Research and analysis

Annual epidemiological spotlight on HIV in the North West: 2021 data

Updated 5 September 2023

Summary

This report presents data for 2021 on new HIV diagnoses, late diagnoses, people living with diagnosed HIV, HIV testing, continuum of HIV care and pre-exposure prophylaxis (PrEP) in North West England.

The impact of the COVID-19 pandemic on sexual health services and patient access in England has made it difficult to interpret changes in the epidemiology of HIV between 2019 and 2021. While the number of people tested but not seen in care (the biggest impact of the COVID-19 pandemic) recovered slightly by 2021, this was not observed uniformly across populations and risk groups (1).

HIV remains an important public health issue in the North West.

There were 321 new HIV diagnoses in the North West in 2021 (12% of all England diagnoses). This represented a 2% increase compared to 2020 (314) but a 19% decline compared to 2019 (397). This is in the context of a long-term decline in diagnoses since 2014. New diagnoses rose by 1% in England between 2020 and 2021 (1). Fifty-four percent of all new diagnoses in the North West were in gay, bisexual and other men who have sex with men (GBMSM) and 41% were in heterosexual men and women.

The HIV testing coverage at specialist sexual health services (SHS) in the North West reduced from 57% in 2019 to 42% in 2021. Similarly testing coverage declined in England over the same period from 65% in 2019 to 46% in 2021. HIV testing coverage refers to the proportion of eligible attendees at specialist SHSs who accepted a 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 a HIV test was not appropriate, or for whom the attendance was related to Sexual and Reproductive Health (SRH) care only, are excluded. Coverage was highest in GBMSM (72%), followed by heterosexual men (53%) then women (32%), and remained below pre-pandemic levels for all groups. However, this measure excludes internet testing which was the main route of access to HIV testing in England in 2021 and was disproportionately accessed by GBMSM (1). The unequal increases in HIV testing uptake across different groups means that opportunities for prevention interventions (including PrEP) may have been missed, reinforcing the need for increased levels of, and expanded access to, HIV testing across a wide range of settings.

Forty-one percent of North West residents with HIV were diagnosed late between 2019 and 2021, compared to 43% in England. The proportion of late diagnoses was higher in heterosexuals than GBMSM (48% in heterosexual males, 47% in heterosexual females, 34% in GBMSM) and in those of black African ethnicity compared to white ethnicity (57% and 40% respectively). Nationally, a comparison with 2019 data suggests there may have been some delay to testing and diagnosis due to the pandemic, particularly affecting heterosexual men and women (1).

The prevalence of diagnosed HIV in the North West in 2021 was 2.1 per 1000, lower than the England rate of 2.3 per 1000. Seven local authorities were classified as having high HIV diagnosed prevalence (2 to 4.99 per 1,000) and 2 local authorities very high HIV diagnosed prevalence (5 and above per 1,000) (2). The prevalence of diagnosed HIV in North West residents was 19 times higher in people of black African ethnicity (19 per 1,000) compared to the white population (1 per 1,000).

HIV Action Plan

The 2022 to 2025 HIV Action Plan (jointly developed by the Office for Health Improvement and Disparities (OHID) and UK Health Security Agency (UKHSA)) aims to reduce HIV transmission by 80%, and HIV related and preventable deaths and AIDS by 50% between 2019 and 2025. This will be achieved by:

• ensuring equitable access and uptake of HIV prevention programmes
• 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 and addressing stigma

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, a number of prevention areas need to be prioritised, these include:

• PrEP access for all
• scaling up of partner notification
• increasing HIV testing among heterosexual men and women
• addressing stigma
• improving retention to care and monitoring inequalities in the attainment of undetectable viral load and all aspects of HIV prevention

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

New diagnoses

In 2021, an estimated 321 North West residents were newly diagnosed with HIV, accounting for 12% of new diagnoses in England (Figure 1). This represents a rise of 2% from 2020 but a 19% reduction from 2019. Nationally, there has been a long-term trend for a decline in the overall number of new diagnoses, although there was a slight upturn in 2021.

The new diagnosis rate for North West residents (4 per 100,000) was below that of England in 2021 (5 per 100,000) (Figure 2). Figure 3 shows new diagnoses by upper tier local authority (UTLA) of residence.

