoses in this category had fallen to 7.

All 3 subcategories had fewer than 10 new HIV diagnoses in 2021.

Figure 6a. Number of new HIV diagnoses by age group and gender, London residents, 2021

Data source: UKHSA, HANDD.

The number of new diagnoses will depend on accessibility of testing as well as transmission.

Figure 6a is a pyramid chart showing the number of new HIV diagnoses by age group and gender in 2021. For males, the 25 to 34 years age group was by far the largest age group (238 new HIV diagnoses) while for females the largest number of new HIV diagnoses was seen in those aged 35 to 44 years (70) and the difference between different age groups (other than those aged less than 25 years) was not so marked.

Figure 6b. Number of new HIV diagnoses by age group and probable route of acquiring HIV, male London residents aged 15 to 64 years, 2021

Data source: UKHSA, HANDD.

The number of new diagnoses will depend on accessibility of testing as well as transmission.

Figure 6b is a pyramid chart showing the number of new HIV diagnoses by age group and probable route of acquiring HIV for males aged 15 to 64 years in 2021. For both those probably acquiring HIV via sex between men (GBMSM) and those probably acquiring HIV by any other route, the 25 to 34 year group was the largest age group. For GBMSM there were 126 diagnoses in this age group and in non-GBMSM there were 40. However, the side of the pyramid representing GBMSM is considerably affecting by skewing, with each age group above the 25 to 34 year group markedly smaller than the one below it. A similar progression is not seen for non-GBMSM.

Figure 7a. Number of new HIV diagnoses probably acquired through sex between men by age group (in years) and year of first UK HIV diagnosis, London residents aged 15 to 64 years, 2012 to 2021 [note 1]

Data source: UKHSA, HANDD.

See [note 1] above.

The number of new diagnoses will depend on accessibility of testing as well as infection and transmission. Numbers may rise as further reports are received and more information is obtained. This is more likely to affect more recent years, particularly 2021.

Figure 7a is a line chart showing the number of new HIV diagnoses by age group for GBMSM London residents aged 15 to 64 years from 2012 to 2021. Diagnoses in those aged between 15 to 64 years accounted for an average of 99% diagnoses in GBMSM Londoners over the 10-year period. The final points on the lines correspond to the bars on the left hand side of the previous pyramid chart.

Diagnoses in 2021 fell for all age groups both in relation to the previous year and to 2012, the first year in the trend period. The largest decrease was seen for the 15 to 24 years age group (a decrease of 85% compared to 2012 and 51% compared to 2020). The smallest decrease over the 10 years was seen for the 55 to 64 years age group with a decrease of 66%. The 35 to 44 years age group had the smallest decease in relation to 2020 with a fall of 12% (92 diagnoses to 81), followed by the 25 to 34 years age group with a fall of 18% (153 diagnoses to 126). These were the 2 largest age groups, accounting for 7 in 10 diagnoses in those aged 15 to 64 years in 2021.

Figure 7b. Number of new HIV diagnoses probably acquired through sex between men and women by age group (in years) and year of first UK HIV diagnosis, London residents aged 15 to 64 years, 2012 to 2021 [note 1]

Data source: UKHSA, HANDD.

See [note 1] above.

The number of new diagnoses will depend on accessibility of testing as well as infection and transmission. Numbers may rise as further reports are received and more information is obtained. This is more likely to affect more recent years, particularly 2021.

Figure 7b is a line chart showing the number of new HIV diagnoses by age group for heterosexual London residents aged 15 to 64 years from 2012 to 2021. Bisexual women are also included. Diagnoses in those aged between 15 to 64 years accounted for an average of 96% diagnoses in heterosexual Londoners over the 10-year period. As with the previous chart, the final points on the lines correspond to the bars on the left-hand side of the previous pyramid chart.

Diagnoses fell for all age groups when 2021 is compared to 2012, the first year of the trend period. Decreases of over 75% were seen for 3 age groups: 35 to 44 years (a fall of 76%), 25 to 34 (a fall of 73%) and 15 to 24 years (a fall of 72%). The smallest decline was seen for the 55 to 64 years age group (a fall of 23%).

When 2021 is compared to the previous year a more varied pattern is seen with increases from 36 diagnoses to 57 in the 55 to 64 years age group and from 14 diagnoses to 19 in the 15 to 24 years age group. However, these were the 2 smallest age groups in both years. By contrast, a fall of 20% (103 diagnoses to 82) was seen for those aged 35 to 44 years. This was the largest age group in both years.

