1. 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

2. 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

3. 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

4. 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

5. 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’

6. 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

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

8. 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)

9. 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 \

10. 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

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

13. 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, ,800)], were unaware of their infection and at risk of passing on the virus to others.

14. 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

15. New HIV diagnoses among heterosexuals, UK
Men
Women

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

17. 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

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

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

20. 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

21. 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%
BA ♀ & ♂
Oral specimens
Positivity rate %
Proportion undiagnosed %

24. Current HIV trends in England

25. Current HIV trends in England

26. Current HIV trends in England

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

28. Back-calculation estimates of HIV incidence and number of prevalent undiagnosed HIV infections among gay/bisexual men aged 15 years and over: England,
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 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

29. 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

30. 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

31. 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

32. 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

33. 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

34. Thank you