Understanding HIV risk and transmission among migrants Example for the UK Valerie Delpech On behalf of the HIV & STI team at Colindale Public Health England

United Kingdom: Context Open access, high quality and free STI & HIV testing and care Antidiscrimination laws, Shifts in cultural norms A tolerant society (almost) Long history of health promotion programmes with relatively high uptake of condoms among gay men Targeted campaigns for gay men and black African communities National testing guidelines New testing modalities (POCT, home sampling and testing) New treatment guidelines promoting earlier treatment for TasP PROUD Prep trial, Internet access of Prep, coming soon IMPACT trial

Facts >100,000 people living with HIV in the UK About one in six unaware > 85,000 people accessing HIV care 6000 people diagnosed (1/10,000) 42% diagnosed late 300 AIDS reports, 500 deaths among people with HIV 75% in first year of diagnosis, majority are late diagnosed

Innovation and scaling up of HIV testing Large increases in testing especially in STI clinics POCT widely used HIV Self Sampling: person takes a sample (saliva or blood from a finger prick), and sends it to a laboratory for testing. Results are then given by the service, advising you what to do next THT and PHE services (discussed this pm) HIV Self Testing: Person performs an HIV test on themselves, in a non-medical setting (e.g. home), and sees a result immediately 6th April 2014: Repeal of the HIV testing and Services Regulations SELPHII Study of underway

Migrant populations at risk of HIV in the UK What is a migrant ? – ethnicity, COB, time in the UK, language, culture, sexuality, legal and social barriers MSM vs Black African Black African vs other ethnicities Migration data is poor Migrant as the ‘other’

Are there major gaps in HIV testing services for any of the following populations? Key populations YES NO Undocumented migrants 17 29 Migrants from high prevalence countries 13 33 MSM 11 35 Sex workers 10 36 PWID 7 39 Prisoners 5 41 Transgender people 2 44

Late HIV diagnoses, UK 2015 COB Ethnicity Heterosexual men Gay and bisexual men Heterosexual men Heterosexual women Ethnicity COB

Key factors contributing to late diagnosis Nr of countries Fear of knowing one’s HIV status 33 Low risk perception 29 Stigma and discrimination within the key population 26 Denial of risk behaviours 25 Lack of knowledge about HIV and AIDS 24 Limited screening of patients with HIV risk factors when they are still asymptomatic 21 Stigma and discrimination among health professionals 20 Inadequate efforts by health professionals to offer/recommend an HIV test to people at risk of HIV infection 16 What are the key factors that contribute to late diagnosis of HIV among MSM in your country? Based on reported data from countries of Europe and Central Asia as part of Dublin Declaration monitoring 2016 (preliminary data)

Understanding risk and transmission of HIV infection HIV incidence - models, new diagnoses, RITA Late diagnosis and mortality HIV prevalence – diagnosed and undiagnosed HIV testing data – volume, frequency, setting, positive rate Viral detectability – individual and population Sexual risk behaviours including probable country of infection Other STIs – proxy for high risk Stigmatisation and discrimination Legal barriers \

Understanding risk and transmission of HIV infection in the UK Routinely collected public health data New diagnoses, recent RITA Subsequent HIV care Modelling – MPES, dynamic, stochastic Evidence of sexual mixing molecular epidemiology eg: the proportion of non-B subtype virus increased among hets born abroad Sex with persons from another ethnicity Elford et al. (2007) 20% of black African heterosexuals reported sexual partners of another ethnicity. Behaviour data – Baseline, Mayisha, Positive Voices

UK HIV continuum of care: progress against UNAIDS targets Presentation title - edit in Header and Footer

UK : Undiagnosed HIV infections The UK can still improve in reducing the number of person who remain undiagnosed with HIV. Of the estimated 101,200 people living with HIV by the end of 2015, 13% [13,500 (95% CrI 10,200- 17,800)], were unaware of their infection and at risk of passing on the virus to others.