Figure 8. Number of new HIV diagnoses by ethnic group (adjusted for missing ethnic group information), London residents, 2012 to 2021 [note 1]

Data source: UKHSA, HANDD.
*NPDA = not previously diagnosed abroad.

See [note 1] above.

The number of new diagnoses will depend on accessibility of testing as well as transmission. Numbers may rise as further reports are received and more information is obtained. This is more likely to affect more recent years, particularly 2021.

Figure 8 is a line chart showing the number of new HIV diagnoses by ethnic group from 2012 to 2021. The white and black African ethnic groups are represented as distinct categories. All other ethnic groups are grouped into a single category. As with the probable route of infection line chart there is a pair of lines for each ethnic category shown, one showing all new HIV diagnoses and one showing the number once those previously diagnosed abroad are excluded.

All 3 of the categories show a declining trend, especially the white group. This group is the most common ethnic group over the 10-year period with 1,314 new HIV diagnoses in 2012 decreasing to 321 in 2021 (or from 1,225 to 256 excluding those previously diagnosed abroad). New HIV diagnoses in the black African group fell from 705 in 2012 to 231 in 2021 (or from 656 to 186 excluding those previously diagnosed abroad) and the category representing all other ethnic groups decreased from 636 in 2012 to 331 in 2021 (or from 601 to 244 excluding those previously diagnosed abroad). This final category is very heterogenous.

The probable route of acquiring HIV and ethnic group are associated to some extent. This should be borne in mind when interpreting trends for either variable.

Figure 9. Number of new HIV diagnoses by world region of birth (adjusted for missing world region of birth information), London residents, 2012 to 2021 [note 1]

Data source: UKHSA, HANDD.
*NPDA = not previously diagnosed abroad.

See [note 1] above.

The number of new diagnoses will depend on accessibility of testing as well as transmission. Numbers may rise as further reports are received and more information is obtained. This is more likely to affect more recent years, particularly 2021.

Figure 9 is a line chart showing the number of new HIV diagnoses by world region of birth from 2012 to 2021. The UK and Africa are represented as distinct categories. All other world regions of birth are grouped into a single category. Again, there is a pair of lines for each category shown, one for all new HIV diagnoses and another showing diagnoses excluding those in people previously diagnosed abroad.

All 3 categories show a declining trend. New HIV diagnoses in those born in the UK decreased from 804 to 183 between 2012 and 2021. This category, as might be expected, is less impacted by the exclusion of those previously diagnosed abroad. The number of new HIV diagnoses becomes 792 for 2012, falling to 182 in 2021.

For those born in Africa the number of diagnoses fell from 775 to 294 (or from 720 to 239 excluding those previously diagnosed abroad).

The largest category over the 10-year period was the highly heterogenous category representing all other world regions of birth where the number of diagnoses decreased from 1,077 to 406. This category was also the one most impacted by the exclusion of those previously diagnosed abroad, particularly in the middle of the 10-year period. Removing those diagnoses the number of new HIV diagnoses was 969 in 2012, falling to 266 in 2021.

Table 1. Number of new HIV diagnoses by ethnic group and whether born abroad, London residents, 2017 to 2021

Ethnic group	UK-born	Born abroad	Unknown country of birth
White	677	929	304
Black African	77	743	68
Black Caribbean	77	98	33
Black Other	49	83	23
Indian/Pakistani/Bangladeshi	42	120	17
Other Asian (including Chinese)	14	148	31
Mixed/Other	117	375	141
Unknown	136	242	559

Data source: UKHSA, HANDD.

Table 1 shows that the relationship between ethnic group and whether a person newly diagnosed with HIV was born abroad. To make it clear that there are differences in completeness of ascertainment of country of birth for different ethnic groups, numbers in this table are not adjusted for missing information.

For black Africans, country of birth was known for 92% of those newly diagnosed with HIV. Of these, 91% of black Africans newly diagnosed with HIV were born abroad (743 new HIV diagnoses).

Country of birth was known for 84% of those in the white ethnic group. Of these, a smaller proportion were born abroad but it was still the majority (58% or 929 new HIV diagnoses).

For black Caribbean residents, 84% had a known country of birth, the same as seen for the white ethnic group. This ethnic group had the lowest percentage born abroad: 56%, equating to 98 new HIV diagnoses.

Figure 10a. New HIV diagnoses in GBMSM not previously diagnosed abroad by whether born abroad, London residents, 2012 to 2021

Data source: UKHSA, HANDD.

