Tag Archives: England

HIV incidence in gay men unchanged in England and Wales, despite more testing

Posted on February 11, 2013 by | Comments Off

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A paper in The Lancet Infectious Diseases by scientists from the UK’s Medical Research Council and the Health Protection Agency (HPA) has calculated that the number of gay men in England and Wales who become infected with HIV each year remained unchanged between 2001 and 2010. This is despite a considerable increase in testing and, they estimate, a 40% reduction in the proportion of gay men with HIV who are undiagnosed.

The paper concludes that, in England and Wales at least, the proportion of gay men with HIV who are on treatment and with undetectable viral loads is currently too low to bring about a decline in annual HIV incidence in this population. This is in contrast to declines in diagnosis, and claims of declines in incidence, seen in places such as San Francisco, the province of British Columbia in Canada, and some locales in South Africa.

As well as extending HIV testing to non-traditional settings and urging gay men to test more frequently, the authors conclude that “the initiation of treatment on diagnosis, regardless of CD4 count might well be necessary to achieve control of HIV transmission”, and welcome the new BHIVA treatment guidelines’recommendation “that clinicians discuss the benefits of early treatment uptake as a prophylaxis to protect sexual partners” as a step towards this.

Calculating incidence

The paper is a mathematical model. It uses available data on diagnoses, CD4 counts at diagnosis, and the proportion of people on antiretroviral therapy (ART) to make estimates of the true annual number of infections (annual incidence) in gay men, the number undiagnosed, average time gap between infection and diagnosis, the distribution of CD4 counts among diagnosed and undiagnosed men and the proportion who are on treatment and with an undetectable viral load.

Although mathematical models are always estimates, in this case surveillance data from the UK are of good enough quality to make them quite robust, though because by definition fewer very recent infections are diagnosed, incidence estimates for the last two years are less certain than for previous years.

The incidence rate is not the same as the new diagnosis rate in HIV, because of the time lag between infection and diagnosis. If the number or frequency of HIV tests go up, the number of diagnoses will tend to go up, since more long-term undiagnosed infections will be identified. The researchers got round this problem by using CD4 count at diagnosis – available for the majority of diagnosed people in England and Wales – as a surrogate for the time delay between infection and diagnosis, given that CD4 counts in people with untreated HIV tend to decline at an even rate over time.

Results – diagnosed and undiagnosed

The number of diagnoses in gay men in England and Wales increased from about 1800 in 2001 to 2600 in 2010. However by adjusting this for CD4 count at diagnosis, the researchers estimated that the true annual total of HIV infections in gay men had remained virtually unchanged, from 2200 in 2001 to about 2300 in 2010. There was an increase in incidence to about 2700 a year in 2003-4, due to increased rates of sex without condoms in gay men, but this has reduced since.

This reduction is due, the researchers say, to more gay men taking tests and to a shorter period between HIV infection and diagnosis. The number of HIV tests taken by gay men in sexual health clinics has grown nearly fourfold, from 16,000 in 2001 to 59,300 in 2010. As a result, the estimated time between infection and diagnosis has shrunk from four years to 3.2 years during this time, and the proportion of gay men with HIV who are undiagnosed from 37 to 22%.

The reason it has not shrunk more, say the authors, is due to gay men not testing often enough. Last year, study co-author Valerie Delpech of the HPA told the IAPAC Prevention Summit that only an estimated 10 to 15% of gay men took an HIV test every year, and that two-thirds of gay men who had had a test at a clinic had, two years later, not returned to that clinic for another one.

Because there are (as of 2010) 3.2 years’ worth of undiagnosed infections in the population, the total number of gay men with HIV who are undiagnosed in England and Wales was estimated as 7690 in 2010. This was only a small increase from 7370 in 2001 and represents a 16% decline from 9140 in 2004-5, again due to more testing.

The proportion of gay men with HIV who are undiagnosed has gone down by 40% while the number has scarcely changed because total HIV prevalence and the number of UK gay men living with HIV has grown over the same period.

Results – implications for treatment

In 2001, at HIV diagnosis, about 65% of gay men had a CD4 count under 500 cells/mm3, 40% under 350 cells/mm3, and 18% under 200 cells/mm3. Ten years later, the proportion in these three categories had only fallen by about 5%. This means that less than 40% of gay men would currently be advised, under treatment guidelines, to begin taking antiretroviral therapy (ART) for treatment reasons as soon as they are diagnosed.

