Annual epidemiological spotlight on HIV in the South East: 2021 data

Q: Further information

Please access the online Sexual and Reproductive Health Profiles for further information on a whole range of sexual health indicators. For more information on local sexual health data sources, access the guide at Sexual and reproductive health in England: local and national data . Annual epidemiological spotlight on STIs in South East: 2021 data . National HIV report: 2021 data . Local authorities have access to additional HIV and STI intelligence via the Data Exchange and the HIV and STI web portal. They should also have received a set of tables containing HIV data specific to their authority. They should contact fes.seal@ukhsa.gov.uk if they do not have access to this information.

Q: About the Field Service

The Field Service was established in 2018 as a national service comprising geographically dispersed multi-disciplinary teams integrating expertise in Field Epidemiology, Real-time Syndromic Surveillance and Public Health Microbiology to strengthen the surveillance, intelligence and response functions of UKHSA. You can contact your local Field Service team at fes.seal@ukhsa.gov.uk If you have any comments or feedback regarding this report or the Field Service, contact josh.forde@ukhsa.gov.uk

Q: Acknowledgements

We would like to thank: local sexual health and HIV clinics for supplying the HIV data the Institute of Child Health the UKHSA Centre for Infectious Disease Surveillance and Control (CIDSC) HIV and STI surveillance teams for collection, analysis and distribution of data

Q: References

1. Lester J, Martin V, Shah A, Chau C, Mackay N, Newbigging-Lister A and others. HIV testing, PrEP , new HIV diagnoses, and care outcomes for people accessing HIV services: 2022 report The annual official statistics data release (data to end of December 2021) 2022: viewed 29 June 2023 2. Department of Health and Social Care UK. Towards Zero – An action plan towards ending HIV transmission, AIDS and HIV -related deaths in England, 2022 to 2025 UK Government White Paper 2022 3. Martin V, Lester J, Adamson L, Shah A, Mackay N, Chau C and others. HIV Action Plan Monitoring and Evaluation Framework: Report summarising progress from 2019 to 2021 2022: viewed 29 June 2023 4. Sumray K, Lloyd KC, Estcourt CS, Burns F, Gibbs J. ‘Access to, usage and clinic outcomes of, online postal sexually transmitted infection services: a scoping review’ Sexually Transmitted Infections 2022: volume 98, issue 7, pages 528-35

Question 1

Summary

Accepted Answer

This report aims to provide intelligence about HIV in the South East of England. Please access UKHSA’s national HIV report (1) for a broader context.

New diagnoses

In 2021, an estimated 370 South East residents were newly diagnosed with HIV. This represents a rise of 16% from 2020 (318). However, the number diagnosed in 2021 was far fewer than the 625 diagnosed in 2012 (41% fall). Nationally, there has been a similar long-term trend for a decline in the overall number of new diagnoses and a slight upturn in 2021.

South East residents accounted for 14% of new diagnoses in England and the new diagnosis rate for South East residents (4 per 100,000) was below that of England in 2021 (5 per 100,000).

In the South East in 2021, 25% (94 out of 370) of new diagnoses were in individuals previously diagnosed abroad. These diagnoses are unlikely to reflect HIV transmission in the UK and so would not be preventable by public health measures taken in the UK.

Gay, bisexual and other men who have sex with men (GBMSM) experience health inequalities related to HIV. In 2021, 44% of all new diagnoses in South East residents were in GBMSM (compared to 47% in 2020 and 51% in 2012). The number of GBMSM resident in the South East newly diagnosed with HIV in 2021 (163, adjusted for missing information) was a 10% increase from 2020 but was 49% lower than in 2012. Of the GBMSM newly diagnosed with HIV in 2021, 75% were white and 50% were UK-born.

Heterosexual contact was the largest infection route for new diagnoses in South East residents in 2021 (47%). Diagnoses in those born in Africa accounted for 45% of all heterosexually acquired cases in 2021 (n=65), compared to 50% (n=133) in 2012. Although there was a 16% increase in heterosexually acquired diagnoses from 2020 to 2021, the number diagnosed in 2021 was much lower than in 2012 (38% lower). Infections in those born in the UK accounted for 35% of all heterosexually acquired cases in 2021.