Figure 10a is a line chart. It shows that, when we exclude GBMSM newly diagnosed with HIV who had been previously diagnosed abroad, people born abroad are still the largest sub-group (104 diagnoses or 65% of those with a known country of birth).

Figure 10b. New HIV diagnoses in heterosexuals not previously diagnosed abroad by whether born abroad, London residents, 2012 to 2021

Data source: UKHSA, HANDD.

Figure 10b is a line chart. It shows that, when we exclude heterosexuals newly diagnoses with HIV who had been previously diagnosed abroad, people born abroad are still by far the largest group (182 diagnoses or 84% of those with a known country of birth).

Figure 11. Percentage of new HIV diagnoses by local authority of residence that were diagnosed late, London, aged 15 years and over, 2019 to 2021 [note 1] and [note 2]

Data source: UKHSA, HIV and AIDS New Diagnosis Database/System, HIV and AIDS Reporting System (HARS).

See [note 1] above.

[note 2] Only includes new diagnoses in those aged 15 years or older with no prior diagnosis abroad and for which a CD4 count was reported within 91 days of diagnosis; late diagnosis defined as CD4 count <350 cells/mm³. Percentages for local authorities with fewer than 5 late diagnoses are excluded as the denominator for this calculation is valid new HIV diagnoses which will always be lower than 10,000. The underlying population will impact on the proportion diagnosed late, for example GBMSM are less likely to be diagnosed late.

Figure 11 is a column chart showing the percentage of HIV diagnoses for the period 2019 to 2021 that are estimated to have been made ‘late’ in relation to the time of acquisition by London local authority for the year 2021. This is based on CD4 count at diagnosis as this count tends to decline over time in people living with undiagnosed HIV. The chart and most of the other late diagnosis charts that follow it used 3 years of data grouped together. This is to improve robustness given that only those new HIV diagnoses that meet the criteria described in the chart’s footnote can be included in the denominator.

The order of local authorities is different from that seen for new HIV diagnoses with outer London local authorities, such as Bexley (55%) and Sutton (54%) having the highest percentages of late diagnoses. By contrast, at the other end of the chart we see local authorities such as Kensington and Chelsea with a late diagnosis percentage of 16%. Although the local authorities at this end of the chart are mostly in inner London, there is also an association with the most common exposure groups for residents diagnosed with HIV. Local authorities with higher proportions of GBMSM tend to have lower late diagnosis percentages.

Figure 12a. Percentage of new HIV diagnoses by probable route of acquisition that were diagnosed late, London residents, aged 15 years and over, 2019 to 2021 [note 3]

Source: UKHSA, HIV and AIDS New Diagnosis Database/System, HIV and AIDS Reporting System (HARS).

[note 3] Only includes new diagnoses in those aged 15 years or older with no prior diagnosis abroad and for which a CD4 count was reported within 91 days of diagnosis; late diagnosis defined as CD4 count <350 cells/mm³. Proportions are only shown for the sex between men, heterosexual contact (males), heterosexual contact (females) and injecting drug use exposure groups and are withheld for any of these categories if they contain fewer than 5 late diagnoses.

Figure 12a is a column chart. For each major exposure category, it shows the percentage of HIV diagnoses for the period 2019 to 2021 that are estimated to have been made late.

Men who probably acquired HIV via sex between men are least likely to be diagnosed late (24%). This reflects the higher testing rates and greater engagement with sexual health services seen for GBMSM.

A late diagnosis was much more common for both men and women who probably acquired HIV through heterosexual sex, with men having an even higher percentage (58%) than women (54%). Some women may have additional opportunities to be diagnosed via antenatal services and this may partly explain some of the difference between men and women in this group.

For those who probably acquired HIV via injecting drug use the percentage diagnosed late was 37%. The confidence interval for this group is much larger, however, as the number of new HIV diagnoses was much smaller.

Figure 12b. Percentage of new HIV diagnoses by ethnic group that were diagnosed late, London residents, aged 15 years and over, 2019 to 2021 [note 4]

Source: UKHSA, HIV and AIDS New Diagnosis Database/System, and HARS.

[note 4] Only includes new diagnoses in those aged 15 years or older with no prior diagnosis abroad and for which a CD4 count was reported within 91 days of diagnosis; late diagnosis defined as CD4 count <350 cells/mm³. Proportions are only shown for the white, black African and black Caribbean ethnic groups and are withheld for any of these ethnic group categories if they contain fewer than 5 late diagnoses.

