HIV and STI Department - Centre for Infections Reducing the burden of undiagnosed HIV infection Dr Valerie Delpech HIV & STI Department Centre for Infections HPA

HIV and STI Department - Centre for Infections Outline New Diagnoses Overall trends in UK and International HIV Incidence UA STARHS Testing Impact on transmission

HIV and STI Department - Centre for Infections Trends in new diagnoses

HIV and STI Department - Centre for Infections Summary of new HIV diagnoses trends in Northern Europe New HIV diagnoses Stabilising overall But Ongoing increases in MSM – (eg: Germany, France, UK, Netherlands). MSM remain the group most at acquiring HIV. Slow increase in number of heterosexuals acquiring HIV in the UK, particularly among black-African individuals – stable in France and Germany

HIV and STI Department - Centre for Infections Summary continued Prevalence low in IDU <2% High amongst black-African populations (>4%) High amongst MSM (10% in major cities) Good uptake of ARV with few AIDS cases and AIDS deaths Late diagnosis and high proportion of persons unaware of their infection is major concern Late diagnoses results in high risk of early death.

HIV and STI Department - Centre for Infections New HIV diagnoses by prevention group, UK: Proportional adjustment for missing information; 2008 also adjusted for reporting delay

HIV and STI Department - Centre for Infections

Factors Driving New HIV Diagnoses New HIV Diagnoses Changes in Population size Testing Improved reporting / methodological change Migration and travel Transmission (incidence)

HIV and STI Department - Centre for Infections HIV Incidence

HIV and STI Department - Centre for Infections Detecting Recent Infections S T A H R S erological esting lgorithms ecent IV eroconversion All dependent firstly on a highly sensitive method to detect anti-HIV Ab Secondly, a method in which the signal takes considerably longer to exceed a threshold beyond which it is a long-standing infection

HIV and STI Department - Centre for Infections HIV Incidence in MSM attending 16 UAPMP STI clinics: BY REGION

HIV and STI Department - Centre for Infections Non Incident Incident infection Number Year 28% 15% 34% 19% 35% 40% 50% 42% 55% 51% Incident infections on first diagnosis among MSM in Brighton

HIV and STI Department - Centre for Infections HIV testing

EuroHIV * Or latest year: † 2002; ‡ 2003; § 2004 † ‡ ‡ ‡ ‡ § § § § § § § HIV tests per 1, < 10 Not available HIV tests performed per thousand population, WHO European Region, 2005

HIV and STI Department - Centre for Infections Improving HIV testing: Sexual Health Strategy ( ) By end 2004, all STI clinic attendees offered an HIV test on their first STI screening (and subsequently according to risk). Uptake by those offered HIV test should be 60% by the end of 2007 (surpassed). The proportion of HIV positive individuals leaving the GUM undiagnosed should be reduced by 50% by 2007 (not yet achieved).

HIV and STI Department - Centre for Infections Estimated proportion of HIV-infected pregnant women diagnosed before delivery 1 and of exposed infants becoming infected with HIV 2, England & Scotland 1 Includes previously diagnosed and those diagnosed through antenatal testing 2 Assumes vertical transmission rate of 26.5% in undiagnosed women and 2.2% in diagnosed women 3 These data contain reports received by the end of June 2008, data for recent years is subject to reporting delay Unlinked anonymous prevalence monitoring National Study of HIV in Pregnancy and Childhood, ICH

HIV and STI Department - Centre for Infections Sexual health screens and HIV tests at GUM clinics, E, W & NI STI data from genitourinary medicine clinics WomenHeterosexual men MSM

HIV and STI Department - Centre for Infections Median CD4 count at diagnosis by prevention group, UK:

HIV and STI Department - Centre for Infections The proportion of heterosexuals attending sentinel GUM clinics receiving an HIV test and the fraction of HIV-infected heterosexuals remaining undiagnosed, UK Unlinked anonymous prevalence monitoring

HIV and STI Department - Centre for Infections The proportion of MSM attending sentinel GUM clinics receiving an HIV test and the fraction of HIV-infected MSM remaining undiagnosed, UK Unlinked anonymous prevalence monitoring

HIV and STI Department - Centre for Infections Undiagnosed Infection & late diagnosis

HIV and STI Department - Centre for Infections Estimated number of adults (15 to 59 years) living with HIV (both diagnosed and undiagnosed) in the UK: 2007 MPES

HIV and STI Department - Centre for Infections Prevalence of previously undiagnosed HIV infection, UK: 2007 Unlinked anonymous prevalence monitoring