In 2021, 54% of all new diagnoses in North West residents were in GBMSM (compared to 52% in 2020 and 56% in 2012) (Figure 4). The number of GBMSM resident in the North West newly diagnosed with HIV (173, adjusted for missing information) was 36% lower than in 2012 (Figure 4). Of the GBMSM newly diagnosed with HIV, 77% were white and 66% were UK-born.

Heterosexual contact was the second largest infection route for new diagnoses in North West residents in 2021 (41%) (Figure 4). Infections in African born persons accounted for 42% of all heterosexually acquired cases in 2021 (n=49), compared to 47% (n=90) in 2012. Infections in UK born persons accounted for 38% of all heterosexually acquired cases in 2021.

Injecting drug use accounted for 4% of new diagnoses in North West residents.

Black African residents represented 23% of all newly diagnosed North West residents in 2021 (compared to 20% in 2020 and 22% in 2012). A small proportion of new diagnoses in 2021 were in black Caribbean residents (1%) (Figure 6).

The number of new diagnoses was highest in the 25 to 34 years age group in males and the 35 to 44 years age group in females in 2021 (Figure 7a).

Late diagnoses

Reducing late HIV diagnoses is one of the indicators in the Public Health Outcomes Framework (PHOF). People who are diagnosed late have a tenfold risk of mortality within one year of diagnosis compared to those diagnosed promptly and they have increased healthcare costs (3).

It is of particular concern that a large proportion of North West residents with HIV are diagnosed late (41% from 2019 to 2021 (248 out of 610), compared to 43% in England (2278 out of 5251)), as defined by a CD4 count of less than 350 cells/mm³ at diagnosis (see Figure 8 for late diagnoses by UTLA of residence).

In the North West, heterosexuals were more likely to be diagnosed late (48% of males, 47% of females) than GBMSM (34%) (Figure 9a). By ethnic group, black Africans were more likely to be diagnosed late than the white population (57% and 40% respectively) (Figure 9b).

People living with diagnosed HIV

The 10,147 people living with diagnosed HIV in the North West in 2021 was 5% higher than 2020 and 43% higher than 2012 (Figure 11). This increase is partly due to the effectiveness of HIV treatment, which has reduced the number of deaths from HIV.

The diagnosed prevalence rate of HIV in the North West in 2021 was 2.1 per 1,000 residents aged 15 to 59 years. This was lower than the 2.3 per 1,000 observed in England as a whole (Figure 12). Seven local authorities (Blackpool, Bolton, Bury, Liverpool, Rochdale, Tameside, Trafford) were classified as having high diagnosed HIV prevalence (2 to 4.99 per 1,000 population aged 15 to 59 years) and 2 local authorities (Manchester, Salford) were classified as having very high diagnosed HIV prevalence (5 and above per 1,000 population aged 15 to 59 years). The British HIV Association (BHIVA) and the British Association for Sexual Health and HIV (BASHH) recommend that all patients attending primary and secondary healthcare in areas of high and very high HIV diagnosed prevalence should be offered a test for HIV (2) (Figure 13).

In 2021, 42% of those living with diagnosed HIV in the North West were aged between 35 and 49 years, and 43% were aged 50 years and over (up from 22% in 2012) (Figure 14). Males represented 74% of North West residents living with diagnosed HIV in 2021 and females represented 26%.

In 2021, 66% of North West residents living with diagnosed HIV were white residents and 24% were black African residents. However, due to the relative sizes of the white and black African populations the rate per 1,000 population aged 15 to 59 years was much higher in the black African population (19 per 1,000) than in the white population (1 per 1,000) (Figure 16).

Continuum of HIV care

In England, excluding London in 2021, 99% of HIV diagnosed residents were receiving anti-retroviral treatment (ART). Of these, 99% were virally suppressed (viral load less than 200) and were very unlikely to pass on HIV, even if having sex without condoms (untransmissible virus). This compares to 99% in England as a whole receiving ART and 99% of these virally suppressed.

For North West residents diagnosed in 2021, the proportion starting treatment within 91 days of diagnosis for the period 2019 to 2021 was 83%. This compares to 84% for England.