Black African people also experience health inequalities related to HIV and represented 22% of all newly diagnosed South East residents in 2021 (compared to 23% in 2020 and 26% in 2012). The numbers diagnosed in 2021 were 56% fewer than in 2012. A small proportion of new diagnoses in 2021 were in black Caribbean residents (2%).

The number of new diagnoses was highest in the 25 to 34 year age group in males and the 35 to 44 year age group in females in 2021.

People who inject drugs accounted for 6% of new HIV diagnoses in South East residents (n=19, of whom 18 were male).

Late diagnoses

People who are diagnosed late with HIV have much higher mortality. A large proportion of South East residents with HIV who were first diagnosed in the UK were diagnosed late (48% from 2019 to 2021 (n=327), higher than the 43% in England as a whole), as defined by a CD4 count of less than 350 cells/mm at diagnosis.

In the South East, heterosexual residents were more likely to be diagnosed late (63% of males, 54% of females) than GBMSM (36%). By ethnic group, black African residents were more likely to be diagnosed late than the white population (53% and 45% respectively).

Compared to the 2015 to 2017 period, the proportion of those newly diagnosed between 2019 and 2021 who were diagnosed late has significantly increased overall (from 38.1% to 47.9%), and among GBMSM (from 24.5% to 35.6%).

People living with diagnosed HIV

The 11,085 people living with diagnosed HIV in the South East in 2021 was 1% higher than 2020 and 30% higher than 2012. This increase is partly due to the effectiveness of HIV treatment which has reduced the number of deaths from HIV.

The diagnosed prevalence rate of HIV in the South East in 2021 was 1.8 per 1,000 residents aged 15 to 59 years, slightly lower than the 2.3 per 1,000 observed in England as a whole. Five upper-tier local authorities (UTLAs) in the South East had a diagnosed HIV prevalence rate greater than 2 per 1,000 population aged 15 to 59 years in 2021, which is the threshold for expanded HIV testing. These were all in more urban areas:

Brighton and Hove (6.97)
Slough (3.38)
Reading (2.65)
Southampton (2.48)
Portsmouth (2.28)

The 2 most common probable routes of transmission for South East residents living with diagnosed HIV in 2021 were sex between men (51%) and sex between men and women (45%).

Those living with diagnosed HIV are an ageing cohort. In 2021, over half of people living with diagnosed HIV (51%) were aged 50 years and over, which is a much higher proportion than seen in 2012 (28%). Males represented 70% of South East residents living with diagnosed HIV in 2021 and females represented 30%.

In 2021, 63% of South East residents living with diagnosed HIV were white and 24% were black African. However, due to the relative sizes of the white and black African populations, the rate per 1,000 population aged 15 to 59 years was much higher in black African residents (21 per 1,000) than in the white population (1 per 1,000).

Continuum of HIV care

In 2021 in England, excluding London, 99% of HIV diagnosed residents were receiving anti-retroviral treatment (1). Of these, 99% were virally suppressed (viral load <200/ml) and were very unlikely to pass on HIV, even if having sex without condoms (untransmittable virus).

For South East residents diagnosed in 2021, the proportion starting treatment within 91 days of diagnosis for the period 2019 to 2021 was 85%. This compares to 84% for England.

People living with undiagnosed HIV

In 2021, it is estimated that 5% (Credible Interval (CrI) 4% to 7%) of people living with HIV in England, excluding London, were undiagnosed. This equates to an estimated 3,039 (CrI 2,305 to 4,410) undiagnosed people (3).

It is estimated that 1,000 GBMSM in England, outside London, were undiagnosed (CrI 500 to 1,900) and 1,900 heterosexuals (CrI 1,400 to 3,000), including 800 black African residents. In England, outside London, the proportion undiagnosed varied by exposure group with the highest proportion undiagnosed among:

people living with HIV who inject drugs (8%, CrI 1% to 27%)
non black African heterosexual women (8%, Crl 6% to 12%)
non black African heterosexual men (7%, Crl 4% to 20%)

HIV testing

The 145,987 people in the South East tested for HIV in 2021 at sexual health services (SHSs) represented a 7% increase from 2020. However, this followed a 29% fall in testing between 2019 and 2020, and the number tested in 2021 remained 24% lower than in 2019.

