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.

Number of HIV tests carried out graph

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

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.

Total number of STI diagnoses, England 2010 to 2019
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.

Resources from PHE

Sexually transmitted infections and chlamydia screening in England: 2019 [PDF].

Latest STI data tables, infographics and supplemental information.

National framework for e-sexual and reproductive healthcare: User guide [PDF]

PrEP knowledge, attitudes and usage among Black African communities in England

There is overwhelming evidence of the effectiveness of PrEP at preventing HIV transmission. Public Health England has credited PrEP as a key factor for the dramatic drop in new HIV diagnoses in the UK, particularly among gay, bisexual and other men who have sex with men (GBM) (PHE, 2019). Recently, it was announced by the UK government that PrEP would become routinely available across England by autumn 2020.

Despite making up less than 1.8% of the British population (ONS, 2020), Black Africans (BA) are over-represented in the rates of new HIV diagnoses every year. The latest figures showed that they constituted 44% of all new heterosexual HIV cases (PHE, 2019). This population stands to benefit from PrEP, however, there is very limited evidence answering the following questions:

  • Whether Black African communities in the UK are aware of PrEP.
  • Whether Black African communities in the UK are willing to use PrEP.
  • Whether Black African communities are currently using PrEP.
  • Whether the current and forthcoming access options are acceptable for Black African communities.

To determine the knowledge of and attitudes towards PrEP in BA communities in England ahead of the rollout of routine commissioning of PrEP, HIV Prevention England (HPE) is currently reviewing available research and health promotion programme data, including HPE community and evaluation survey results and PHE innovation fund reports.

Key findings

PrEP Knowledge

Initial data suggests that knowledge of PrEP is very low among BA men and women particularly compared to GBM counterparts. HPE ran a small face-to-face community survey in 2019 for BA men and women where only 22% (15/68) people were aware of PrEP. An online survey that was run as part of the It Starts With Me (ISWM) 2019 campaign evaluation found also that just 53% (124/234) of BA had heard about PrEP before, compared to 84% (465/554) of GBM.

In some cases where BA have reported hearing of PrEP, individuals may conflate it with PEP (post-exposure prophylaxis) or believe it to be for GBM only. For example, 21% of people who said they knew what PrEP was in HPE’s face-to-face community survey had these misunderstandings (4/19).

PrEP attitudes

Once BA people know what it is and how it works, many say that they would be willing to take PrEP under certain circumstances. In the HPE community survey, when asked if they would be willing to take PrEP in a scenario where condoms were unavailable, 63% (43/68) said that they would in the following situations:

  • Where personal risk perception is high. For example, if sexual risk-taking behaviour increased or if other methods, such as condoms, were not available or individuals did not want to use them.
  • For protection (‘to be safe’) as a general precaution towards others’ unknown status.
  • Due to belief in the science, that it is effective at prevention.

At the same time, a number of BA people were hesitant to take PrEP for some of the following reasons:

  • Needing more information on PrEP.
  • Scepticism and worries regarding the evidence/science: whether they could trust messages regarding side effects and interactions, PrEP effectiveness.
  • A dislike of taking ‘Western’ medication unless absolutely necessary.
  • Finding it not personally relevant (‘I don’t do those things anymore’ or ‘I prefer condoms’).

PrEP Use

In the ISWM evaluation findings, BA men and women consistently report low condom use: only 18% used condoms ‘all the time’ or ‘often’; 77% ‘never’ or ‘sometimes’ only. Despite this, none reported using PrEP. This contrasts with GBM, where 38% of low condom use individuals reported using PrEP.

When considering data from the rest of the UK, from July 2017-June 2019, there were only 14 individuals with African ethnicity taking PrEP in Scotland (0.4% of all PrEP users) (HPS, 2019). In Wales, from July 2017-March 2019, <10 individuals taking PrEP were of Black ethnicity (<1% of all PrEP users) (PHW, 2019).

Summary

In these examples there is a low level of knowledge among Black Africans about PrEP, which is markedly different from GBM cohorts. In addition to this, people who have heard of PrEP may have misconceptions about what it means, who it is for and how to access it.

A significant proportion of BA individuals are open to taking PrEP in situations where they have the correct information about it and can recognise that they may benefit from taking it.

According to available data, extremely few Black Africans are currently using PrEP in the UK.