People living with undiagnosed HIV

In 2021, it is estimated that 5% (95% credible Interval (CrI) 4%-7%) of people living with HIV in England, excluding London were undiagnosed. This equates to an estimated 3,039 (CrI 2,305 to 4,410) undiagnosed people.

It is estimated that 1,000 GBMSM in England, outside London, are undiagnosed (CrI 500 to 1,900) and 1,900 heterosexuals (CrI 1,400 to 3,000), including 800 in the black African population. In England, outside London, the proportion undiagnosed varied by exposure group with the highest proportion undiagnosed among people who inject drugs (8%, CrI 1% to 27%), non black African heterosexual women (8%, 6% to 12%), and non black African heterosexual men (7%, 4% to 20%).

HIV testing

A total of 74,676 people were tested in specialist sexual health services (SHSs) in the North West in 2021, a decrease of 26% since 2017. The HIV testing coverage at specialist SHSs in the North West was 42%, which compares to 46% across England. HIV testing coverage in specialist SHSs in the North West is higher in men (58%) than women (32%), and highest in GBMSM (72%) (Figure 19).

HIV testing coverage is monitored for specialist and non-specialist SHSs. Some HIV tests are performed in settings other than at SHSs. These include tests done through online consultations. The HIV testing coverage measure does not include tests delivered via online SHSs or in non-sexual health settings.

Since 2020, the proportion of HIV testing which takes place through online services has risen sharply. As a consequence, clients may not be fully coded in relation to HIV testing if they were referred to online testing following triage by a specialist SHS or they were referred to specialist SHS following online testing (where further testing, treatment or care was required).

Pre-exposure prophylaxis (PrEP)

In 2021, 5% of HIV-negative North West residents accessing SHSs in England were defined as having a PrEP need (defined as people who were HIV negative accessing specialist sexual health services who were at substantial HIV risk, and therefore could benefit from receiving PrEP) (4), among whom 62% initiated or continued PrEP. Of those with PrEP need, 76% had this need identified at a clinical consultation. Among GBMSM, the group with greatest need, these proportions were 53%, 64% and 79%. Consistent use of PrEP can be an efficacious and effective intervention to prevent HIV acquisition. Despite PrEP being routinely available through specialist SHS, awareness, accessibility and uptake of primary prevention initiatives is variable for different population groups. Addressing this disparity is key to HIV prevention.

Charts, tables and maps

Figure 1. New HIV diagnoses and deaths, the North West, 2012 to 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 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 accessing treatment reach older ages. Charts in previous years’ reports showed deaths by region of death, rather than region of residence 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 in more recent years.

Figure 1 shows trend lines for the number of new HIV diagnoses and deaths over the previous 10 years. The number of new HIV diagnoses increased from 2012 to 2014. Since 2014, HIV diagnoses have generally trended downwards but there were slight increases from 2017 to 2018 and from 2020 to 2021. The number of deaths began to rise after 2018. However, this coincides with improved ascertainment of deaths as a result of the National HIV Mortality Review. Additional deaths due to COVID-19 were reported during the pandemic in people living with HIV.

Figure 2. New HIV diagnoses per 100,000 population (all ages) by UKHSA region of residence, 2021

Data source: UKHSA, HANDD.

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

Figure 2 is a bar chart showing that the rate of new HIV diagnoses per 100,000 in the North West (4.4) was the second highest in the country in 2021. London had the highest rate of new HIV diagnoses at 9.8 per 100,000. The rate of new HIV diagnoses across England was 4.8 per 100,000.

Figure 3. New HIV diagnoses per 100,000 population (all ages) by upper tier local authority of residence, North West residents, 2021

Data source: UKHSA, HANDD.

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

Figure 3 is a bar chart showing that Manchester, Blackpool, and Liverpool have the highest rates of new HIV diagnoses per 100,000 in the North West in 2021 at 13, 12, and 9 per 100,000 respectively. The rate of new HIV diagnoses across the North West was 4.4 per 100,000.

Figure 4. New HIV diagnoses by probable route of infection (adjusted for missing route of infection information), North West residents, 2012 to 2021 [note 1]

Data source: UKHSA, HANDD.
*NPDA = Not previously diagnosed abroad.
See [note 1] above on interpreting trends.

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 on area of residence of those diagnosed. This is more likely to affect more recent year, particularly 2021.