The researchers calculated that, because more undiagnosed infections are recent ones, only 20% ofundiagnosed gay men had a CD4 count under 350 cells/mm3 and only 45% under 500 cells/mm3. Further decreasing the proportion of gay men with HIV who are undiagnosed, and raising or abolishing the CD4 threshold for treatment initiation, would therefore have considerable cost implications for the National Health Service in England and Wales.

Conclusions

In many ways, the UK’s response to HIV has been excellent. The proportion of gay men with a CD4 count under 350 cells/mm3 who are on ART has increased from 75% in 2001 to 84% in 2010; 65% of all patients in care, including the untreated, have undetectable viral loads; and annual loss to follow-up of those attending care is under 5%.

In the US, in contrast, it is estimated that there are more gay men who are diagnosed but not taking ART than there are undiagnosed, and that only 28% of people with HIV are virally suppressed. But gay men in other countries test more frequently: as an accompanying editorial by Reuben Granich of UNAIDS points out, the 22% of gay men who remain undiagnosed in the UK is not as good as an estimated 14% in Vancouver and only 6% in San Francisco.

Because most of those with detectable viral loads in the UK are undiagnosed, it is estimated by the HPA that up to 50% of HIV infections in gay men here could be being transmitted by men in primary HIV infection and another 35% by undiagnosed men with long-term infection. The authors conclude that treatment initiation at diagnosis, earlier, more targeted testing, and better primary HIV prevention all need to be part of any national HIV prevention plan for England and Wales.

References

Birrell PJ et al. HIV incidence in men who have sex with men in England and Wales 2001-2010: a nationwide population study. The Lancet Infectious Diseases, early online edition:http://dx.doi.org/10.1016/S1473-3099(12)70341-9. See abstract here. 2013.

Granich R HIV in MSM in England and Wales: back to the drawing board? The Lancet, early online edition: http://dx.doi.org/10.1016/S1473-3099(13)70035-5. See first few lines here. 2013.

Original Article by Gus Cairns at aidsmap

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The Need for A HIV Strategy

Posted on December 7, 2012 by | 1 Comment

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By the end of 2012 it is estimated that there will be 100,000 people living with
HIV in the UK.  HIV diagnoses remain stubbornly high.  The two communities most affected are gay and bisexual men and African men and women.

Approximately one in twenty gay and bisexual men and one in twenty African men and women in the UK are living with HIV. In 2010, 3,000 gay and bisexual men were newly diagnosed with HIV; this is the highest number of gay and bisexual men newly diagnosed with HIV ever reported in a single year.

In the same year, half of all people diagnosed were diagnosed late; people diagnosed late have a ten-fold increased risk of death within one year of HIV
diagnosis compared to those diagnosed promptly. And still nearly a quarter of people living with HIV in the UK are unaware of their status. This is of real
concern given that the majority of transmissions come from people who are themselves unaware that they have HIV.

Advances in treatment have seen enormous improvements in quality of life and life expectancy for people living with HIV. In 2010, 85% of people on treatment had an undetectable viral load within a year of starting medication, a marker of
successful treatment. However, this success in treatment has not been matched by improvements in social support for people living with HIV. Many still  experience stigma and discrimination, live in poverty and cannot access the psychological support they need.

Although HIV remains one of the most serious infectious diseases affecting the UK, public understanding and knowledge of HIV is poor and getting worse. Recent Ipsos MORI research commissioned by NAT revealed that only one in
three adults were able to correctly identify all the ways HIV is and is not transmitted from a list of options, with almost a fifth mentioning one incorrect
method such as spitting or sharing a glass. One in five were unaware that HIV is transmitted through sex without a condom between a man and woman.

The research also showed a link between poor knowledge about HIV and negative and judgemental attitudes towards people living with HIV. There is
clearly still a need to improve awareness among the public, both to prevent the spread of HIV – each new infection costs the UK over a quarter of a million
pounds in direct lifetime medical costs alone – and to prevent misconceptions which fuel stigma and discrimination.

Despite this situation, there is no strategy for HIV in England – the last national strategy for sexual health and HIV came to an end in 2010. Over 90% of people living with HIV in the UK live in England, and yet England is the only country within the UK not to have a strategy.

Would you like to know more? Read the National AIDS Trust HIV Strategy.

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From today, HIV treatment is free for all who need it!

