Africans and HIV in the UK: an epidemiological perspective Nov 2006 Tim Chadborn On behalf of the HIV Reporting Section with special thanks to Julia Abernethy and Bela Vatsa HIV & STI Department, Health Protection Agency Centre for Infections

What I will cover…  UK epidemiology  Access to treatment and care  Access to services  Access to treatment  AIDS and death  Late diagnosis  Preventable mortality  Key messages

New HIV diagnoses

HIV and AIDS diagnoses and deaths in HIV-infected black Africans, E,W&NI Widespread introduction of HAART 1 Numbers will rise, for recent years, as further reports are received; reports from the Channel Islands excluded Data Source: HIV/AIDS and death reports. Reports received by the end of September 2006.

HIV diagnoses of black Africans by exposure category 1 Numbers will rise, for recent years, as further reports are received; reports from the Channel Islands excluded Data Source: HIV/AIDS and death reports. Reports received by the end of September 2006.

1 Numbers will rise, for recent years, as further reports are received; reports from the Channel Islands excluded Data Source: HIV/AIDS and death reports. Reports received by the end of September HIV diagnoses of black Africans by exposure category – excluding heterosexuals

HIV diagnoses of infections that were probably acquired in Africa among non-black Africans 1 Numbers will rise, for recent years, as further reports are received; reports from the Channel Islands excluded Data Source: HIV/AIDS and death reports. Reports received by the end of September 2006.

HIV prevalence in adults in sub-Saharan Africa, end % − 34% 10% − <20% 5% − <10% 1% − <5% 0% − <1% trend data unavailable outside region Countries in the Commonwealth

HIV diagnoses of infections acquired through heterosexual contact >75%

People seen for HIV care

HIV-infected individuals accessing care by ethnic group, 1996 and 2005 (E, W, NI) 38% n= % 2% 16% 1% 4% White Black Caribbean Black African Asian/ Oriental Other/Mixed n= % 3% 39% 3% 5% Note: excluded from figure are 1736 from 1996 and 792 individuals from 2005 for whom no ethnicity was reported

Percentage of ethnic groups diagnosed as HIV-infected: 2005 Source: SOPHID and ONS Black AfricanBlack Caribbean Indian/Pakistani/ Bangladeshi White Number aged diagnosed with HIV infection and receiving care (SOPHID) 16,3551, ,448 Population, aged (ONS 2004 estimates) 442,300384,6001,522,40026,977,300 Percentage aged living with diagnosed HIV 3.7%0.3%0.03%0.08%

Undiagnosed infection

Undiagnosed HIV infections One in 3 persons living with HIV are undiagnosed (approx people) - Persons unaware are at increased risk of:  presenting late/ AIDS  preventable death  transmitting HIV to sexual partners - varies with different groups: Among black Africans ca: 17,000 diagnosed, 6,000 not

Prevalence of previously undiagnosed 1 HIV infection among heterosexuals attending sentinel GUM clinics 1 Previously undiagnosed HIV infection includes those diagnosed at the clinic attendance and those remaining undiagnosed. Data source: Unlinked Anonymous prevalence monitoring, England, Wales and Northern Ireland

Epidemiology summary

Black Africans living with HIV in the UK 17,206 black Africans living with diagnosed HIV in 2005 (22,521 white) Over 3500 new diagnoses each year (approx 20,000 total) 2/3 are women Most HIV-infected black Africans were born in Africa and infected through heterosexual sex in Africa (small number of MSM) Most came to the UK during the last ten years and were diagnosed in the UK within a few years of arrival around 100 children (<15 years) 97% infected MTCT Two-fifths of black-African adults were diagnosed late in 2005 (CD4<200) >10% have AIDS at the time of HIV diagnosis Almost all active TB identified at HIV diagnosis is among black Africans

Black Africans living with HIV in the UK About 1 in 40 women giving birth who were born in SSA are HIV positive. 1 in 30 of those born in Central and Eastern Africa 1 in 80 of women born in Southern or Western Africa (1 in 2500 women born in the UK) In 2005, 3036 women newly diagnosed with HIV 18% reported being tested antenatall Other reasons: symptoms (28%), routine screening at GUM clinics (25%) and known positive partner (10%). <10% die aged 50 years or more and many die shortly after HIV diagnosis (MSM: 30% and relatively few)