Figure 4 shows trend lines for new HIV diagnoses by probable route of infection over the past 10 years. Three probable routes of infection are shown, including sex between men, sex between men and women, and other infection routes. Each route of infection is represented by 2 lines, one solid line showing all cases and a dashed line showing only cases who were not previously diagnosed abroad. Sex between men has been the probable route of infection for the largest number of cases for the past 10 years, excluding 2019 when the largest number of cases were likely infected through sex between men and women. The numbers of HIV cases with a probable route of infection of sex between men or sex between men and women have both generally trended downwards since 2014, with the largest reduction where the probable route of infection was sex between men. The number of new HIV diagnoses likely attributable to other infection routes has remained consistently low.

Figure 5. Number of new HIV diagnoses by world region of birth (adjusted for missing world region of birth information), North West residents, 2012 to 2021 [note 1]

Data source: UKHSA, HANDD.
*NPDA = Not previously diagnosed abroad.
See [note 1] above on interpreting trends.

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 on area of residence of those diagnosed. This is more likely to affect more recent year, particularly 2021.

Figure 5 shows trend lines of number of new HIV diagnoses by world region of birth over the past 10 years. World region of birth is broken into 3 categories: UK, Africa, and all other countries. Each world region of birth category is represented by 2 lines: one solid line showing all cases and a dashed line showing only cases who were not previously diagnosed abroad. Among people born in the UK, new HIV diagnoses increased from 2012 to 2014 but have generally trended downwards since 2014 (325 new diagnoses in 2012 down to 170 in 2021). The number of new HIV diagnoses among people born in Africa has decreased slightly from 104 in 2012 to 70 in 2021. The number of new HIV diagnoses among people born in countries outside of the UK and Africa has increased slightly from 56 in 2012 to 81 in 2021.

Figure 6. Number of new HIV diagnoses by ethnic group (adjusted for missing ethnic group information), North West residents, 2012 to 2021 [note 1]

Data source: UKHSA, HANDD.
*NPDA = Not previously diagnosed abroad.
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 on area of residence of those diagnosed. This is more likely to affect more recent year, particularly 2021.

Figure 6 shows trend lines of the number of new HIV diagnoses by ethnic group over the past 10 years. Ethnicity is divided into 3 groups: white, black African, and all other ethnic groups. Each ethnic group is represented by 2 lines: one solid line showing all cases and a dashed line showing only cases who were not previously diagnosed abroad. The number of new HIV diagnoses among people who are white increased from 2012 to 2014 but has trended downwards since 2014. The number of new HIV diagnoses among people who are black African has decreased slightly since 2012 but remained similar over the past 10 years. The number of new HIV diagnoses in the ‘all other ethnic groups’ category have also remained similar.

Figure 7a. Number of new HIV diagnoses by age group and gender, North West residents, 2021

Data source: UKHSA, HANDD.

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

Figure 7a is a bar chart showing numbers of new HIV diagnoses by age group and gender. The highest number of new HIV diagnoses is seen in men aged 25 to 34 years. Within each age group, consistently fewer new HIV diagnoses are seen in women in comparison to men.

Figure 7b. Number of new HIV diagnoses by age group and probable route of infection, male North West 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 infection and transmission.

Figure 7b is a bar chart showing number of new HIV diagnoses by age group and probable route of infection. Route of infection is divided as sex between men and all other exposures. Within each age group, the number of new HIV diagnoses with a probable route of infection of sex between men is the same or higher than the number of new HIV diagnoses with a probable route of infection of all other exposures combined. The largest number of new HIV diagnoses is found among men aged 25 to 34 years with a probable exposure of sex between men.

Figure 8. Percentage of new HIV diagnoses that were diagnosed late by upper tier local authority of residence, North West, aged 15 years and over, 2019 to 2021 [note 2]

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

See [note 1] above on interpreting trends.

[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, with late diagnosis defined as CD4 count <350 cells/mm³.

The underlying population will impact on the proportion diagnosed late, for example men who have sex with men (MSM) are less likely to be diagnosed late.

Figure 8 is a bar chart showing the percentage of new HIV diagnoses that were diagnosed late by upper tier local authority from 2019 to 2021. It shows that the highest percentage of late diagnoses was found in Halton (71%) followed by Liverpool (57%) and Tameside (53%). The percentage of new HIV diagnoses that were diagnosed late across the entire North West was 40.7%.