While there was a recovery in overall testing between 2020 and 2021, this was not seen equally across different demographic groups, with testing increasing most in GBMSM (17% increase) while testing in heterosexual men declined by 4%.

Testing in GBMSM in 2021 exceeded that seen in 2019 (7% increase). However, testing among heterosexual and bisexual women who have sex with women in 2021 remained 25% lower than in 2019, and testing among heterosexual men was 44% lower.

The HIV testing coverage at specialist SHSs in the South East was 44%, lower than the 46% coverage across England. HIV testing coverage in specialist SHSs in the South East was higher in men (62%) than women (36%), and highest in GBMSM (73%).

Some HIV tests are performed in settings other than at SHSs. These include tests done through online consultations. It is not currently possible to include these in the HIV testing coverage measure. There are 2 reasons for this. Firstly, online and other non-specialist SHSs are not mandated by the British Association of Sexual Health and HIV (BASHH) to offer an HIV test to everyone. Secondly, they may not code and report the outcome of an HIV test in their GUMCAD STI Surveillance System (GUMCAD) submissions.

Most people who had an HIV test in the South East in 2021 accessed their test through online testing (60%, compared to 3% in 2017). The number of people tested via the internet increased by 17% from 2020 and has risen nearly 16-fold since 2017.

Pre-exposure prophylaxis (PrEP)

HIV PrEP is the use of antiretroviral agents by people who do not have HIV prior to a potential exposure to HIV to prevent acquisition of infection.

In 2021, 6% of HIV-negative South East residents accessing specialist SHSs in England (9,856 of 155,887 HIV negative attendees) were defined as having a PrEP need, among whom 65% initiated or continued PrEP. Of those with a PrEP need, 77% had this need identified at a clinical consultation. Among GBMSM, the group with greatest need, these proportions were 62%, 68% and 79%.

Public health implications

The 2021 data demonstrates that significant health inequalities relating to HIV remain in the South East, with GBMSM and black African people disproportionately affected. Interpreting the increase in new HIV diagnoses from 2020 to 2021 is challenging as it was accompanied by an increase in HIV testing in 2021, after a marked drop in testing in 2020 during the COVID-19 pandemic. Therefore, the rise may reflect better ascertainment. However, it is an important reminder of the importance of strengthening combination prevention, including condom use, expanded HIV testing, prompt antiretroviral therapy and the availability of PrEP and post-exposure prophylaxis (PEP).

HIV Action Plan

The 2022 to 2025 HIV Action Plan, jointly developed by the Office for Health Improvement and Disparities (OHID) and UK Health Security Agency (UKHSA), aims to reduce HIV transmission by 80%, and HIV-related and preventable deaths and AIDS by 50% between 2019 and 2025. This will be achieved by:

ensuring equitable access and uptake of HIV prevention programmes
scaling up HIV testing in line with national guidelines
optimising rapid access to treatment and retention in care
improving the quality of life for people living with HIV and addressing stigma

While there has been considerable progress towards ending HIV transmission in the UK, the interim ambitions of the HIV Action Plan were adversely impacted by COVID-19. To ensure the goals are reached, several prevention areas need to be prioritised which include:

PrEP access for all
scaling up of partner notification
increasing HIV testing among heterosexual men and women
improving retention to care
monitoring inequalities in all aspects of HIV prevention

The further ambition to achieve zero new HIV infections, AIDS and HIV-related deaths in England by 2030 will require significant improvement in diagnoses for heterosexual residents and black African residents.

Consistent use of PrEP can be an efficacious and effective intervention to prevent HIV acquisition. Despite PrEP being routinely available through specialist SHS, awareness, accessibility and uptake of primary prevention initiatives is variable for different population groups. Addressing this disparity is vital for HIV prevention.

HIV testing, including online testing, is freely available in the UK and remains pivotal for reducing HIV transmission. It decreases the number of people living with HIV who are unaware of their infection and is also critical in reducing late diagnosis. Late diagnosis is the most significant predictor of premature mortality among people with HIV infection (2), with those first diagnosed late in the UK 11 times more likely to die within a year of their diagnosis, compared to those who were diagnosed promptly (1).