As England prepares for the routine commissioning of PrEP in the autumn, it is important that the issues outlined in this article are considered further and appropriate steps taken to ensure that everyone who may stand to benefit, including Black African communities, are aware of and can access PrEP appropriately.

Hepatitis C: testing in sexual health services and HIV co-infection

In May, Public Health England (PHE) published their Hepatitis C in England 2020 [PDF] report. In order to improve national surveillance of the cascade of care for the first time, PHE included data on people attending sexual health services and people who are homeless.

Of the estimated 89,000 people in England who are chronically infected with hepatitis C (HCV), many are from marginalised and underserved groups in society. It is hoped the new and updated data will help to identify where improvements can be introduced to stop people falling through the net.

Co-infection in people living with HIV can be common in certain population groups. The liver has an essential role in processing medicines used to treat HIV and other conditions. Viral infections that affect the liver, such as hepatitis A, hepatitis B and hepatitis C, can make the liver less able to process medicines properly. This is one of the reasons the British HIV Association (BHIVA) have introduced targets for the micro-elimination of HCV in people with HIV.

Testing in sexual health services (SHS)

  • The number of individuals tested for HCV in sexual health services shows an increase of 37.4% between 2014 and 2018.
  • The proportion of individuals testing anti-HCV positive (reactive or positive antibody test means you have been infected with the hepatitis C virus at some point in time) shows little change over the same time period, remaining at around 1.3% (1.2 to 1.4%).

GUMCAD data (from 2014 to 2018)

  • Decrease in rates of HCV diagnoses in all individuals attending specialist SHSs in England.
  • Among attendees of negative or unknown HIV status, rates decreased from 48 per 100,000 attendees to 21 per 100,000 attendees (fall of 56.3%).
  • Among HIV-positive attendees, the decrease was greater from 14 to 3 per 100,000 over the same period (fall of 78.6%)/
    • The lower rates are attributed to people living with HIV (PLWH) being diagnosed with HCV in their HIV care rather than in SHS.
  • Compared to the overall rate in all attendees, men who have sex with men (MSM) showed elevated rates of HCV diagnoses regardless of HIV status: likely due to high-risk behaviours including higher number of condomless anal sex partners, and injecting recreational drug use.

HIV HCV PHE 2020 rates

HIV/HCV co-infection

BHIVA has targets for the micro-elimination of HCV in people with HIV: curing HCV in 80% of those co-infected by April 2019, 90% by April 2020, and 100% by April 2021.

HARS data suggests that of people with HIV accessing care in England:

  • 0.69% (598/86,997) tested positive for either an acute or chronic HCV infection in 2017
  • 1.47% (1,298/88,002) in 2018

In 2018 HCV prevalence highest in:

  • People living with HIV who inject drugs (27%)
  • MSM living with HIV who inject drugs (6.5%)

Lowest in:

  • Heterosexual men living with HIV (0.8%)
  • Women (0.5%)

HIV HCV PHE 2020

Impact and opportunities of COVID-19

While the COVID-19 pandemic poses a threat to HCV elimination targets, it has also presented opportunities to test and link individuals from some underserved groups into care.

Many local authorities and charities worked together during lockdown to support homeless people and rough sleepers by moving them off the streets into individual hotel rooms. This provided a unique, short-lived opportunity to reach out to this group to address some health needs while their accommodation was more secure.

In June The Martin Fisher Foundation and EmERGE M-Health Ltd launched a new partnership to provide Hepatitis and HIV testing in Brighton and Hove for approximately 200 temporarily housed rough sleepers in the city.

Working with outreach workers from Brighton & Sussex University Hospitals NHS Trust and the Terrence Higgins Trust, aided by St Mungo’s support workers, colleagues visited hotels to offer screening using a simple finger-prick test. All face-to-face interactions involved the use of personal protective equipment (PPE). The project incentivised people to test by offering them £5 food vouchers for their engagement.

107 people had been tested through the programme by 20 July 2020. Processing lab results takes some time but from the cohort of the first 25 individuals tested, five HCV infections had been identified, which is broadly in line with the anticipated HCV prevalence. There were no HIV diagnoses within the first 25 tests returned.

Normalising testing and enabling early access to treatment, which reduces onwards transmission risk of both viruses, has the potential to significantly reduce the public health impact of HIV and HCV during the next decade.

A combined method of upscaling integrated testing and exploring innovative ways to reach people most likely to be affected by HIV/HCV co-infection (as we have seen during the COVID-19 epidemic) would help to achieve this.