Figure 12b is a column chart. It is structured in the same way as figure 9a and shows percentages of HIV diagnoses made late for major ethnic groups. When interpreting these percentages, it is important to remember the association between probable route of acquiring HIV and ethnic group.

The white ethnic group had the lowest percentage of diagnoses made late (32%), while the black African group had the highest (57%). For black Caribbean residents, the percentage was 36%. This group had a wider confidence interval than the other 2 as the number of new HIV diagnoses was smaller.

Figure 13. Percentage of new HIV diagnoses that were diagnosed late by probable route of acquiring HIV and year of first UK HIV diagnosis, London residents, aged 15 years and over, 2012 to 2021 [note 5]

Source: UKHSA, HIV and AIDS New Diagnosis Database/System, and HARS.

[note 5] Only includes new diagnoses in those aged 15 years or older with no prior diagnosis abroad and for which a CD4 count was reported within 91 days of diagnosis; late diagnosis defined as CD4 count <350 cells/mm³.

Figure 13 is a line chart showing trends in late diagnoses between 2012 and 2021 by exposure group in 3 categories: sex between men, sex between men and women and all other acquisition routes. Percentages in this chart are less robust as it is by single year and should be interpreted as indicative of broad trends only. The chart shows that late diagnoses in those probably acquiring HIV through sex between men were lowest but started to rise after 2018, reaching 32% in 2021 (compared to 24% in 2012).

For those probably acquiring HIV via heterosexual sex the percentage diagnosed late remained high throughout the period, rising slowly from 55% in 2012 to 62% in 2021, with a brief downturn in 2019, the last pre-pandemic year, when it dropped to 48%.

The trend for the other HIV acquisition routes was more variable. The percentage of late diagnoses was similar at both ends of the 10-year period (57% in 2012 and 56% in 2021) but tended to fall in the first half of the period, reaching 32% in 2016, before rising, falling and then rising again in the final 2 years. However, this group is heterogenous and the number of new HIV diagnoses are low.

Figure 14. Percentage of new HIV diagnoses that were diagnosed late in GBMSM and heterosexuals by whether born in the UK: London residents aged 15 years and over, 2019 to 2021 [note 5]

Data source: UKHSA, HIV and AIDS New Diagnosis Database/System, and HARS.

See [note 5] above.

Figure 14 is a column chart. For 2 exposure groups, GBMSM (those probably acquiring HIV through sex between men) and those probably acquiring HIV through sex between men and women, 2 columns are displayed. The first shows the percentage of UK-born London residents in each group that were diagnosed late, the second the percentage of London residents born abroad in each group that were diagnosed late. The data spans 3 years: 2019 to 2021.

For GBMSM there was little difference between those born in the UK and those born abroad (around a quarter of each group were diagnosed late). However, for those probably acquiring HIV via sex between men and women, the percentage diagnosed late was higher for those born abroad: 40% of UK-born heterosexuals and 60% of heterosexuals born abroad were diagnosed late.

Figure 15. Age distribution (in years) of new HIV diagnoses that were diagnosed late by year of first UK HIV diagnosis, London residents, aged 15 years and over, 2012 to 2021 [note 5]

Data source: UKHSA, HIV and AIDS New Diagnosis Database/System, and HARS.

See [note 5] above.

Figure 15 is a line chart showing the age distribution of those diagnosed late between 2012 and 2021. Unlike the previous late diagnosis charts the percentages indicate the proportion of late diagnoses that occurred within each age group, rather than showing the proportion within each group that were diagnosed late. Percentages in this chart are less robust as they are by single year and numbers are small when broken down by age group. They should be interpreted as indicative of broad trends only.

The proportion of those diagnosed late in the youngest age groups has remained broadly stable over the 10-year trend period. People aged 15 to 24 years accounted for 6% of those diagnosed late in 2012 and 7% in 2021, while those aged 25 to 34 years accounted for 27% of those diagnosed late in 2012 and 26% in 2021.

A large and sustained increase was seen in the oldest age group, those aged 55 years and older, beginning a few years into the trend period. Although there has been fluctuation between years the percentage of those diagnosed late in this age group had remained well above the 10% seen in 2012 and was 24% in 2021.