Heterosexual residents in the South East were more likely to be diagnosed late (especially black African residents). They also had a lower HIV testing uptake and national data suggests that internet testing is disproportionately accessed by GBMSM (4). The unequal increases in HIV testing uptake across different groups means that opportunities for prevention interventions (including PrEP) may have been missed, Therefore, efforts need to be taken to redress this inequity, accompanied by increased access to testing in other settings (2), such as opt-out testing in emergency departments in areas of high prevalence, and full implementation of HIV testing among people presenting with indicator conditions. Partner notification following diagnosis also remains a highly effective way to detect undiagnosed HIV.

Symptoms due to HIV and AIDS may not appear for many years, and people who are unaware of their infection may not feel themselves to be at risk. Prevention messages should reinforce that anyone can acquire HIV regardless of age, gender, ethnicity, sexuality or religion, and it is essential to challenge assumptions about who is at risk of HIV. As well as increasing awareness of HIV, efforts to reduce stigma and other socio-cultural barriers that prevent people from testing and seeking long-term care should be strengthened.

Free and effective antiretroviral therapy (ART) has transformed HIV from a fatal infection into a chronic, manageable condition. People living with HIV in the UK can now expect to live into old age if diagnosed promptly. It is now widely understood that effective HIV treatment results in an ‘undetectable’ viral load which protects individuals living with HIV from passing on the virus to others. The vital message is that Undetectable = Untransmittable (U=U). People with HIV who maintain an undetectable viral load for at least 6 months do not transmit HIV.

HIV treatment and care provision continued to have high coverage and effectiveness in 2021, with high proportions of those diagnosed with viral suppression. However, national data indicates that people exposed by vertical transmission and injecting drug use continue to display significantly lower levels of viral suppression (1). These points highlight the need for interventions to maintain and re-engage people in care, thereby increasing the number of people on treatment with undetectable levels of virus to reduce the potential for onwards transmission. As the population of people living with diagnosed HIV is growing older, it is important that HIV and other services continue to evolve to meet the needs of older people living with HIV including the management of comorbidities and other complex health conditions.

As rates of other infections transmitted sexually such as gonorrhoea, syphilis, lymphogranuloma venereum, hepatitis C and Shigella have been shown to be higher in GBMSM who are HIV positive, it is important that GBMSM living with HIV are specifically made aware of the risks of these infections and how to prevent them.

Question 2

Charts, tables and maps

Accepted Answer

Figure 1. New HIV diagnoses per 100,000 population (all ages) by UKHSA region of residence, 2021

Source: UKHSA, HIV & AIDS New Diagnoses and Deaths (HANDD). The number of new diagnoses will depend on accessibility of testing as well as infection and transmission.

Figure 1 is a bar chart showing that the rate of new HIV diagnoses per 100,000 in the South East (4.1/100,000) was the fourth lowest regional rate. The rate in London (9.8/100,000) was more than double of the other UKHSA regions.

Figure 2. New HIV diagnoses per 100,000 population (all ages) by upper tier local authority of residence, South East residents, 2021

Source: UKHSA, HIV & AIDS New Diagnoses and Deaths (HANDD). The number of new diagnoses will depend on accessibility of testing as well as infection and transmission.

Figure 2 is a bar chart showing the rate of new HIV diagnoses per 100,000 population in South East residents by upper-tier local authority (UTLA) of residence in 2021. Seven of the local authorities had a rate higher than the regional rate (4.1/100,000). The rates in local authorities ranged from 17 per 100,000 in Slough to 0.6 per 100,000 in West Berkshire.

Figure 3. New HIV diagnoses and deaths, the South East, 2012 to 2021

The number of new diagnoses will depend on accessibility of testing as well as infection and transmission. Numbers may rise as we receive more reports and more information. This will impact on interpretation of trends in more recent years. New HIV diagnoses are shown by UK region of residence at diagnosis. Deaths are also shown by UK region of residence at diagnosis which in some instances may not be the same as UK region of death. Deaths in people living with HIV may not be related to HIV in all cases, and this is likely to become increasingly true as people accessing treatment reach older ages. Charts in previous years’ reports showed deaths by region of death, rather than region of residence at diagnosis, and so the trend for deaths cannot be compared directly with that seen in earlier reports. Region of residence at diagnosis has been used for deaths due to better data quality in more recent years.