Posted on October 1, 2012 by | 1 Comment

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In March of this year we shared the the news that Asylum Seekers and other non-British citizens were to be given free HIV treatment after the government indicated it was willing to accept an amendment from Lord Fowler to the health bill.

That removal of charges for undocumented migrants and non-UK citizens accessing HIV treatment and care in England comes into effect today. From now on, HIV treatment will be provided free of charge to all who need it, regardless of citizenship or immigration status.

The move was first announced in February and the relevant legislation passed in June. Health ministers have justified the change on the grounds of public health, pointing to the impact that HIV treatment has on onward transmission.

Although it was initially proposed that free HIV treatment should only be available to people who have been living in the UK for more than six months, this requirement has not been retained in the legislation.

While treatment in HIV clinics will always be free of charge, migrants living with HIV who need hospital treatment for another health condition, such as diabetes, heart disease or cancer, or who require antenatal care, may still be subject to charging regulations.

Moreover, the rules have only changed in England. In Scotland and Wales, although charges for HIV treatment have not been levied or actively pursued in recent years, the legislation still states that HIV treatment may be chargeable. In Northern Ireland, the legislation still states that HIV treatment may be chargeable, and these regulations have sometimes been rigorously enforced.

The National AIDS Trust (NAT) has called for a formal change in the law in Scotland, Wales and Northern Ireland, to ensure that free universal access to HIV treatment is guaranteed across the UK.

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Sex education: we should teach young people about more than the mechanics

Posted on May 25, 2012 by | 4 Comments

Sex education: too much emphasis on the mechanics, says Doortje Braeken, who argues for more teaching about sexuality. Photograph: David Levene (The Guardian)

Sex education polarises opinion, sets legislators against parents and parents against schools and regularly inflames media opinion. Somewhere in the middle sit young people: ill-served, receiving confused messages and gaining their information from famously unreliable sources, such as peers or the internet.

Sex education, as all too many experience it, is like teaching people how to drive by telling them in detail what’s under the bonnet, how the bits work, how to maintain them safely to avoid accidents, what the controls do and when to go on the road. It’s all about the mechanics. And that’s it.

There’s a growing consensus that young people don’t need sex education, they need comprehensive sexuality education or CSE..  CSE is sex education plus: the mechanics, plus a lots more about sexuality.

That means not just teaching young people about the biology of sex, but also teaching them about the personal, emotional, societal and cultural forces which shape the way in which they choose to conduct their lives. Armed with this understanding, young people can make far more considered decisions.

This approach has the potential to unite the warring factions that bicker over the fundamental rights and wrongs of sex education: CSE equips young people with basic biological knowledge, but at the same time it equips them to question why they act in certain ways, and whether or not it is right, valuable or desirable to do so. CSE imparts information, and promotes responsibility.

CSE contains components which allow learners to explore and discuss gender, and the diverse spectrum of gender identities that exist within and between and beyond simple heterosexuality. It also contains components that examine the dynamics of power in relationships, and individual rights.

These are not taught as theoretical concepts. They have serious practical effects on the way in which young people interact with each other, both in the sexual and the wider social and educational spheres. Studies have shown that addressing such issues can have a marked impact both in school and the expansion of young people’s social networks.

CSE also engages with what some doubtless regard as difficult territory. Sexuality – however, individually, we choose to regard it – is a critical aspect of personal identity. The pleasure that we derive from sexuality, even if that pleasure is the pleasure of feeling that a reproductive duty is being fulfilled, is a vital part of our lives: it’s what makes us human. CSE views sexuality as a positive force.

CSE exploits a variety of teaching and learning techniques that are respectful of age, experience and cultural backgrounds, and which engage young people by enabling them to personalise the information they receive.

What is most telling is that a large number of studies have reached the clear conclusion that CSE does not lead to earlier sexual initiation or an increase in sexual activity. To paraphrase, traditional sex education seems to say: “If you’re going to do it, this is how everything works and you need to protect yourself in these ways to prevent this.” CSE says all that, but it also asks young people to ponder what exactly “it” is, and to deepen their perception of its implications.

In a political environment which is quantitatively driven, we measure the success of sex education in straightforward health behaviour indicators. These are easy to manage: numbers which build on existing health surveillance and measurement systems, and which are simple to understand from an objective point of view.

However, CSE is a far more nuanced discipline, and it will be necessary to include other measures of programme success: qualitative, subjective indicators which relate to gender equity, empowerment and critical thinking skills.