Access to services (2004 study using 2003 data)

2003 HIV treatment centres (red dots) and patients (blue dots) © Crown Copyright. All rights reserved (Health Protection Agency – )

Distance to and use of local centre Out of LondonLondon (25km radius) Distance to local centre (Km) % using local centre Total % using local centre Total <=5 697,304 (69%)4316,299 (98%) 6 to ,741 (17%)19344 (2%) 11 to ,114 (11%) (4%)-0 Total 6110,554 (100%)4216,643 (100%)

Individuals accessing HIV care: SOPHID 2003

Summary of findings Half of all individuals used their local services (<1km – 90km). Majority of individuals live within 5km of an HIV service. Local service use is greatest in those living very near to the service. There is much greater local service use outside of London. There are some differences by population sub-group. E.g. Those requiring specialist services use non-LS (paediatrics & haemophiliacs).

Access to treatment

BHIVA guidelines on ARV treatment initiation (relating to CD4 cell counts) CD4 cell count (per mm 3 ) before starting therapy General recommendation for asymptomatic individuals <200All patients should be on ARV ARV commencement 350+ARV not recommended

Number of individuals on ARV by CD4 cell count category

Percentage with CD4<200 that were not on ARV

Percentage with CD4<200 that were not on ARV by region where treated n =

Summary of 2005 findings 92% of adults not on ART had CD4>=200 and so did not require ART according to guidelines Among severely immunocompromised individuals (CD4<200), 20% were not receiving ART Some may be expected to start ART consequently Little variation by ethnicity or exposure category Some variation by region

AIDS and death

HIV and AIDS diagnoses and deaths in HIV-infected black Africans, E,W&NI Widespread introduction of HAART 1 Numbers will rise, for recent years, as further reports are received; reports from the Channel Islands excluded Data Source: HIV/AIDS and death reports. Reports received by the end of September 2006.

Incidence of death (all causes) Widespread introduction of HAART

Late diagnosis

Late diagnoses by exposure category, 2005

Percentage diagnosed late: region of diagnosis All significantly different to London

n = , Infected in the UK Infected in the UK Infected in Africa partner infected outside EU partner infected within EU Percentage diagnosed late : profile by ethnicity, region of infection and region of infection of partner

Preventable mortality

Short-term mortality: univariable analysis (Short-term mortality = Percentage who died within a year of diagnosis) OR = 9.6 p = <0.01

Short-term mortality as a percentage of all deaths

Crude estimation of preventable deaths Black Caribbeans White 1 in England and Wales, , excluding those previously diagnosed abroad 650 1,630 No. new diagnoses 1 2 those arrived in UK less than 2 years before diagnosis (data only available from clinician reports) 15% (98) 4% (65) Percentage recent arrivals 2 3 only individuals with both a clinician report and a CD4 count at HIV diagnosis 33% (32) 38% (25) Percentage of recent arrivals diagnosed late 3 4 assuming short-term mortality of those diagnosed late is 6.12% 2 2 Est. no. deaths: recent arrivals diagnosed late 4 5 assuming short-term mortality of those not diagnosed late is 0.67% 4 11 Est. no. deaths: other individuals 5 6 / 19 (32%) 13 / 73 (18%) Est. deaths/ Obs. deaths Total deaths Black Africans 11,52537% (4,264)43% (1,834) / 356 (51%) 550

Key messages

Late diagnosis is considerable among heterosexuals Summary of results Substantial mortality within the first year after diagnosis continues in the HAART era Individuals diagnosed late were about 10 times more likely to die within a year of diagnosis Almost 50% of all deaths now occur within a year of diagnosis Early diagnosis could prevent deaths

Groups at high risk of late diagnosis should be targeted for appropriate health promotion activities, opportunistic screening, and removal of any barriers to testing - stigma Conclusions HIV testing in a variety of settings would reduce missed diagnoses, numbers with AIDS at HIV diagnosis, and costs. New patient checks in primary care may be the earliest opportunity to diagnose infection among recent arrivals to the UK.

Acknowledgements The continuing collaboration of clinicians, nurses, microbiologists, health advisors and data managers who contribute to HIV surveillance in the UK is gratefully acknowledged. Without their generosity, time and effort, the current level of understanding of the epidemic could not have been attained. Nov 2006