European Testing Week 2020: Testing vulnerable populations in COVID-19 restricted contexts

Together with European Testing Week, HIV Prevention England is hosting a webinar on Monday 23 November 2020 looking at testing vulnerable populations during the pandemic.

This interactive session will provide a brief overview of how providers have addressed the challenges and maximised opportunities during lockdown and other COVID-19- restricted contexts to continue to reach particularly vulnerable populations to provide testing for Blood-Borne Viruses, including HIV and Hepatitis.

While this November we are supporting European Testing Week 2020, we remind colleagues that, owing to COVID-19, England’s own National HIV Testing Week has been postponed to 1-7 February 2021.

New HIV diagnoses fall by 10% in 2019

Public Health England (PHE) has released its latest Trends in HIV testing, new diagnoses and people receiving HIV-related care in the United Kingdom: data to the end of December 2019 report [PDF].

The latest surveillance data reaffirms that the UK is continuing to see a downward trend in new HIV diagnoses, but the fall is greater in some key populations than others.

New diagnoses

It is now estimated that there are 105,200 people living with HIV in the UK, of which an estimated 6,600 (6%) remain undiagnosed.

The total number of people newly diagnosed with HIV in 2019 was 4,139. This is 10% lower than the 4,580 diagnosed in 2018 and a drop of more than a third (34%) since the peak of 6,312 reported in 2014.

The biggest fall in new diagnoses is seen in gay and bisexual men (GBM), with PHE reporting an 18% fall from 2,079 in 2018 to 1,700 diagnosed in 2019. Amongst GBM the steepest declines were seen in men who were: White; born in the UK; living in London.

The drop in diagnoses from heterosexual contact was 6% from 1,664 in 2018 to 1,559 in 2019.

Late diagnoses remain stubbornly high, with 42% of people diagnosed late in 2019, this has only decreased by one percentage point since 2018. Calculations comparing their mortality rate to those diagnosed promptly indicate an eight fold increased risk of death.

Disparities in late HIV diagnoses continue to be seen across ethnicity with Black people more likely to be diagnosed late than White, Asian or mixed/other.

Percent diagnosed late in 2019 by ethnicity:

Unknown – 52%
Black African – 47%
Black Caribbean – 46%
Black other – 44%
Asian – 39%
White – 39%
Other/mixed – 35%

Late diagnoses are also higher in older populations, 56% of 50-64 year olds, and 59% of 65 and overs. Only 35% of GBM were diagnosed late compared to 52% of men who were likely exposed to HIV via heterosexual contact, and 44% of women.

HIV care and treatment

For the third consecutive year the UK has surpassed the UNAIDS 90-90-90 targets, in 2019:

94% of people living with HIV were diagnosed
98% of those diagnosed were on treatment
97% of those on treatment had an undetectable viral load.

Continuum of HIV care in the UK graph

HIV testing

HIV testing remains the cornerstone of combination prevention efforts, as newly diagnosed people can access immediate HIV treatment ensuring they can live well and prevent onward transmission of HIV.

In 2019 1.3m eligible people were tested for HIV in sexual health services (SHS), this is an increase of 6% from 2018. Of all those tested via SHS, 18% did so via internet services. Positivity rates in SHS remains stable at 0.2%.

Popularity in internet services has increased substantially with 232,738 people tested for HIV in 2019 via this method, 63% more than in 2018.

Whilst people using internet services were largely similar to those using face-to-face SHS in demographic profile (ethnicity and sexual orientation), there were more likely to be younger, with 81% using internet services aged under 35, compared to 77% in specialist SHS.

PHE’s National Home Sampling Service (NHSS) continues to be a supportive tool in enabling people to access HIV testing. In 2019, 25,514 self-sampling kits were returned to the service with a reactivity rate of 0.5%.

PHE’s ‘Survey of HIV Testing in Community Settings’ reported 35,095 tests and a reactivity rate of 0.5%. People testing through the NHSS were more likely to be GBM and under the age of 25, whereas those testing in community settings were more likely to be Black African and first-time testers.

The next decade

The continued fall in new HIV diagnoses is to be celebrated and it’s crucial that the momentum behind our combination prevention efforts is maintained to achieve the nation’s goal of zero new HIV diagnoses by 2030.

There is no doubt that the COVID-19 pandemic will have impacted HIV diagnoses rates, access to testing and treatment this year. The HIV sector will need to work hard to ensure the efforts of the last ten years are repeated in the next.