While governments have recognised young people’s right to CSE via various intergovernmental resolutions and conventions, the journey from recognition to delivery will be a long one. Even in the UK, there are notable differences, with England having a bare-bones biological approach “puberty, menstruation, contraception, abortion, safer sex, HIV/Aids and STIs should be covered”, while Wales and Scotland have curriculums which incline far more towards the CSE agenda.

The International Planned Parenthood Federation, the organisation I work for, and its 153 member associations around the world, has been instrumental in pressing for the adoption of international policy commitments to CSE. For many, it may seem like we are pushing 10 steps ahead of the agenda when the basic principle of young people’s right to even the most basic introduction to the biology of sex is still not universally accepted.

Our view is different: it is that CSE is what will secure widespread acceptance of sex education, because it is about more than the mechanics of sex. It is about helping young people, the world over, to become more healthy, more informed, more respectful and more active participants in the life of their community and their nation.

Doortje Braeken is the IPPF’s senior adviser on adolescents and young people, responsible for co-ordinating programmes in 26 countries implementing a rights-based approach to youth friendly services and comprehensive sexuality education. She will be among the panellists for a live discussion on sex and sexuality education, taking place on the SocietyGuardian site from noon to 2pm on Thursday 31 May

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New partnership for HIV Prevention in England launched

Posted on May 4, 2012 by | 1 Comment

A new partnership for HIV prevention in England is launched today.  The TRUST Partnership is a collaboration between established players in the HIV sector and beyond to develop a new and inclusive vision for targeted HIV prevention in England.

TRUST is led by METRO, African Health Policy Network (AHPN), PACE, Birmingham LGBT, Sheffield Centre for HIV and Sexual Health and Leicestershire AIDS Support Service (LASS). These specialist organisations are joined by a range of clinical, commercial, academic and policy experts including the School of Medicine and Health and the Centre for Gender, Sex and Sexualities at Durham University, and Lateral Group.

With rates of HIV infection remaining high, the key aims of the Partnership are to reduce late and undiagnosed HIV and to prevent new infections.  In working towards those aims, the partnership is also looking at the general health and well being of those communities most affected by HIV – men who have sex with men (MSM) and African people.

The Partnership is founded on a model of transparency and inclusion that welcomes all organisations engaged in HIV Prevention work. TRUST’s vision is for an ‘open door’ approach based on community engagement to allow for focused, inclusive and collaborative HIV prevention work. This vision was developed through extensive consultation with the groups most affected by HIV.  Seven principles have been developed that all TRUST partners subscribe to.  TRUST will continue to engage with HIV prevention providers and wider stakeholders to develop new collaborations.

TRUST has submitted a response to the Department of Health’s tendering for a National Programme of Targeted HIV Prevention for a new programme, which will combine the current CHAPS and NAHIP programmes for MSM and African populations. TRUST is proposing a significant improvement to current service delivery and a significant number of existing CHAPS and NAHIP partners have signed up to the TRUST vision for change.

Dr Greg Ussher, Metro Deputy CEO said:

We know that HIV infection levels are high and that current prevention approaches are not as effective as they could be.  In the TRUST Partnership we believe that collaboration to harness the wealth of experience, knowledge and expertise of affected communities and the sector is the only way forward. United with people whose lives are affected by HIV, we can really make a difference.  Our vision and model of working together and welcoming all is the best defence in the fight against HIV and the best use of limited public sector resources.

Francis Kaikumba, AHPN CEO said:

TRUST aims to build on the successful work of engaging with community groups, faith  leaders and organisations to ensure that local activity is scaled up to improve quality and innovation in HIV prevention in England. TRUST partners look forward to working together in the future on other bids and to the TRUST approach becoming the standard of cooperative and innovative , multi-sector approaches to HIV prevention in the UK and beyond .It is through such a multidisciplinary and sector wide approach that we can truly address the complex issue of HIV prevention in England and deliver a really world class programme.

Denis Onyango, Acting CEO of Africa Advocacy Foundation (AAF) and Trustee of the African Health Forum said:

Africa Advocacy Foundation and the African Health Forum welcome the opportunity to join with the TRUST Partnership and to contribute to the development of its vision. Collaborative working has been the cornerstone of successful HIV prevention with African communities for the past decade and we are committed to seeking new and innovative ways to share learning and continuously improve services. Any national programme must be directly engaged with the people and communities it seeks to support. The TRUST Partnership represents a strong, coherent model for both national and regional HIV prevention in the future that is grounded in the reality of people’s lives.

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