HIV and STI Department - Centre for Infections

* Estimates of median time from infection to each CD4 count category: 2 yrs, >499; 4.2 yrs, ; 6.2 yrs, ; 8.5 yrs, <200 Health Check “No Time To Wait”, CMO Annual report 2003 fig 2 Estimated time between infection and diagnosis: people diagnosed in London in % 10% 20% 30% 40% 50% Men who have sex with men White HeterosexualsBlack African Heterosexuals 8.5 years 6.2 years 4.2 years 2 years

HIV and STI Department - Centre for Infections Late HIV diagnosis and mortality in London: Homosexual & bisexual menBlack Africans/black Caribbeans Proportion diagnosed late (%) Percentage dying within a year (%) late diagnoses death within a year of HIV diagnosis (others) death within a year of HIV diagnosis (late diagnosis)

HIV and STI Department - Centre for Infections HIV prevention indicator Each PCT to reduce late diagnosis of HIV to 15% by Definition: CD4<200 Baseline: average of late diagnoses for to increase numbers Baseline of 34% means a halving of late diagnoses across London Data collected and analysed by the HPA for NHS London No differential targets by ethnic group/risk group

HIV and STI Department - Centre for Infections Map of proportion diagnosed late by PCT for 2007 (CD4 <200 cells per mm 3 ) Data for London SHA to performance manage London PCTs on late HIV diagnosis (the HIV Prevention Indicator)

HIV and STI Department - Centre for Infections Expanding HIV testing

HIV and STI Department - Centre for Infections GUM, antenatal service, TOP services, Drug dependency programmes, TB, Hepatitis B, hepatitis C and lymphoma services Populations where diagnosed prevalence > 2 per 1000 population Patients thought to be “at risk” of HIV infection HIV test monitoring: New Testing guidelines

HIV and STI Department - Centre for Infections Data source: SOPHID Rates of diagnosed HIV-infected adults (15+) seen for HIV-related care in the UK, by PCT of residence: 2007 London

HIV and STI Department - Centre for Infections DH funded project in 2009 Nov 2008 DH call for project proposals aimed at increasing the offer and uptake of voluntary HIV testing and reduce undiagnosed HIV Eight projects funded (7 in high prevalence areas) to run for 6-12 months Hospital setting (3) Community including GP (5) Evaluation Feasibility Acceptability Cost effectiveness Efficacy

HIV and STI Department - Centre for Infections Funded Projects Leicester Routine testing year olds 3 hospitals Medical admission units Brighton and Sussex Routine testing year olds Acute general medicine UA arm London Routine testing year olds 3 hospitals Emergency department, selected outpatients departments, acute medical unit Brighton and Hove Routine testing New GP registrations

HIV and STI Department - Centre for Infections Projects cont. London (Lewisham) Comparison of 2 models HIV testing in GP practices Sheffield Piloting home sampling Includes internet use London (THT) Money transfer and African community shops London (Metro Centre, West London Gay Men’s Project and Positive East) HIV testing as part of a broader health screen within African communities Peer-led and nurse lead initiatives for MSM testing

HIV and STI Department - Centre for Infections Preventing Onward Transmission

HIV and STI Department - Centre for Infections What is driving the HIV & STI epidemic in 2009 Socio-Political Stigma and discrimination Migration Biological Increasing pool Late diagnosed Undiagnosed fraction Increasing STIs Early seroconverters ?Drug resistance Risk context and behaviour Stigma and discrimination Increase risk behaviours Changing sexual networks WRONG!!!

HIV and STI Department - Centre for Infections Disproportionate HIV transmission from those unaware of their infection ~25% Unaware of Infection ~75% Aware of Infection Accounting for: ~54% of New Infections ~46% of New Infections Marks G, Crepaz N, Janssen RS. Estimating sexual transmission of HIV from persons aware and unaware that they are infected with the virus in the USA. AIDS Jun 26;20(10):

HIV and STI Department - Centre for Infections Treatment as prevention Evidence Serodiscordant studies (on ART & not) Models (CA: need to increase persons on ART up to 75%) Concerns Ethics and feasibility Treatment access ART resistance Adverse events (bio & behavioural) Undiagnosed or ‘false negatives’ still drive the epidemic BUT in line with Clinical guidelines

HIV and STI Department - Centre for Infections Proportion of HIV-infected persons not on ARV by CD4 category: UK, 2006 CD4 cell count category 31%19%31% Proportion not on ARV Annual survey of HIV-infected persons accessing care n = 5,144 2,407 18%30%31% 11,595 4,983 29,165 9,894

HIV and STI Department - Centre for Infections Next steps Expanding testing a must – evaluate This will lead to earlier treatment Revisiting MSM health promotion strategies New interventions for black African and migrant populations Improving surveillance to better inform programs –rollout STARHS testing to detect incident cases –better monitoring of people in care

HIV and STI Department - Centre for Infections Thank you Surveillance – Needs to guide and monitor prevention efforts