Figure 9a. Percentage of new HIV diagnoses that were diagnosed late by probable route of infection, North West residents, aged 15 years and over, 2019 to 2021 [note 3]

Data source: UKHSA, HIV and AIDS New Diagnosis Database/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 9a is a bar chart showing the percentage of new HIV diagnoses that were diagnosed late by probable route of infection. It shows that the percentage of new HIV diagnoses that were diagnosed late is higher among those likely infected through heterosexual contact in comparison to those where sex between men is the probable route of infection and those where injecting drug use is the probable route of infection. However, these differences are not statistically significant.

Figure 9b. Percentage of new HIV diagnoses by ethnic group that were diagnosed late, North West residents, aged 15 years and over, 2019 to 2021 [note 4]

Data source: UKHSA, HIV and AIDS New Diagnosis Database/System, 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 9b is a bar chart showing the percentage of new HIV diagnoses that were diagnosed late by ethnic group. It shows that the percentage of late new HIV diagnoses was higher among people who are black African (57%) in comparison to people who are white (40%).

Figure 10. Percentage of new HIV diagnoses that were diagnosed late by probable route of infection and year of first UK HIV diagnosis, North West residents, aged 15 years and over, 2012 to 2021 [note 5]

Data source: UKHSA, HIV and AIDS New Diagnosis Database/System, 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 10 is a line chart showing the trend in percentage of new HIV diagnoses that were diagnosed late by probable route of infection over the past 10 years. Probable route of infection is broken into 3 categories: sex between men, sex between men and women, and other infection routes. The percentage of new HIV diagnoses that were diagnosed late with a probable route of infection of sex between men, or sex between men and women have remained similar over the past 10 years. The percentage of new late HIV diagnoses among those with other probable infection routes has fluctuated significantly due to the small overall number of people in that category.

Figure 11. Number of residents living with diagnosed HIV and accessing care, the North West, 2012 to 2021

Data source: UKHSA, HARS.

Figure 11 is a line chart showing the trend in the number of North West residents living with HIV and accessing care. The number living with HIV and accessing care has steadily increased for the past 10 years.

Figure 12. Diagnosed HIV prevalence per 1,000 residents aged 15 to 59 years by UKHSA region, 2021

Data source: UKHSA, HARS.

Figure 12 is a bar graph showing that the prevalence of HIV in the North West is the second highest in England at 2.1 per 1,000 residents aged 15 to 59 years. The highest HIV prevalence is found in London at 5.4 diagnoses per 1,000 residents aged 15 to 59 years.

Figure 13. Diagnosed HIV prevalence per 1,000 residents aged 15 to 59 years by local authority, the North West, 2021

Data source: UKHSA, HARS.

Figure 13 is a bar chart showing that diagnosed HIV prevalence per 1,000 residents is significantly higher in Manchester, Salford, and Blackpool in comparison to the other local authorities in the North West. Across the North West, the prevalence rate of diagnosed HIV is 2.1 per 1,000 residents. Nine local authorities had a diagnosed HIV prevalence greater than the threshold for expanded HIV testing of 2 per 1,000 population.

Figure 14. Percentage of residents with diagnosed HIV and accessing care by age group, the North West, 2012 and 2021

Data source: UKHSA, HARS.

Figure 14 is a bar chart showing the percentage of North West residents living with diagnosed HIV and accessing care by age group. It shows that in 2012 the majority of North West residents living with diagnosed HIV and accessing care were in the 35 to 49 years age group (52%) while in 2021, the proportion was similar in the 35 to 49 years and those aged 50 years and over groups (42% and 43% respectively). The proportion living with diagnosed HIV and accessing care reduced in North West residents aged less than 35 years old from 26% in 2012 to 15% in 2021.

Figure 15. Number of residents living with diagnosed HIV and accessing care by probable route of transmission (adjusted for missing information), the North West, 2021

Data source: UKHSA, HARS.