Number of people newly diagnosed with HIV by exposure category: United Kingdom, 2006 - 2015 The overwhelming majority (>94%) of people newly diagnosed with HIV in the United Kingdom over the past 10 years acquired their infection through sexual contact. After adjusting for missing risk information, people newly diagnosed with HIV who acquired their infection through heterosexual contact accounted for 39% (n=2,360) of the 6,095 new diagnoses in 2015, while 55% (n=3,320) of new diagnoses were among men who have sex with men. New HIV diagnoses among people who inject drugs, and acquired through other routes have remained low over time, accounting for 210 and 190 new diagnoses in 2015, respectively. Values are adjusted for missing exposure group where stated © Crown copyright 2016

New HIV diagnoses among heterosexuals, UK Men Women

New HIV diagnoses by place of birth: UK, 2006-2015 HIV in the UK – an update

Proportion of people newly diagnosed with HIV by world region of birth: United Kingdom, 2006 - 2015 Over the past decade, the proportion of people born in the UK among those newly diagnosed with HIV has increased from 38% (2,587/6,798) of all diagnoses in 2006 to 52% (2,703/5,151) in 2015, although numbers have remained relatively stable. Excludes people with missing country of birth information © Crown copyright 2016

Proportion of heterosexuals born abroad who probably acquired HIV while living in the UK, by world region of birth: UK,2014

New HIV diagnoses among heterosexuals by place of birth: UK, 2006-2015 HIV in the UK – an update

Mayisha 2016 Community survey methods & participants Cross-sectional survey with black Africans recruited in social and commercial venues (Sep – Dec 2016) anonymous questionnaire and oral specimen Mayisha 2016 (n = 604: 292 women, 312 men) 51% born in W Africa, 23% in E Africa, 17% in UK median age: men = 35, women = 31 years 42% living in SE London one sexual partner in last year - 52% of women, 42% of men about 1 in 10 had condomless sex last sex (unknown HIV) STI were high – 15% of women, 23% of men (p=0.01) no knowledge of PrEP – 74% of women, 77% of men

HIV testing: Mayisha survey BA ♀ BA ♂ Self-reported data Ever had an HIV test 73% 69% HIV test in last year 35% 26% Tested in last 3 months - - Last tested at GUM clinic 40% 37% Last tested at GP 27% 35% Living with HIV 7% 7% BA ♀ & ♂ Oral specimens Positivity rate 8% Proportion undiagnosed 11%

Current HIV trends in England

Current HIV trends in England

Current HIV trends in England

What’s next? Improving estimates - incidence - undiagnosed prevalence - transmissibility

Back-calculation estimates of HIV incidence and number of prevalent undiagnosed HIV infections among gay/bisexual men aged 15 years and over: England, 2006-2015 A CD4 back-calculation model was used to estimate HIV incidence among gay/bisexual men living in England and also provides an estimate on undiagnosed prevalence in this group. In 2015, a total of 2,800 gay/bisexual men (95% credible interval 1,700-4,400) were estimated to have acquired a new HIV infection in England. This is in line with the previous five years where an estimated 2,800 men on average acquired HIV each year between 2010 and 2014. This back-calculation method is not currently used for other populations, due to the complexity of incorporating the effects of migration. AIDS at HIV diagnoses is within 3 months of HIV diagnoses. © Crown copyright 2016

Transmissibility: Estimated number of gay men with viral load > 200 copies/mL by clinic strata *Estimated undiagnosed, diagnosed untreated and those treated with viral load >200 copies/mL

Transmissibility Ratio Men with transmissible Viral Load Assumption that all men that are undiagnosed or have a viral load >200 copies/mL at date last seen for HIV care can potentially transmit HIV Men at high risk of HIV acquisition HIV negative men with a documented STI in previous year was defined as High risk Transmissibility Ratio: Total number of men with transmissible VL Total number of high risk men since at clinic

Transmissibility ratio by clinic strata, 2015 Need the denom and numerator number as well I think for context Transmissible VL: Estimated undiagnosed, diagnosed untreated or on ART with viral load >200 copies/mL High risk men: HIV negative with a history of an STI in previous year Current HIV trends in England

Take home messages We are witnessing and recording a down turn in new HIV diagnoses among gay and bisexual men in the United Kingdom Combination prevention is working! We need to consolidate scaling up of testing and early ART across all parts of the country for all groups at greatest risk of HIV, this is challenging particularly in reaching diverse populations Prep use likely to have also contributed to the fall in new diagnoses but we need to scale up and better track its use across all populations Current HIV trends in England

Acknowledgements We gratefully acknowledge people living with HIV, clinicians, microbiologists, immunologists, public health practitioners, occupational health doctors and nurses and other colleagues who contribute to the public health monitoring of HIV and STIs in the UK. Thank you to colleagues at Public Health England in particular: Alison Brown, Cuong Chau, Peter Kirwan, Jameel Khawam, Zheng Yin and the rest of the HARS and GUMCAD teams Fiona Burns and the Mayisha project team, Fumiyo Nakagawa and Andrew Phillips David Dunn and the UK resistance DB team Assessing HIV clinical complexity

Thank you