Figure 3 shows the number of new HIV diagnoses and deaths in people with HIV in the South East from 2012 to 2021. In 2021, an estimated 370 South East residents were newly diagnosed with HIV. This represents a rise of 16% from 2020 (318). However, the number diagnosed in 2021 was far fewer than the 625 diagnosed in 2012 (41% fall). The number of deaths declined over the 10 years. The chart shows 3 deaths in 2021. However, an extended reporting delay may be seen for deaths as these are not always notified directly to the HIV surveillance system. In addition, region of death may not be established immediately. Therefore, this number could increase.

Figure 4. New HIV diagnoses by probable route of infection (adjusted for missing route of infection information), South East residents, 2012 to 2021 [note 1]

Source: UKHSA, HIV & AIDS New Diagnoses and Deaths (HANDD)

Asterisk: NPDA = Not previously diagnosed abroad. The number of new diagnoses will depend on accessibility of testing as well as infection and transmission.

[note 1] Numbers may rise as further reports are received and more information is obtained on area of residence of those diagnosed. This is more likely to affect more recent year, particularly 2021.

Figure 4 shows the trend of new HIV diagnoses by probable route of infection in South East residents from 2012 to 2021. Between 2020 and 2021, the number of new diagnoses among heterosexual residents rose by 16% (150 to 174) and among GBMSM the number rose by 10% (148 to 163). The dashed lines show the number of new HIV diagnoses for those not previously diagnosed abroad (NPDA).

Figure 5a. Number of new HIV diagnoses by age group and gender, South East residents, 2021

Source: UKHSA, HIV & AIDS New Diagnoses and Deaths (HANDD). The number of new diagnoses will depend on accessibility of testing as well as infection and transmission.

Figure 5a is a bar chart showing the number of new HIV diagnoses by age group and gender in 2021. Among males, the highest number of new HIV diagnoses was among males in the 25 to 34 year (102) and 35 to 44 year group (69), and among females, the 35 to 44 year group (40).

Figure 5b. Number of new HIV diagnoses by age group and probable route of infection, male South East residents aged 15 to 64 years, 2021

Source: UKHSA, HIV & AIDS New Diagnoses and Deaths (HANDD). The number of new diagnoses will depend on accessibility of testing as well as infection and transmission.

Figure 5b is a bar chart showing the number of new HIV diagnoses, among male residents, by age group and probable route of infection in 2021. This figure excludes males without a known exposure. The number of new HIV diagnoses was highest among GBMSM in the 25 to 34 year (74) and 35 to 44 year groups (39).

Figure 6. Number of new HIV diagnoses by ethnic group (adjusted for missing ethnic group information), South East residents, 2012 to 2021 [note 2]

Source: UKHSA, HIV & AIDS New Diagnoses and Deaths (HANDD)

Asterisk: NPDA = Not previously diagnosed abroad.

The number of new diagnoses will depend on accessibility of testing as well as infection and transmission.

[note 2] Numbers may rise as further reports are received and more information is obtained on area of residence of those diagnosed. This is more likely to affect more recent year, particularly 2021.

Figure 6 shows the number of new HIV diagnoses by ethnic group in South East residents from 2012 to 2021. It shows a fall, over the 10 years, in the number of new HIV diagnoses among both the white (49%; 402 in 2012 to 204 in 2021) and black African ethnic groups (50%; 162 in 2012 to 81 in 2021). There was an increase in the number of new HIV diagnoses by ethnic group between 2020 and 2021 among both white (15%) and black African ethnic groups (11%).

Figure 7. Number of new HIV diagnoses by world region of birth (adjusted for missing world region of birth information), South East residents, 2012 to 2021 [note3]

Source: UKHSA, HIV & AIDS New Diagnoses and Deaths (HANDD)

Asterisk: NPDA = Not previously diagnosed abroad.
The number of new diagnoses will depend on accessibility of testing as well as infection and transmission.