Figure 15 is a bar chart showing the number of North West residents living with diagnosed HIV and accessing care broken down by probable route of transmission. Probable route of transmission is grouped into 5 categories: sex between men, sex between men and women, mother to child transmission, injecting drug use, and blood or healthcare worker (HCW). It shows that sex between men (5,520 diagnoses) and sex between men and women (4,240 diagnoses) were the probable route of transmission for far more HIV diagnoses than mother to child transmission (154 diagnoses), injecting drug use (138 diagnoses), and blood or healthcare worker (94 diagnoses) combined.

Figure 16. Diagnosed HIV prevalence per 1,000 residents by ethnic group (all ages), the North West, 2021

Data source: UKHSA, HARS.

Figure 16 is a bar chart showing the prevalence of diagnosed HIV in the North West by ethnic group. Ethnic group is grouped into 6 categories: black African, black Caribbean, black other/unspecified, other/mixed, white, and Asian. The chart shows that HIV prevalence is significantly higher among people who are black African (19.3 diagnoses per 1,000 population) in comparison to all the other ethnic groups.

Figure 17. Diagnosed HIV prevalence per 1,000 residents aged 15 to 59 years by local authority, the North West, 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 17 is a map of diagnosed HIV prevalence per 1,000 residents in 2021 by local authority.

Figure 18. The continuum of HIV care, England excluding London, 2021

Data source: UKHSA, HARS, MPES model

Figure 18 is a bar chart showing the United Nations Programme on HIV/AIDS (UNAIDS) 90:90:90 HIV targets and 2021 levels of achievement in England outside of London. It shows that, if London is excluded, England is meeting the UNAIDS targets. Of those in England (excluding London) who are estimated to be living with HIV, 95% have been diagnosed with HIV, 94% of them are on treatment, and 93% of them are virally suppressed.

Figure 19. HIV test coverage by population group, North West residents, 2017 to 2021

Data source: UKHSA, GUMCAD STI Surveillance System (GUMCAD).

The proportion of eligible attendees at specialist SHS who accepted a 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 a HIV test was not appropriate, or for whom the attendance was related to SRH care only, are excluded.

Figure 19 is a line graph showing trends in the percentage of eligible attendees at specialist SHS who accepted a HIV test in the North West since 2017. Trends are displayed by population group: all, males (including all men), GBMSM, and females. Percentage test coverage is consistently highest in GBMSM, followed by all men, then all people, and then women. Test coverage decreased in 2020 across all population groups due to the COVID-19 pandemic. Although test coverage has increased in 2021 across all population groups, percentages have not returned to pre-pandemic levels.

What is happening in the North West

A summary of some of the HIV-related projects and activities taking place in the North West has been provided by HIV services below.

Age+, George House Trust, Greater Manchester

George House Trust’s innovative Age+ was launched in June 2021 to empower and support people aged over 55 years who are living with HIV to live healthy and confident lives free from stigma and discrimination.

Since Age+ began, 242 older people living with HIV have been actively engaged with the project by attending events, through communication via telephone and email and within one-to-one advice and support sessions.

Relationships with local organisations such as The Whitworth Art Gallery and Age UK have been developed and a programme of arts and skills based activities, information sessions and workshops has proved extremely successful. A fortnightly ‘Knit and Natter’ group and monthly Art Workshops continue to be well attended. Feedback from service users has been extremely positive.

A key element of the project is the provision of HIV awareness training, co-developed with service users, including basic HIV facts and a Positive Speaker talking about the lived experience of HIV. The training is for residential care homes, domiciliary care providers and hospices in Greater Manchester with the aim of equipping care staff with up-to-date HIV knowledge. To date, 60 hours of this training has been delivered to 213 staff over 27 training sessions.

Volunteering opportunities are also offered within the project in a variety of roles.

Be PrEPed, Renaissance UK, Lancashire

The ‘Be PrEPed’ campaign at Renaissance UK began in May 2022. The focus, to raise awareness about the suitability, efficacy and availability of the HIV prevention medication PrEP in Lancashire. The project has been built with service user consultation and designed with a sex positive approach.

The campaign currently uses a mixture of social media, networking events and training delivery, to reach as wide an audience as possible. We have prioritised those who are considered at risk of poor sexual health and contracting HIV, but maintain an open-door policy for any interested parties. The greatest asset we have is an accessible mobile clinical space complete with, power, TV, heating and air conditioning, and WiFi which has been purpose built to support events where testing, promotion and even the dispensing of PrEP can be delivered.