Median age at diagnosis was older for both GBMSM and heterosexuals when those diagnosed late were compared to all new diagnoses in those who met the following criteria: aged 15 years and older with no prior diagnosis abroad (the group eligible for inclusion in the late diagnosis calculation as long as they had a CD4 count within 91 days of diagnosis). For 2019 to 2021, for GBMSM, the median age at diagnosis for those diagnosed late was 35 years, compared to 33 years for all GBMSM newly diagnosed who met the criteria above. For heterosexuals for the same period, the median age at diagnosis for those diagnosed late was 46 years, compared to 43 years for all heterosexuals newly diagnosed who met the criteria above.

Figure 16. Diagnosed HIV prevalence per 1,000 residents aged 15 to 59 years by UKHSA region, 2021

Data source: UKHSA, HARS.

Figure 16 is a column chart showing the prevalence of diagnosed HIV by English region for the year 2021. Rates are by 1,000 population and are restricted to those aged 15 to 59 years. The chart shows that London has a much higher rate than any other English region (5.4). The region with the next highest rate is the North West, with a rate (2.1) of less than half of London’s.

Figure 17. Number of residents living with diagnosed HIV and accessing care, London, 2012 to 2021

Data source: UKHSA, HARS.

Figure 17 is a line chart showing the number of Londoners living with diagnosed HIV who accessed HIV-related care in the years 2012 to 2021. As everyone living with diagnosed HIV in the UK can access care for free, this number acts as a proxy for the number of people living with diagnosed HIV. The line reflects changes in new HIV diagnoses, mortality in those living with diagnosed HIV and immigration patterns. It may also be affected by disruptions to care and changes in residence during the main pandemic year 2020. It shows that from 32,450 in 2012 the number reached a high of 37,200 in 2019, dropping down to 35,891 in 2020 before rising to 36,767 in 2021.

Figure 18. Number of residents living with diagnosed HIV and accessing care by probable route of transmission (adjusted for missing information), London, 2021

Data source: UKHSA, HARS.

Figure 18 is a column chart which displays the number of Londoners living with diagnosed HIV and accessing care in 2021 by probable transmission route. It shows that people living with diagnosed HIV were overwhelmingly likely to have acquired HIV via sex, with 18,792 probably acquiring HIV through sex between men and 16,389 probably acquiring HIV through sex between men and women. By contrast, those probably acquiring HIV through vertical transmission (before or at birth or via breastfeeding), which was the next largest exposure group, numbered only 680.

Figure 19. Percentage of residents with diagnosed HIV and accessing care by age group (in years), London, 2012 and 2021

Data source: UKHSA, HARS.

Figure 19 is a column chart which shows the percentage of Londoners living with diagnosed HIV and accessing care who belong to each age group. Two years are shown, 2012 and 2021. The chart shows an ageing cohort effect as, due to decreased transmission, fewer people receive a new HIV diagnosis and, due to effective treatment, fewer die prematurely.

In 2012 the largest age group was the 35 to 49 years group and only 25% were aged 50 years or over. By 2021, the 50 years or over group was the largest group, accounting for 49% of those living with diagnosed HIV. In both years fewer than 1% of those living with diagnosed HIV were aged under 15 years. The value for 2021 was too low to register on the chart but was not zero.

Figure 20. Diagnosed HIV prevalence per 1,000 residents by ethnic group (all ages), London, 2021

Data source: UKHSA, HARS.

Figure 20 is a column chart which shows the prevalence of diagnosed HIV by ethnic group for Londoners in 2021. Rates are per 1,000 population. They are not age-restricted as age-restricted denominator data was not available which means they are sensitive to differences in age distribution.

The ethnic group with the highest rate was the black African group (15.5). The white ethnic group had a rate of 3.4, but the white population has an older age distribution than the other groups, which may cause its rate to be artificially depressed in relation to other groups.

Figure 21. Diagnosed HIV prevalence per 1,000 residents aged 15 to 59 years by local authority, London, 2021

Data source: UKHSA, HARS.

Figure 21 is a column chart which displays the prevalence of diagnosed HIV by London local authority of residence. Rates are restricted to those aged 15 to 59 years and are by 1,000 population. As with the previous charts of this type, local authorities are shown in descending order. The pattern is similar to that seen for new HIV diagnoses: inner London local authorities with more diverse populations have higher rates while rates in outer London local authorities are lower. The highest rate is seen in Lambeth (12.7) and the lowest in Kingston upon Thames (1.9). This borough is the only local authority where the rate is below the 2 per 1,000 threshold, above which expanded testing is advised.