Further decline in new HIV diagnoses in the UK

New HIV diagnoses have fallen for a third consecutive year, the latest data from Public Health England (PHE) shows. In 2018 a total of 4,484 people were diagnosed with HIV in the UK, a 6% reduction from the 4,761 diagnosed in 2017.

PHE has advised the intensification of combination prevention has been critical to the decline in HIV incidence in gay and bisexual men since 2012. Further information will be released in PHE’s annual report, which will be published in November.

The increase in HIV testing, access and availability to immediate antiretroviral therapy for people diagnosed with HIV, and the scale-up of access to pre-exposure prophylaxis (PrEP) have all played a role in the continued decline of new diagnoses.

The decline in gay and bisexual men

Since 2015 there has been a staggering 39% decline in new HIV diagnoses among gay and bisexual men. Within this group, the steepest declines have been recorded within men who are:

  • White (46% decline since 2015)
  • Born in the UK (46%)
  • Aged 15-24 (47%)
  • Resident in London (50%)

The biggest declines outside of London in gay and bisexual men were seen in:

  • West Midlands (47%)
  • Scotland (43%)
  • East Midlands (40%)

In 2018, two out of every five gay and bisexual men newly diagnosed with HIV lived in London.

The decline via heterosexual contact

During the same time period (2015-2018) the fall in new diagnoses from heterosexual contact was 24%. Within this group the biggest declines have been recorded in people who are:

  • Adults in London (40% decline since 2015)
  • Aged 25-34 (34%)
  • Born in Africa (24%)

Late diagnoses

There are still challenges for the sector despite the continued decline in new HIV diagnoses. In 2018, 43% of all diagnoses were late. PHE has once again repeated its warning that people diagnosed late face a ten-fold increased risk of short-term mortality.

Population groups with particularly high late diagnoses rates include:

  • Heterosexual men (60%)
  • Black African adults (52%)
  • Those aged 50 and older (59%)

People diagnosed late are more likely to experience an AIDS-defining illness at the time of their diagnosis: this was true of 225 people in 2018, a similar number to 2017.

People receiving HIV care in 2018

In 2018 there were 96,142 people receiving HIV care in the UK, of which:

  • 97% were receiving antiretroviral treatment
  • 97% of people on treatment were virally suppressed

The percentage of those receiving treatment was slightly less in 15-24 year olds and in people who inject drugs. Viral suppression was consistent across all population groups.

Trans people

For the second consecutive year PHE has supplied data on HIV diagnoses in trans people. In 2018, 11 trans people were diagnosed with HIV, which is a fall from 16 in the previous year.

The data from PHE now shows that 152 trans people were seen in HIV care in 2018. Of these, 33% were 50 or older and 39% were black, Asian or minority ethnic (BAME). All trans people seen in care were on treatment.

What this means for HIV prevention in England

The hard work to sustain the decline in new HIV diagnoses must continue. The combination prevention approach is working in the UK and efforts to increase awareness and knowledge of correct condom use, HIV testing, PrEP and HIV treatment are necessary to maintain this momentum.

Late diagnoses remain an area that the entire health system needs to take responsibility for, ensuring that all population groups have access to HIV testing. The HIV sector must work with primary and secondary care providers to increase opportunities for people to test outside of traditional sexual health services.

Particular attention needs to be paid to regions outside of London and to those subgroups which are not seeing as large declines in new diagnoses as witnessed in white gay and bisexual men.

National HIV Testing Week presents the next opportunity for the sector to continue to increase HIV testing and reduce late diagnoses in all groups affected by HIV across England. The campaign starts Saturday 16 November 2019. Stay informed with our plans for the campaign by signing up to our newsletter using the form on this page and following us on Twitter.

New local PHE indicators

PHE has announced a number of new HIV indicators on its Fingertips online sexual and reproductive health profiles. In addition to existing measures including HIV testing coverage and new HIV diagnoses rates you can now access local and regional information on:

  • Late diagnoses rates for MSM, heterosexual men, heterosexual women and people who inject drugs
  • Repeat HIV testing in MSM within the past year
  • Prompt ART treatment initiation in people newly diagnosed with HIV

PHE Fingertips webinar

If you would like to know more about PHE’s online health profiles, join us at 1pm on Tuesday 24 September for our webinar looking at getting the most out of PHE’s fingertips tool.

Find out more and register for this event

Official Statistics from PHE

Read HIV annual data tables