The ‘Be PrEPed’ campaign was originally funded for 12 months but, thanks to further funding, we have been able to extend for an additional 12 months and we continue to explore further funding opportunities to extend this project beyond the deadline of May 2024.

HIVe programme: ending all new cases of HIV in Greater Manchester

Under the leadership of the Greater Manchester (GM) Population Health Board, a transformation programme (‘ending all new cases of HIV in Greater Manchester within a generation’ (HIVe)) was launched in 2018, to scale and accelerate prevention efforts, to establish intensive support for those with the greatest level of need and to reduce inequalities in HIV testing, diagnosis, and treatment. The HIVe programme draws on the strengths and expertise of the Sexual Health Network, and voluntary, community and social enterprise (VCSE) organisations, such as the Passionate About Sexual Health (PaSH) partnership.

HIVe initiatives to date include:

• a peer-led GM-wide campaign and website to address HIV stigma, encourage and support people to test for HIV, use effective prevention methods and, if they are HIV positive, to manage their HIV with medication
• increasing testing and combination prevention for communities most affected by HIV and residents who might be living with undiagnosed HIV
• an intensive support service for people living with HIV who have complex needs
• increasing awareness of HIV in primary care
• co-production of an HIV-related stigma e-learning module

Important achievements include:

• a 46% uplift in community testing pre-COVID
• 10,218 HIV home test kits have been ordered by GM residents since October 2019
• people accessing the intensive support service had an average 96% improvement in clinic attendance. Increased adherence to ART resulted in nearly 4 out of 5 clients (79%) having, or being close to having, an undetectable viral load. Furthermore, 79% of people reported an improvement in general wellbeing within 9 months of allocation to the programme, and 85% reported an improvement in general wellness. After engagement with the service, 3 pregnant clients gave birth to HIV negative babies
• 3,800 downloads of online HIV training, resources and podcasts for Primary Care
• ‘HIV: Let’s sort this together’ awarded ‘Best Health and Beauty’ campaign at the 2020 Northern Marketing awards
• roll out of stigma e-learning module locally within Manchester Foundation Trust as mandatory and inclusion on national e-LFH platform

HIV opt-out testing within emergency departments, Greater Manchester

National Institute for Health and Care Excellence (NICE) guidelines (NG60)) on HIV testing in 2016 and the Joint British HIV Association/British Association of Sexual Health and HIV/British Infection Association guidelines 2020 recommend that, in areas of high and extremely high HIV prevalence, all adults admitted to hospital or attending the emergency department (ED) should be offered and recommended to have an HIV test.

In line with this, Manchester University NHS Foundation Trust (MFT) went live with HIV opt-out testing within the ED at Manchester Royal Infirmary (MRI) in December 2021. This was followed by further roll-out of the project to the EDs at Wythenshawe Hospital (March 2022) and North Manchester General Hospital (September 2022). National funding was made available to support the project in April 2022, as part of commitments within the HIV action plan Towards Zero.

Since December 2021, over 120,000 people have been tested for HIV through ED opt-out testing at MFT, and the project has quickly become the source of most new HIV diagnoses at the Trust. Of those tested, 48 people have been newly diagnosed with HIV, and an additional 35 people have been picked up who previously had a diagnosis but were not linked to care. In addition, 170 new diagnoses of Hepatitis C have been detected. The intention is that everyone diagnosed with HIV is offered community support at their first clinic appointment, and an intensive support service is also available for people living with HIV who have complex needs.

In addition to improving the health and wellbeing of people living with HIV, and preventing onward transmission, it is anticipated that the project will reduce the stigma and health inequalities still associated with HIV, and lead to significant long-term cost-savings for the NHS and social care.

Targeting and promotion of HIV testing during National HIV Testing Week, Wirral

During National HIV Testing Week (NHTW) in February 2023 Wirral Council’s Health Protection Service (HPS) worked closely with local partners and commissioned services; Sexual Health Wirral, Sahir House and Wirral Ways to Recovery, to target and promote HIV testing across key communities during a week-long awareness campaign. To support the national campaign, the HPS established an awareness plan to identify and target settings with direct engagement and onsite visits and leaflet distribution as well as promotion through posters signposting to testing availability. This campaign was also delivered alongside Sexual Health Wirral, Sahir House and Wirral Ways to Recovery.