Figure 22. Diagnosed HIV prevalence per 1,000 residents aged 15 to 59 years by local authority, London, 2021

Data source: UKHSA, HARS. Map contains Ordnance Survey data (© Crown copyright and database right 2023) and National Statistics data (© Crown copyright and database right 2023).

Figure 22 is a map. It displays the same information as figure 16 but shows more clearly the difference in diagnosed prevalence in inner London local authorities compared to those in outer London. The map is shaded to show 4 rate bands, the highest of which is 5+ per 1,000 population aged 15 to 59 years. All inner London local authorities fall into this band, whereas in outer London only a minority of local authorities do, including Haringey, Greenwich, Croydon, Newham and Barking and Dagenham.

Figure 23. Diagnosed HIV prevalence per 1,000 residents (all ages) by middle super output area of residence, London, 2021

Data source: UKHSA, HARS.

Figure 23 is a map. It displays the prevalence of diagnosed HIV by London middle super output area (MSOA) of residence in 5 rate bands. Unlike the local authority level map, rates are not age restricted. This reflects the smaller size of an MSOA which is a geographical unit with populations of around 7,500. It shows that there are areas of inner London that have higher rates even than inner London as a whole. These are usually areas with large GBMSM populations. There are other areas of raised prevalence even outside inner London. These include areas like the Thames Gateway area (the area that runs along either side of the river in outer east London) that have large populations of black Africans and other groups with higher rates of HIV.

Figure 24. The continuum of HIV care, England excluding London, 2021

Data source: UKHSA, HARS, MPES model

Figure 24 shows the continuum of care for Londoners living with HIV. This shows the progress that London is making in relation to the United Nations Programme on HIV/AIDS (UNAIDS) 90-90-90 target and the higher 95-95-95 target (6). The chart consists of 4 columns with a y-axis which shows a percentage. A red line across each column shows the height that is needed for the column to meet the 90-90-90 UNAIDS target.

The first column represents all Londoners living with HIV, both diagnosed and undiagnosed and is therefore set to 100%. The second shows the percentage of those living with HIV who are diagnosed (96%), the third the percentage of those living with HIV who are diagnosed and on treatment (95%) and the fourth the percentage of those living with HIV who are diagnosed, on treatment and successfully virally suppressed (94%). If people are virally suppressed, they cannot transmit HIV to others.

The percentages and the column heights relate each group to the total number of those living with HIV. However, the UNAIDS target relates each group to the group that precedes it. In other words, 90% of those living with HIV should be diagnosed, 90% of those diagnosed should be on treatment and 90% of those on treatment should be virally suppressed. Therefore, between each column there is an arrow. This shows the relationship of each column to the one before it. The first arrow contains 96% as there is no difference and in both approaches the second column is looked at in relation to the first. The second arrow contains 98% as the 95% of those living with HIV who are on treatment are 98% of those who are diagnosed. The third arrow contains 99% as this is the percentage of those on treatment who are virally suppressed. This means that in 2021, London achieved 96-98-99, exceeding both the standard and higher UNAIDS targets.

Figure 25. HIV test coverage by population group, London residents attending specialist SHSs, 2017 to 2021

Data source: UKHSA, GUMCAD.

The proportion of eligible attendees at specialist sexual health services (SHSs) who accepted an HIV test. An eligible attendee is defined as a patient attending specialist SHS at least once during a calendar year. Patients known to be HIV positive, or for whom an HIV test was not appropriate, or for whom the attendance was related to sexual and reproductive health (SRH) care only, are excluded.

Figure 25 is a line chart displaying HIV test coverage for Londoners attending specialist SHSs from 2017 to 2021 as percentage of eligible attendances. An attendance will not be eligible for inclusion in the denominator if a person is already known to be living with HIV. Four groups are shown which include all residents, men, women and GBMSM. Throughout the 5-year period GBMSM had the highest coverage, although this declined from 90% in 2017 to 82% in 2021. Women had the lowest test coverage, and this also declined from 64% in 2017 to 41% in 2021. HIV test coverage for males declined from 83% in 2017 to 72% in 2021.

Some HIV tests are performed in settings other than at specialist SHSs. These include tests done through online consultations. It is not currently possible to include these in the HIV testing coverage measure. There are 2 reasons for this. Firstly, online and other non-specialist SHSs are not mandated by the British Association of Sexual Health and HIV (BASHH) to offer an HIV test to everyone. Secondly, they may not code and report the outcome of an HIV test in their GUMCAD submissions.

