Reducing the burden of undiagnosed HIV infection Dr

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: 1999 -2008 Proportional adjustment for missing information; 2008 also adjusted for reporting delay HIV and STI Department - Centre for Infections

HIV and STI Department - Centre for Infections

Factors Driving New HIV Diagnoses Testing Changes in Population size Improved reporting / methodological change New HIV Diagnoses Transmission (incidence) Migration and travel HIV and STI Department - Centre for Infections

HIV Incidence HIV and STI Department - Centre for Infections

Detecting Recent Infections S erological Testing A lgorithms R ecent H IV S 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

Incident infections on first diagnosis among MSM in Brighton 51% 100 90 42% 80 50% 70 40% 40 30 Non Incident 35% 60 Number 50 55% Incident infection 28% 15% 34% 19% 20 10 0 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 Year HIV and STI Department - Centre for Infections

HIV testing HIV and STI Department - Centre for Infections

HIV tests performed per thousand population, WHO European Region, 2005 ‡ § § § ‡ ‡ † HIV tests per 1, 000 § ‡ § 50 + 25 - 49 10 - 24 < 10 Not available * Or latest year: † 2002; ‡ 2003; § 2004 Euro. HIV

Improving HIV testing: Sexual Health Strategy (2001 -2011) 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 Women STI data from genitourinary medicine clinics Heterosexual men MSM HIV and STI Department - Centre for Infections

Median CD 4 count at diagnosis by prevention group, UK: 1998 -2007 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

HIV and STI Department - Centre for Infections

Estimated time between infection and diagnosis: people diagnosed in London in 2006 50% 40% 8. 5 years 30% 6. 2 years 4. 2 years 20% 2 years 10% 0% Men who have sex with men White Heterosexuals Black African Heterosexuals * Estimates of median time from infection to each CD 4 count category: 2 yrs, >499; 4. 2 yrs, 350 -499; 6. 2 yrs, 200 -349; 8. 5 yrs, <200 Health Check “No Time To Wait”, CMO Annual report 2003 fig 2 http: //www. publications. doh. gov. uk/cmo/annualreport 2003/notime. htm HIV and STI Department - Centre for Infections

Late HIV diagnosis and mortality in London: 2006 late diagnoses Proportion diagnosed late (%) death within a year of HIV diagnosis (late diagnosis) 50 10 40 8 30 6 20 4 10 2 0 0 Homosexual & bisexual men Black Africans/black Caribbeans HIV and STI Department - Centre for Infections Percentage dying within a year (%) death within a year of HIV diagnosis (others)

HIV prevention indicator Each PCT to reduce late diagnosis of HIV to 15% by 2010 -11 Definition: CD 4<200 Baseline: average of late diagnoses for 2004 -05 to increase numbers Baseline of 34% means a halving of late diagnoses across London Data collected analysed by the HPA for NHS London No differential targets by ethnic group/risk group HIV and STI Department - Centre for Infections

Data for London SHA to performance manage London PCTs on late HIV diagnosis (the HIV Prevention Indicator) Map of proportion diagnosed late by PCT for 2007 (CD 4 <200 cells per mm 3) HIV and STI Department - Centre for Infections

Expanding HIV testing HIV and STI Department - Centre for Infections

HIV test monitoring: New Testing guidelines 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 and STI Department - Centre for Infections

Rates of diagnosed HIV-infected adults (15+) seen for HIV-related care in the UK, by PCT of residence: 2007 Data source: SOPHID 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 15 -59 year olds 3 hospitals Medical admission units Brighton and Sussex Routine testing 15 -59 year olds Acute general medicine UA arm London Routine testing 15 -65 year olds 3 hospitals Emergency department, selected outpatients departments, acute medical unit Brighton and Hove Routine testing 15 -59 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 !!! NG RO W HIV and STI Department - Centre for Infections

Disproportionate HIV transmission from those unaware of their infection ~25% Unaware of Infection Accounting for: ~54% of New Infections ~75% Aware of Infection ~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. 2006 Jun 26; 20(10): 1447 -50. 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 CD 4 category: UK, 2006 Proportion not on ARV 11, 595 n = 5, 144 4, 983 29, 165 9, 894 2, 407 19% 18% 31% 30% 31% CD 4 cell count category Annual survey of HIV-infected persons accessing care 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 HIV and STI Department - Centre for Infections