Seventy settings were initially identified using both national data and intelligence from prior project work and campaigns to review and inform the mapping such as engagement rates and previous interest in blood borne viruses. Wirral’s Health Protection team prioritised those settings which were highest risk, and focused on Birkenhead as an area in which there are a high proportion of neighbourhoods in the most deprived quintile (20%) nationally (source: Indices of Multiple Deprivation 2019).

This resulted in Wirral Council’s Health Protection team visiting 31 settings, primarily those working with high risk clients, across NHTW, distributing information leaflets and promotional materials, discussing HIV testing and engaging with staff and members of the public, as well as signposting to local services where required.

Across the week, the Health Protection Service:

• hand delivered 2,187 HIV and HIV testing leaflets and 850 health protection and infectious disease leaflets
• held 31 detailed discussions around HIV with different settings
• signposted 26 organisations and people to local HIV services

The campaign was also promoted across Wirral Council, NHS and personal social media platforms to the public, internal colleagues, local organisations and community stakeholders. The team engaged with managers and staff from high-risk settings, hostels and third sector organisations to promote pathways for other infectious diseases.

In February 2023, 235 HIV and blood-borne virus tests were completed by Sexual Health Wirral, Sahir House and Wirral Ways to Recovery, with 2 in 3 of these tests (66% or 155) undertaken during NHTW; none were positive.

The project enhanced useful partnership working and collaboration with local partners and national organisations, as well as work to understand potential gaps in provision where the HPS could provide support, with Wirral’s team acting as a conduit for linkages between local and national organisations to aid holistic working. The team built on existing community relationships to ensure targeted promotion and materials and resources were sourced and produced rapidly in advance. This positive work initiated during NHTW has continued to date as the service aims to maintain awareness for communities around HIV prevention and testing pathways.

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 infection 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 data extract: 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 (credible) intervals presented in the text are produced by Bayesian analysis. The 95% credible interval is the range in which the true (unknown) value falls with 95% probability.

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, that is 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, meaning the proportion of new diagnoses where probable route of infection was sex between men would be calculated using new diagnoses for which route of infection was known as the denominator.

All analyses in this report are residence-based. Information about a patient’s place of residence is not collected by HANDD. Reports to this database are cross-linked to the database of people accessing care for HIV, HARS.

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 North West: 2021 data.

Find more information in the national HIV report: 2022.

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 fes.northwest@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, Public Health Microbiology and Food, Water and Environmental Microbiology to strengthen the surveillance, intelligence and response functions of UKHSA.

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

If you have any comments or feedback regarding this report or the Field Service, contact fes.northwest@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
• UKHSA Blood Safety, Hepatitis, Sexually Transmitted Infections (STI) and HIV Division for collection, analysis and distribution of data
• Anna Hughes, George House Trust, Manchester for providing a summary of the Age+ project
• Anthony Harrison-West, Renaissance UK, Blackpool for providing a summary of the “Be PrEPed” campaign
• Dr Alison Pye, NHS Greater Manchester Integrated Care for providing a summary of the HIVe Programme and HIV opt-out testing in emergency departments in Greater Manchester
• Alexandra Davidson, Health Protection Service - Public Health at Wirral Council for providing a summary of activities in Wirral for National HIV Testing Week

References

1. Lester J, Martin V, Shah A, Chau C, Mackay N, Newbigging-Lister A and others. ‘HIV testing, PrEP, new HIV diagnoses, and care outcomes for people accessing HIV services: 2022 report’ The annual official statistics data release (data to end of December 2021). London; 2022.

2. British HIV Association. ‘British HIV Association/British Association for Sexual Health and HIV/British Infection Association Adult HIV Testing Guidelines 2020’ 2020.

3. Byrne R, Curtis H, Sullivan A, Freedman A, Chadwick D and Burns F. ‘A National Audit of late diagnosis of HIV: action taken to review previous healthcare among individuals with advanced HIV’ British HIV Association, London; 2018.

4. UK Health Security Agency. ‘Routine commissioning of HIV preexposure prophylaxis (PrEP) in England: Monitoring and evaluation framework’ London; 2022.