The latest data from PHE provides some indication of which areas require attention from the sector, including:

The interrogation of missed opportunities for HIV testing in SHS
Ensuring all of England, not just London benefits from combination prevention methods
Addressing the health disparities linked to ethnicity in relation to late diagnoses and mortality rates
Upscaling the knowledge of pre-exposure prophylaxis (PrEP) in all key populations, not just GBM
A nuanced, cross-sector approach to raising awareness of HIV in order to address numbers of undiagnosed people who aren’t GBM or Black African men and women.

Resources

HIV annual data tables from PHE.

New PrEP campaign launching in October 2020

The next phase of the It Starts With Me campaign will focus on raising awareness of HIV Pre-Exposure Prophylaxis (PrEP) in Black African communities. It will start on Monday 19 October 2020.

Campaign update: Download the social media resource pack here. Contact [email protected] for more information.

Black African men and women continue to be over-represented in the rates of new HIV diagnoses every year, but do not have the same levels of knowledge and awareness of PrEP compared to other groups affected by HIV.

This campaign will encourage Black Africans to have more in-depth conversations on PrEP with community educators and clinical experts. To support this, the campaign will include Q&As between key experts via radio phone-ins, live video sessions on social media, targeted TV chat-shows and influencer-led conversations via relevant podcasts.

We encourage the sector to get involved and support the campaign. You could:

Share our social media assets and key campaign messages through your communications channels
Direct people to our online PrEP Quiz and information pages on the It Starts With Me website
Organise your own virtual events and information sessions to discuss the key questions people have about PrEP
Review your local HIV prevention resources to ensure they are fully up-to-date and include clear and accessible information about PrEP.

Sexual Health Week 2020

Get your RSE in gear, Sexual Health Week 2020

The theme of this year’s Sexual Health Week is ‘Get your RSE in gear’, focusing on the introduction by the Department of Education of compulsory Relationships Education for primary pupils and Relationships and Sex Education (RSE) for secondary pupils this month in England.

Despite the impact the school curriculum has faced since March 2020 due to COVID-19, schools are being encouraged to begin teaching RSE. The subject is now compulsory, with schools who are facing challenging circumstances being advised to begin lessons by at least the start of the summer term 2021.

The implementation of compulsory RSE provides an opportunity to provide young people with the tools and skills they need to have good sexual health, and enable them to make informed decisions which impact their wellbeing. It will also provide young people with the education they need to learn about HIV and sexually transmitted infections (STIs).

What support do teachers need?

– Dave Grimmett, Head of PHSEE, Highgate Wood School

‘RSE is an important part of every student’s education which should not be underestimated. RSE empowers students to make informed life choices in situations which may affect their mental or physical health, RSE also holds the power to reduce the negative consequences of these decisions in the future.

‘RSE is often thought of as being focussed on romantic and/or sexual relationships. However, it also empowers students to become better citizens by encouraging them to value or at least appreciate the differences of others’ states of being, experiences, choices and beliefs. Whether this relates to gender, sexuality, culture or religious custom it inspires students to reflect on their own actions and how this may positively or negatively impact on someone else. In other words we are teaching students to be kind in their adult relationships, a trait which we try to instil at a young age in friendships but don’t always discuss as they become older.

‘My school highly welcomed RSE becoming compulsory as it has provided us with a greater understanding of what education young people need rather than what areas we think we should cover. It was validating as I felt our school had already delivered key areas of RSE, but it was obvious there were subjects we still needed to tackle.

‘As we create and update our curriculum, it is the perfect time to be innovative in what is taught and the way it is taught. This can be daunting for schools and colleagues who are new to teaching the content or have limited experience of teaching RSE. It may also be difficult for some schools to know how to adapt to the change, and to create enough time and space for RSE to be taught effectively, although this is important.’

Teachers can be supported with practical information from experienced health professionals and Voluntary, Community and Social Enterprise (VCSE) partners including:

The shared experiences of how to approach sensitive issues in group settings.
Examples of group activities that deliver health promotion work effectively that teachers could adapt to deliver RSE.
Resources such as videos or stories that communicate with young people clearly and could be used as a platform for further discussion and learning.
Key contacts in your organisations who can liaise with RSE leads in local schools and pass on relevant information and messages across local authorities.
Willing colleagues visiting schools or engaging via video conferencing to speak with RSE teachers and other key groups such as students school councils to answer questions they may have or to provide advice.
As the experts in sexual health, provide particular messages or local campaigns you want teachers to share with young people in your area.

While teachers and educational professionals are updating their curriculums and ensuring the professional development of RSE leads and their peers includes training on RSE, now is the best time to embed good practice and creatively share ideas and experiences.

Sexual health and HIV prevention ambitions

The Government has made clear commitments to establishing a national sexual health strategy to tackle increasing rates of STIs, and to reducing new HIV transmissions to zero by 2030.

