1. Africans and HIV in the UK: an epidemiological perspective May 2006 Valerie Delpech On behalf of the HIV Reporting Section with special thanks to Julia Abernethy HIV & STI Department, Health Protection Agency Centre for Infections

2. What I will cover…  Global trends  UK trends  Focus on black Africans  Diagnosed  Seen for care  Undiagnosed  Implications

3. Global picture

4. Global estimates for adults and children end 2005 People living with HIV New HIV infections in 2005 Deaths due to AIDS in 2005 40.3 million [36.7 – 45.3 million] 4.9 million [4.3 – 6.6 million] 3.1 million [2.8 – 3.6 million]

5. Adults and children estimated to be living with HIV as of end 2005 Total: 40.3 (36.7 – 45.3) million Western & Central Europe 720 000 [570 000 – 890 000] North Africa & Middle East 510 000 [230 000 – 1.4 million] Sub-Saharan Africa 25.8 million [23.8 – 28.9 million] Eastern Europe & Central Asia 1.6 million [990 000 – 2.3 million] South & South-East Asia 7.4 million [4.5 – 11.0 million] Oceania 74 000 [45 000 – 120 000] North America 1.2 million [650 000 – 1.8 million] Caribbean 300 000 [200 000 – 510 000] Latin America 1.8 million [1.4 – 2.4 million] East Asia 870 000 [440 000 – 1.4 million] 1.3 million on ARV

6. Estimated adult and child deaths from AIDS during 2005 Total: 3.1 (2.8 – 3.6) million Western & Central Europe 12 000 [<15 000] North Africa & Middle East 58 000 [25 000 – 145 000] Sub-Saharan Africa 2.4 million [2.1 – 2.7 million] Eastern Europe & Central Asia 62 000 [39 000 – 91 000] East Asia 41 000 [20 000 – 68 000] South & South-East Asia 480 000 [290 000 – 740 000] Oceania3600 [1700 – 8200] North America 18 000 [9000 – 30 000] Caribbean 24 000 [16 000 – 40 000] Latin America 66 000 [52 000 – 86 000]

7. Estimated number of adults and children newly infected with HIV during 2005 Total: 4.9 (4.3 – 6.6 ) million Western & Central Europe 22 000 [15 000 – 39 000] North Africa & Middle East 67 000 [35 000 – 200 000] Sub-Saharan Africa 3.2 million [2.8 – 3.9 million] Eastern Europe & Central Asia 270 000 [140 000 – 610 000] East Asia 140 000 [42 000 – 390 000] South & South-East Asia 990 000 [480 000 – 2.4 million] Oceania8200 [2400 – 25 000] North America 43 000 [15 000 – 120 000] Caribbean 30 000 [17 000 – 71 000] Latin America 200 000 [130 000 – 360 000] Total: 4.8 (4.2 – 6.3) million

8. About 14 000 new HIV infections a day in 2005  More than 95% are in low and middle income countries  Almost 2000 are in children under 15 years of age  About 6000 are in persons aged 15 -24 years  About 50% are women

9. 20% − 39% 10% − 20% 5% − 10% 1% − 5% 0% − 1% trend data unavailable outside region HIV prevalence in adults in sub-Saharan Africa, end 2003 UNAIDS levels Low: < 5% in any sub-population. Concentrated: 5% in at least one sub-population but < 1% in pregnant women. Generalised: > 1% in pregnant women

10. HIV prevalence in adults in sub-Saharan Africa, 1988−2003 20% − 39% 10% − 20% 5% − 10% 1% − 5% 0% − 1% trend data unavailable outside region

11. 0 5 10 15 20 25 30 19902000 ‘ 91 ‘ 92 ‘ 93 ‘ 94 ‘ 95 ‘ 96 ‘ 97 ‘ 98 ‘ 99 ‘ 01 Source: Department of Health, Republic of South Africa HIV prevalence among pregnant women in South Africa, 1990 to 2001 HIV prevalence (%) 01 July 2002 slide number SSA-11

12. Has global incidence peaked? Declines in HIV prevalence in some countries Uganda, Urban Kenya and Haiti, Zimbabwe, Botswana, South Africa, Malawi ? Due to behaviour change ? Blood safety interventions ? AIDS deaths Caution: Incidence versus prevalence

13. Prevalence in 15-24 years old first time testers in Kampala, Uganda: 1992-2000 Source: Uganda National AIDS Programme 0 5 10 15 20 25 30 199219931994199519961997199819992000 Males Females HIV Prevalence (%) 01 July 2002 slide number SSA-13

14. UK picture

15. HIV diagnoses and deaths by year, UK Widespread introduction of HAART

16. HIV diagnoses by exposure category Source: HIV/AIDS diagnoses reports to end of March 2006, UK

17. HIV diagnoses acquired through heterosexual contact by sub-category Source: HIV/AIDS diagnoses reports to end of March 2006, UK >75%

18. HIV infections where the probable country of infection was a named country in Africa – heterosexual men and women UN geographical areas 1 Numbers will rise for recent years, as further reports are received. Data source: HIV/AIDS reports. Reports received by the end of September 2005. 1