Table 2. People tested for HIV by population group, London residents attending all SHSs, 2017 to 2021

Gender and sexual orientation	2017	2018	2019	2020	2021	% change 2017 to 2021	% change 2020 to 2021
GBMSM	55,220	60,475	70,716	64,749	71,534	30%	10%
Heterosexual men	119,214	124,490	130,855	84,170	88,775	-26%	5%
Subtotal (men)	178,047	192,222	211,959	157,099	174,272	-2%	11%
Heterosexual and/or bisexual women	173,801	186,999	203,048	154,127	170,873	-2%	11%
WOSW [note 6]	1,089	1,320	2,367	2,586	4,681	330%	81%
Subtotal (women)	178,987	196,423	216,236	163,738	184,592	3%	13%
Total (all genders)	357,523	390,888	431,253	322,636	362,571	1%	12%

Data source: UKHSA, GUMCAD.

[note 6] WOSW = women who only have sex with women.

Table 2 differs from the preceding figure in that it shows information about HIV testing for Londoners attending all SHSs from 2017 to 2021, rather than specialist only. Numbers include people tested as a result of consultations via online services. Residence information for online consultations may be less robust than that for consultations in specialist SHS. The proportion of HIV tests via online services has increased rapidly since the pandemic. The table shows numbers of people tested for each year and proportional change from 2017 to 2021 and from 2020 to 2021. In addition to the overall total, numbers are provided by gender and, within gender, by sexual orientation.

The table shows that, while the proportion of those tested who are male has remained roughly stable over the 5 year period at around half of those with a known gender, this masks a decline in HIV tests in heterosexual men both in absolute numbers and compared to GBMSM. Absolute numbers of heterosexual men tested decreased from 119,214 in 2017 to 88,775 in 2021, a decline of 26%, and only increased by 5% from the 84,170 tests reported for 2020, the main pandemic year. Even allowing for a decrease in the percentage of men for whom sexual orientation was reported over the 5 year period (from 98% to 92%), the number of heterosexual men tested as a percentage of men with known sexual orientation decreased from 68% in 2017 to 55% in 2021.

The number of GBMSM tested for HIV dropped slightly in the main pandemic year, but the number reported for 2021 was the highest over the period of comparison, with 71,534 tests, a 30% rise on the 55,220 tests reported for 2017.

The number of women tested for HIV also rose in 2021 to its highest level for the comparison period. There were 184,592 women tested, a 13% increase compared to the 178,987 reported for 2017. As with men there was a fall in the proportion of women for whom sexual orientation was reported, from 98% in 2017 to 95% in 2021. Where sexual orientation was known, the percentage of WOSW tested for HIV increased from 1% (1,089) in 2017 to 3% (4,681) in 2018, an increase of 330% over the comparison period. While the number of those in this group who were tested was small in relation to heterosexual and bisexual women it nevertheless masked a slight drop in the number of those tested for the latter group (from 173,801 to 170,873) over the 5 years.

Figure 26. HIV pre-exposure prophylaxis (PrEP) need and initiation/continuation in residents attending specialist sexual health services (SHSs): London, 2021

Data source: UKHSA, GUMCAD.

Figure 26 is a column chart showing information about PrEP need and use by gender and sexual orientation. The first column represents the percentage of London residents attending specialist SHSs who were determined to be in need of PrEP based on clinical and other information. The second column shows the percentage of those in need in PrEP whose PrEP need was identified by the service and the third shows the percentage of those in need of PrEP for whom PrEP was initiated or continued. These 2 final columns for each group must be looked at in relation to the first column.

GBMSM had by far the highest need for PrEP (75%). Of these, 85% had their need identified and PrEP was initiated or continued for 80%.

The group with the next highest level of need was women who only have sex with women, but the percentage was much lower (5%) and the absolute numbers for this group were also much lower than for any other group.

Figure 27. Lower and upper level estimates for the number of people living with HIV with transmissible levels of virus, London, 2021

Data source: UKHSA, HARS.

Figure 27 are a pair of data visualisations that show the proportions of Londoners living with transmissible levels of HIV by sub-category. Each chart, one of which shows lower level estimates and the other upper level estimates, is a stacked bar chart.