[note 3] Numbers may rise as further reports are received and more information is obtained on area of residence of those diagnosed. This is more likely to affect more recent year, particularly 2021.

Figure 7 shows the number of new HIV diagnoses by world region of birth from 2012 to 2021. It shows that year-on-year the number of new HIV diagnoses were highest in those born in the UK. Between 2020 and 2021 there was an increase in the number of new HIV diagnoses among UK-born (29%) and those born in Africa (16%).

Figure 8. Percentage of new HIV diagnoses by UTLA of residence that were diagnosed late, South East, aged 15 years and over, 2019 to 2021 [note 4]

Source: UKHSA, HIV and AIDS New Diagnosis Database/System, HIV & AIDS Reporting System (HARS)

[note 4] Only includes new diagnoses in those aged 15 years and over with no prior diagnosis abroad and for which a CD4 count was reported within 91 days of diagnosis; late diagnosis defined as CD4 count <350 cells/mm3.

The underlying population will impact on the proportion diagnosed late, for example GBMSM are less likely to be diagnosed late.

Figure 8 is a bar chart showing the percentage of new HIV diagnoses that were diagnosed late in South East residents by UTLA. The percentage of those diagnosed late was highest in Reading (78%) and lowest in the Isle of Wight (25%). The regional average was 47.9%.

Figure 9a. Percentage of new HIV diagnoses by probable route of infection that were diagnosed late, South East residents, aged 15 years and over, 2019 to 2021 [note 5]

Source: UKHSA, HIV and AIDS New Diagnosis Database/System, HIV & AIDS Reporting System (HARS)

[note 5] Only includes new diagnoses in those aged 15 years or older with no prior diagnosis abroad and for which a CD4 count was reported within 91 days of diagnosis; late diagnosis defined as CD4 count <350 cells/mm3. Proportions are only shown for the sex between men, heterosexual contact (males), heterosexual contact (females) and injecting drug use exposure groups and are withheld for any of these categories if they contain fewer than 5 late diagnoses.

Figure 9a shows the percentage of new HIV diagnoses by probable route of infection that were diagnosed late in the South East (2019 to 2021). The percentage diagnosed late was highest among males that had heterosexual contact (63%) and lowest among GBMSM (36%).

Figure 9b. Percentage of new HIV diagnoses by ethnic group that were diagnosed late, South East residents, aged 15 years and over, 2019 to 2021 [note 6]

Source: UKHSA, HIV and AIDS New Diagnosis Database/System, HIV & AIDS Reporting System (HARS)

Note that were no patients in the black Caribbean ethnic group who were diagnosed late, however, there are small numbers newly diagnosed in this group.

[note 6] Only includes new diagnoses in those aged 15 years and over with no prior diagnosis abroad and for which a CD4 count was reported within 91 days of diagnosis – late diagnosis defined as CD4 count <350 cells/mm3. Proportions are only shown for the white, black African and black Caribbean ethnic groups and are withheld for any of these ethnic group categories if they contain fewer than 5 late diagnoses.

Figure 9b shows the percentage of new HIV diagnoses by ethnic group that were diagnosed late in South East residents (2019 to 2021). It shows that 53% of black African residents were diagnosed late and 45% of the white ethnic group were diagnosed late.

Figure 10. Percentage of new HIV diagnoses that were diagnosed late by probable route of infection and year of first UK HIV diagnosis, South East residents, aged 15 years and over, 2012 to 2021 [note 7]

Source: UKHSA, HIV and AIDS New Diagnosis Database/System, HIV & AIDS Reporting System (HARS)

[note 7] Only includes new diagnoses in those aged 15 years and over with no prior diagnosis abroad and for which a CD4 count was reported within 91 days of diagnosis – late diagnosis defined as CD4 count <350 cells/mm3.

Figure 10 shows the percentage of new HIV diagnosis that were diagnosed late by probable route of infection increased among GBMSM from 29% in 2020 to 42% in 2021. Whereas among heterosexual residents the percentage of new HIV diagnoses that were diagnosed late increased to 60% in 2017 and has only recently fallen to 51% in 2021.