Research

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 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%)

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.

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

New HIV diagnoses have fallen for a second consecutive year, the latest data from Public Health England (PHE) shows.

In 2017 a total of 4,363 people were diagnosed with HIV in the UK, a 17% reduction from the 5,280 diagnosed in 2016 and a 28% reduction from the 6,043 diagnosed in 2015.

PHE have attributed the latest results primarily to improvements in the uptake of antiretroviral therapy in people living with HIV and the large increases in HIV testing. Particular attention has been paid to men who chose to repeat HIV testing.

While these results are published against the backdrop of the roll-out of pre-exposure prophylaxis (PrEP) through the IMPACT trial, and the increase in predominantly gay and bisexual men accessing generic PrEP privately online, PHE advises that it is too early to know the size of impact this is having on HIV transmission rates.

Gay and bisexual men

PHE has advised that the continuing downward trend in new diagnoses is largely due to a decline in new diagnoses among gay an bisexual men: the rate in this group has decreased more than any other group affected by HIV, with a 31% fall since 2015. This drop is even more significant in London where new diagnoses fell by 44%, compared to 30% outside the capital.

Black African and Black Caribbean men and women

Numbers of new diagnoses in black African and black Caribbean heterosexuals have been falling steadily for almost a decade and experienced an even more dramatic drop of almost 25% in the last year – from 1, 040 in 2016 to 800 in 2017.

Other heterosexuals

In previous years this group had reported approximately 1,000 diagnoses per year. However, in 2017 the new PHE data shows a 20% decline, the reasons for which are currently uncertain.

Trans people

For the first time PHE have supplied data on HIV diagnoses in trans people. In 2017, eight trans women were diagnosed with HIV, a slight fall from 10 in the previous year and 15 trans women in 2015.

Late diagnoses

While the fall in new HIV diagnoses is to be celebrated, there are still challenges facing the HIV sector. Late diagnoses rates have remained stubbornly high at around 40% for the past five years, and in 2017 43% of people were diagnosed late.

PHE has repeated its warning that people diagnosed late face a ten-fold increased risk of short-term mortality. People diagnosed late are more likely to experience an AIDS-defining illness at the time of their diagnosis: this was true of 230 people in 2017.

People receiving HIV care in 2017

The UK is making great strides, continuing to ensure people living with HIV remain in care and have access to treatment which benefits their health and reduces the chance of transmission to their sexual partners. In 2017 there were 93,385 people receiving HIV care in the UK, of which:

• 98% were receiving antiretroviral treatment
• 97% of people on treatment were virally suppressed

Overall, gay and bisexual men continue to be the most disproportionately affected by HIV, with 43,494 people seen for HIV care in 2017, followed by black African heterosexual men and women with 27,212 people seen for care. Trans people accounted for 123 individuals seen for care, the vast majority of which were trans women.

What this means for HIV prevention in England

It is clear that the combination prevention approach to drive down new HIV diagnoses across the country is working. However, to sustain this trend the hard work must continue.

The sector must tackle late diagnoses and ensure that all groups affected by HIV know how they can take responsibility of their own sexual health, by making use of the range of HIV prevention and sexual health tools available to them.

National HIV Testing Week presents the next opportunity for the sector to continue to increase HIV testing and reduce diagnoses rates and late diagnoses in all groups affected by HIV across England. The campaign starts Saturday 17 November 2018.

Stay informed with our plans for the campaign by signing up to our newsletter and following us on Twitter.

Official Statistics from PHE

• HIV surveillance data in the UK by demographic characteristics and geographical region

Further information from HPE

• National HIV Testing Week
• Our new GP strategy: engaging primary care in HIV prevention efforts to bring down late diagnosis [PDF]