The introduction of compulsory RSE adds vital support to these initiatives achieving their targets. Not only does RSE educate current and future generations of young people, but it also increases the volume of professionals working within the systems that can nurture good sexual health.

Health professionals working in sexual health and HIV, including those from VCSE organisations, commissioners and public health experts, clinicians and researchers, must support teachers as they navigate the new curriculum.

Educational professionals can provide vital expertise and pathways to reaching young people, who are some of the most disproportionately affected populations by high rates of STIs.

‘Get your RSE in gear’ is a perfect call to action to encourage experts in sexual health and HIV to think about how they evaluate the support they provide to educational professionals, and to motivate teachers to deliver good quality and engaging RSE in their classrooms.

Sexually transmitted infections in 2019

Public Health England (PHE) has released the latest sexually transmitted infection (STI) surveillance data for 2019. Following the upward trend since 2015, STIs diagnoses have risen again and 468,342 diagnoses were made in England in 2019, a 5% increase from 2018.

Key findings

Diagnoses

468,342 diagnoses of STIs in England in 2019.
- 249,690 recorded gender ‘male’.
- 216,058 recorded gender ‘female’.
26% increase in gonorrhoea since 2018, the highest since records began in 1918.
10% increase in syphilis since 2018. In women the increase is 36%, but 81% of infections were recorded in men who have sex with men (MSM), of which almost a third (31%) were MSM living with diagnosed HIV.
7% increase in number of consultations at sexual health services.
- This is largely driven by a 84% increase in consultations reported by internet services (from 260,708 to 480,112).
11% decrease in genital warts.

Testing and screening

The National Chlamydia Screening Programme (NCSP) conducted 2% more tests in 2019 compared to 2018; however, there has been a 13% decline since 2015 (from 1,546,180 in 2015 to 1,339,913 in 2019).
181 sexual health services reported testing for Mycoplasma genitalium (M.Gen) in 2019, compared to 107 in 2018.
- This increase in testing capabilities has largely influenced the 196% increase in M.Gen diagnoses in 2019, up to 5,311.

Disproportionately impacted populations

Young heterosexuals 15 to 24 years; black ethnic minorities; and gay, bisexual and other MSM continue to report the highest rates of STIs in England.

Young heterosexuals

The majority of chlamydia diagnoses (62%) and gonorrhoea diagnoses (54%) in sexual health services were made in young heterosexuals. This group was also attributed to 41% of genital herpes diagnoses and 40% of genital warts.

MSM

Bacterial STIs are more likely to be diagnosed in MSM than other men. 81% of syphilis diagnoses were in MSM as well as 66% of gonorrhoea. The most common STIs have seen substantial increases in this population, with gonorrhoea diagnoses increasing by 26% and chlamydia diagnoses by 21%.

Of all MSM diagnosed with an STI in sexual health services in 2019, 18% were living with diagnosed HIV. A breakdown of STIs diagnosed in MSM by HIV status is provided in the graph below.

STI diagnoses among MSM by HIV status, 2010-2019

Black minority ethnic and other impacted populations

Black minority ethnic (BME) populations continue to be disproportionately impacted by STIs. In particular, the rate of gonorrhoea in BME people is 3.5x that of the general population and the rate of trichomoniasis is 9x that of the general population.
The largest proportional increase in all new STI diagnoses was in people of Asian ethnicity (16%; from 15,168 to 17,522), this was largely due to large increases in new gonorrhoea (36%) and chlamydia (27%) diagnoses.
The disparities between different ethnic groups are best seen in these images below, looking at rates of STIs for both men and women.

Rates of STI diagnoses by ethnic group among males, England 2019

Rates of STI diagnoses by ethnic group among females, England 2019

PHE has provided data based on World regions of birth, these have shown high overall increases of STI diagnoses in England with:

9% of people born in the EU,
11% of people born in North America,
12% of people born in South Asia,
16% of people born in South America,
21% of people born in Central America.

Impact of COVID-19

The latest data release does not cover the period since the COVID-19 pandemic began. However, PHE has advised that they are already analysing the surveillance data and how the impact of the COVID-19 response in England has affected HIV and STI service provision and epidemiology. Provisional findings are due in the coming months.

The latest report outlines how the national programme with PHE, Terrence Higgins Trust and 56 Dean Street delivered 10,000 free self-sampling HIV (and opt-in syphilis test) kits as part of the summer ‘Break the chain’ campaign.

PHE has also published a new national framework for e-sexual and reproductive healthcare. This provides information on how e-sexual and reproductive services can complement specialist, clinic-based facilities in local areas, providing other methods of accessing healthcare.