19. Number of UK diagnoses & HIV prevalence in selected African countries Probable country of infection Number HIV among heterosexuals in UK (2000-2005) UNAIDS Adult prevalence (15-49 yrs) in 2003 Zimbabwe 627625% South Africa 131822% Uganda 12354% Zambia 80817% Nigeria 7595% Malawi 64914% Kenya 5667% Congo Zaire 4375% Ghana 4123% Cameroon 2927% *Total HIV infections acquired in Africa = 22 432

20. Black Africans

21. HIV diagnoses among black Africans Over 3500 diagnoses per year (approx 20 000 total)  Almost 2/3 are women  About 1/3 have been in the UK less than 2 years  90% acquired heterosexually, majority in Africa  7% through sex between men (?sigma)  around 100 children (<15 years) 97% infected MTCT  >10% present late (with AIDS symptoms)  TB most important AIDS defining illness

22. Diagnoses of HIV infection in black Africans by age and sex Source: HIV/AIDS diagnoses reports to end of March 2006, UK

23. Diagnoses of HIV infection in black African women diagnosed through antenatal care Source: HIV/AIDS diagnoses reports to end of March 2006, UK

24. Diagnoses of HIV infection in black Africans acquired through heterosexual contact within the UK, by partner's probable world region of infection Source: HIV/AIDS diagnoses reports to end of March 2006, UK

25. Late diagnoses of HIV among black and minority ethnic adults, with and without TB Source: HIV/AIDS diagnoses reports, UK

26. People seen for HIV care

27. HIV-infected individuals accessing treatment and care services by ethnic group, 2004 Source: SOPHID N= 42,182 38%

28. Black and minority ethnic individuals diagnosed as HIV-infected accessing treatment and care services by exposure category Source: SOPHID

29. Data source: SOPHID Rates of diagnosed HIV-infected adults (15+) seen for HIV-related care in the UK, by SHA of residence 20002004

30. Percentage of ethnic groups diagnosed as HIV-infected: 2004 Source: SOPHID and ONS Black AfricanBlack Caribbean Indian/Pakistani/ Bangladeshi White Number aged 16-44 diagnosed as HIV-infected (SOPHID) 11 91192532213 617 Population, aged 16-44 (Census 2001) 269 179281 3161 003 83418 592 356 Percentage aged 16-44 living with diagnosed HIV 4.4%0.3%0.03%0.07%

31. HIV prevalence among women giving birth by world region of birth Source: Unlinked anonymous testing of newborn infant blood spots

32. HIV prevalence among women giving birth by African region of birth Source: Unlinked anonymous testing of newborn infant blood spots

33. Diagnosed HIV-infected adults (15+) seen for HIV-related care by level of anti-retroviral therapy (ART) Data source: SOPHID

34. Undiagnosed infection

35. Undiagnosed HIV infections One in 3 persons living with HIV are undiagnosed (approx 20 000 people) - Persons unaware are at increased risk of:  presenting late/ AIDS  preventable death  transmitting HIV to sexual partners - varies with different groups

36. Prevalence previously undiagnosed 1 HIV infection among UK-born heterosexuals attending sentinel GUM clinics 1 Previously undiagnosed HIV infection includes those diagnosed at the clinic visit as well as those who remained unaware of their infection Data source: Unlinked Anonymous prevalence monitoring, United Kingdom

37. 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

38. Estimates 1 of prevalent HIV infections in adults aged 15-59, 2004 Exposure CategoryNumber diagnosedNumber undiagnosedTotal Sex between men 17 400 (16 900, 17 900) 9100 (6600, 13 300) 26 500 (23 900, 30 700) Injecting drug use 1300 (1300, 1400) 600 (500, 800) 2000 (1800, 2100) Heterosexuals 19 900 (19 300, 20 600) 9800 (7600, 13 000) 29 700 (27 600, 32 900) Men 7400 (7100, 7600) 4700 (3600, 6700) 12 000 (10 900, 14 100) African born 460016006200 Non-African born 280030005900 Women 12 500 (12 100, 13 000) 5100 (3900, 6700) 17 700 (16 500, 19 200) African born 9300240011700 Non-African born 330027006000 Grand total 38 600 (37 500, 39 800) 19 700 (16 100, 24 800) 58 300 (54 700, 63 400) 1 Multi-parameter Evidence Synthesis method - Goubar A et al. 2005, United Kingdom

39. Black and ethnic minority populations Conclusions  rapid increase in the numbers of infections acquired through heterosexual contact diagnosed in the UK  three-quarters were probably acquired in Africa – reflects focus of pandemic in sub-Saharan Africa  large proportion of undiagnosed individuals (>4000)  disproportionate high number of late diagnoses and deaths

40. Black and ethnic minority populations Need to ensure:  Access to confidential HIV testing  Targeted health promotion to encourage testing, reduce stigma, encourage early presentation  Access to safer sex and other sexual health skills  condom negotiation, disclosure of status  Support to those living with diagnosed infection  Effective treatment access and care

41. 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. May 2006

42. Thank you