The information on this page is taken from the UKHSA report, HIV testing, new HIV diagnoses, outcomes and quality of care for people accessing HIV services: 2021 Report, Dec 1st 2021.
The annual official statistics data release (data to end 2020) UKHSA.
HIV testing
In 2020, the number of people who tested for HIV at sexual health services in England fell by 30% from 1,320,510 in 2019 to 927,760. This decline was not equal between population groups.
Among gay, bisexual and other men who have sex with men, the number having an HIV test at sexual health services fell by 7% from 157,710 in 2019 to 146,900 in 2020 but remained higher than in 2018 (132,770). Furthermore, the number of frequent testers (at least two tests within a year) remained high; many of these frequent testers may have been receiving pre-exposure prophylaxis (PrEP).
By contrast, the number of heterosexuals tested for HIV fell sharply by 33% (from 1,142,950 in 2019 to 760,260 in 2020). Similar drops in testing were observed among Black African heterosexuals (34% for men and 24% for women) and White heterosexuals (43% and 30%, respectively).
New HIV diagnoses and incidence
Among gay and bisexual men, the number of HIV diagnoses first made in England decreased by 41% from 1,500 in 2019 to 890 in 2020 (adjusted for missing probable route of exposure).
Taken together with only small declines in testing and a continuing availability of PrEP, the fall in diagnoses in gay and bisexual men suggests a continued year-on-year reduction in transmission in this group. These declines in diagnoses were less apparent among gay and bisexual men who were living outside London, those of Black, Asian, mixed or other ethnicity ethnic groups, and those born abroad.
The decline in new HIV diagnoses first made in England was steepest in gay and bisexual men in London (56%, from 800 in 2019 to 350 in 2020), White men (45%, from 1,210 in 2019 to 660 in 2020) and those aged under 50 years (47%, from 1,500 in 2019 to 800 in 2020).
The smallest declines in gay and bisexual men first diagnosed in England (adjusted for missing demographic data) were observed among Black African men (33%, from 60 in 2019 to 40 in 2020), aged 50 years and over (36%, from 220 in 2019 to 140 in 2020) and living in England outside of London (36% drop, from 920 in 2019 to 590 in 2020).
In 2020, after adjusting for missing information, an estimated 67% (630 out of 940) of gay and bisexual men first diagnosed in England probably also acquired HIV in England.
Just over half (54%, 360 out of 670) of newly diagnosed gay and bisexual men first diagnosed in England in 2020 were born in the UK and 17% elsewhere in Europe. Both groups experienced a decline in HIV diagnoses since 2016; 1,080 to 360 (67%) in UK-born men and 350 to 110 (69%) among men born elsewhere in Europe. The number of new diagnoses first made in England among gay and bisexual men born in Africa declined by 40% between 2016 and 2020 (from 50 to 30), by 62% among those born in Asia (130 to 50), by 62% among those born in Latin America and the Caribbean (130 to 50) and by 75% among those born in another place (40 to 10).
In 2020, 1,010 people who probably acquired HIV through heterosexual contact were first diagnosed with HIV in England (after adjusting for missing exposure information), a 23% decrease from 1,320 in 2019. The decline was 40% among White heterosexuals (from 470 in 2019 to 280 in 2020) and 40% among Black Caribbean heterosexuals (from 50 to 30) but less pronounced among Black Africans (25%, 400 to 300) and among Asians (17%, 60 to 50). Among heterosexual men and women born abroad but diagnosed with HIV in England, 49% were estimated to have acquired HIV after arrival in England.
The number of HIV diagnoses first made in England among heterosexual people decreased by 23% (from 1,310 in 2019 to 1,010 in 2020, adjusted for missing information). The decline was 40% among White heterosexuals (from 470 in 2019 to 280 in 2020) and Black Caribbean heterosexuals (from 50 to 30) but less pronounced among Black Africans (25%, 400 to 300) and among Asians (17%, 60 to 50). The decline in HIV diagnoses first made in England among heterosexual men and women is likely to have been impacted by reduced access to HIV testing in 2020 and rather than longer term decreased transmission.
The proportion of heterosexual men and women who probably acquired HIV in England and were also first diagnosed in England was 44% (160 out of 360) and 41% (160 out of 390), respectively. Among heterosexual men and women born abroad but diagnosed with HIV in England, 49% were estimated to have acquired HIV after arrival in England.
Access to PrEP
In England, PrEP was made available through the Impact trial, which recruited 24,255 participants between October 2017 and July 2020 (37). Participants enrolled up to February 2020 were more likely to identify as gay and bisexual men (96%), to be White (76%) and aged 25 to 39 years (median age 33 years). Just under 3% of the participants identified as women and 1.5% as Black African.
Since the autumn of 2020, oral PrEP, using a fixed dose combination of emtricitabine and tenofovir (F/TDF), has been available through routine commissioning at specialist sexual health services.
The 2020 UK PrEP User survey recruited 1,500 participants (86% gay and bisexual men, 85% White) from October to November 2020 (38). The most recent survey showed that among people using PrEP, 60% of respondents obtained PrEP from the Impact trial, 20% sourced PrEP from the internet and the remainder from Scottish and Welsh clinics, from other services, friends and other sources. This indicates a decrease in the use of PrEP during social restrictions periods in 2020.
Conclusion
HIV testing and HIV care services were significantly reduced in 2020, and during the first wave of COVID-19 in particular, with a shift to telephone consultations and internet testing. However, the decline in HIV testing among gay and bisexual men was modest; the number tested was higher than that reported in 2018. These facts coupled with evidence of reduced sexual contact indicate that the decline in HIV diagnoses in gay and bisexual men observed in 2020 reflects a true reduction in transmission.
In contrast, there is little evidence that the decline in new HIV diagnoses among heterosexual men and women are due to reduced transmission. These declines must be interpreted with great caution. This is because the rate of decline was low in previous years and the uptake of PrEP remains very low in this group. Furthermore, in 2020, the number of heterosexual adults having an HIV test fell substantially and high numbers of eligible heterosexuals did not have an HIV test due to service reconfigurations in response to COVID-19. We may see a rise in late HIV diagnoses in the coming years as a result.
If we are to be successful in ending HIV transmission, we must tackle transmissible viral load using a combination approach that not only prevents people from acquiring HIV (through condoms and PrEP) but works to improve HIV testing services and to ensure people living with diagnosed HIV infection receive the support they need to remain in care, on treatment, and virally suppressed with a good quality of life.