Research

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.

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.

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.