The first chart shows that the lower level estimate of Londoners living with transmissible levels of HIV in 2021 was 4,530. Of those, 1,300 were undiagnosed (first section of bar). This number is a point estimate from the Multi-Parameter Evidence Synthesis (MPES) model of undiagnosed infections. A further 78 people were known to be newly diagnosed in 2021 but had no corresponding record of being seen for care during the year (second section of bar). The third section of the bar shows the number who were seen for care in 2021 but who were specified as not being on treatment. There were 604 Londoners in this category. In the fourth section of the bar, a further 739 people were reported as in care and on treatment but not virally suppressed (viral load greater than or equal to 200 copies/mL of blood). Finally, there were 1,809 people who had not been seen for care in the 15 months to the end of 2021, but who had been seen for care in the 12 months prior to that and who had not been reported as having died. This final section of the bar represents those not retained in care.

The second chart shows that the upper level estimate of Londoners living with transmissible levels of HIV in 2021 was 11,072. This number is 6,542 higher than the lower estimate. The main difference in the composition of this chart, compared to the lower level estimate chart, is the much greater size of the final section, which estimates 6,385 people as being not retained in care, a number which is 4,576 higher than that seen in the lower estimate chart. The reason for the difference lies in the criteria for inclusion. As with the lower level estimate chart, this section reports people who had not been seen for care in the 15 months to the end of 2021. However, in this case, all those who had been seen for care in the 5 years prior to that 15 months are included (excluding those known to have died).

This chart also includes an additional section which reports the number of people who are not definitely known to have been virally unsuppressed in 2021, but for whom information on viral suppression was missing and who had been reported as not virally suppressed in 2020. There were 1,091 people in this category.

Information on data sources

HANDD collects information on new HIV diagnoses, AIDS at diagnosis and deaths among people diagnosed with HIV. Information is received from laboratories, specialist SHSs, GPs and other services where HIV testing takes place in England, Wales and Northern Ireland. The Recent Infection Testing Algorithm (RITA) and CD4 surveillance scheme are linked to HANDD to assess trends in recent and late diagnoses. Data is deduplicated across regions and therefore figures may differ from country-specific data.

The Survey of Prevalent HIV Infections Diagnosed (SOPHID) began in 1995 and was a cross-sectional survey of all adults living with diagnosed HIV who attend for HIV care in England, Wales and Northern Ireland. SOPHID collected information about the individual’s place of residence along with epidemiological data including clinical stage and ART. In 2015, SOPHID reporting in England was replaced by the HIV and AIDS Reporting System (HARS) which captures information at every attendance for HIV care.

The date of the data extract for this report was January 2023. Updates to HANDD, SOPHID and HARS made after this date will not be reflected in this report.

Calculations

Confidence intervals for rates in the figures have been calculated to the 95% level using the Byar’s method. Confidence intervals for percentages have been calculated to the 95% level using the Wilson Score method. Confidence intervals presented in the text are produced by Bayesian analysis.

Office for National Statistics (ONS) mid-year estimates for 2020 were used as a denominator for rates for 2021.

The data behind charts showing absolute numbers has been adjusted for missing information. However, unless stated otherwise, the numbers in the summary section are the numbers as reported, such as unadjusted counts. Where charts are displaying adjusted data, this is indicated in the chart title.

The denominators for all percentages exclude records for which information was unknown, such as the proportion of new diagnoses where probable route of acquisition was sex between men would be calculated using new diagnoses for which route of acquisition was known as the denominator.

All analyses in this report are residence-based. Numbers may change as more information becomes available to assign area of residence to cases and historical data is refreshed accordingly.

Further information

For further information, access the Sexual and Reproductive Health Profiles.

Find more information on local sexual health data sources on GOV.UK.

Find more information in the annual epidemiological spotlight on STIs in London: 2021 data.

Find further information in the national HIV report: 2021 data.

Local authorities have access to additional HIV and STI intelligence via the Data Exchange and the HIV and STI web portal. They should also have received a set of tables containing HIV data specific to their authority. They should contact josh.forde@ukhsa.gov.uk if they do not have access to this information.

About the Field Service

The Field Service was established in 2018 as a national service comprising geographically dispersed multi-disciplinary teams integrating expertise in field epidemiology, real-time syndromic surveillance and public health microbiology to strengthen the surveillance, intelligence and response functions of UKHSA.

You can contact your local Field Service team at fes.seal@ukhsa.gov.uk

If you have any comments or feedback regarding this report or the Field Service, contact josh.forde@ukhsa.gov.uk

Acknowledgements

We would like to thank:

• local sexual health and HIV clinics for supplying the HIV data
• the Institute of Child Health
• the UKHSA HIV and STI surveillance teams for collection, analysis and distribution of data

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