hiv and sti department - centre for infections reducing the burden of undiagnosed hiv infection dr...

HIV and STI Department - Centre for Infections

Reducing the burden of undiagnosed HIV infection

Dr Valerie DelpechHIV & STI DepartmentCentre for InfectionsHPA


Outline

New DiagnosesOverall trends in UK and International

HIV IncidenceUASTARHS

Testing Impact on transmission


Trends in new diagnoses


Summary of new HIV diagnoses trends in Northern Europe

New HIV diagnosesStabilising overall

ButOngoing 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


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.


New HIV diagnoses by prevention group, UK: 1999-2008

0

1000

2000

3000

4000

5000

6000

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

Year of first HIV diagnosis in the UK

Num

bers

of new

HIV

dia

gnose

s

MSM (adjusted)

MSM (observed)

Heterosexuals (adjusted)

Heterosexuals (observed)

IDU (adjusted)

IDU (observed)

Proportional adjustment for missing information; 2008 also adjusted for reporting delay


Factors Driving New HIV Diagnoses

New HIVDiagnoses

Changes in Population size

Testing

Improved reporting / methodological change

Migrationand travel

Transmission(incidence)


HIV Incidence


Detecting Recent Infections

STA

HR

S

erological

esting

lgorithms

ecent

IV

eroconversion

All dependent firstly on a highly sensitive method to detect anti-HIV AbSecondly, a method in which the signal takes considerably longer to exceed a threshold beyond which it is a long-standing infection


HIV Incidence in MSM attending 16 UAPMP STI clinics: BY REGION

HIV Incidence in MSM attending 16 UAPMP STI clinics: BY REGION

0%

1%

2%

3%

4%

5%

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Pre

va

len

ce

of

pre

vio

us

ly u

nd

iag

no

se

d in

fec

tio

n a

nd

inc

ide

nc

e Annual HIV incidence - London HIV incidence - Outside London

1Previously undiagnosed HIV infection includes those diagnosed at the clinic attendance and those remaining undiagnosed but excludes those diagnosed earlier.2 Estimated using the Serological Testing Algorithm for Recent HIV Seroconversion (STARHS)3 Trends not significantUnlinked anonymous surveillance in 16 sentinel GUM clinics


Non IncidentNon Incident

Incident infectionIncident infection

0

10

20

30

40

50

60

70

80

90

100

Number

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Year

28% 15%

34% 19%

35%40%

50%

42%55%

51%

Incident infections on first diagnosis among MSM in Brighton


HIV testing

EuroHIV* Or latest year: † 2002; ‡ 2003; § 2004

†

‡

‡

‡

‡

§

§ §

§ §

§

§

HIV tests per 1,00050 +25 - 4910 - 24 < 10Not available

HIV tests performed per thousand population,

WHO European Region, 2005


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).


Estimated proportion of HIV-infected pregnant women diagnosed before delivery1 and of exposed

infants becoming infected with HIV2, England & Scotland

1 Includes previously diagnosed and those diagnosed through antenatal testing2 Assumes vertical transmission rate of 26.5% in undiagnosed women and 2.2% in diagnosed women3 These data contain reports received by the end of June 2008, data for recent years is subject to reporting delay

Unlinked anonymous prevalence monitoringNational Study of HIV in Pregnancy and Childhood, ICH

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Pro

po

rtio

n o

f ex

po

sed

in

fan

ts w

ho

bec

om

e in

fect

ed

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Pro

po

rtio

n o

f H

IV-i

nfe

cted

wo

men

wh

o a

re d

iag

no

sed

bef

ore

del

iver

y

Estimated proportion of infants exposed who become infected with HIV

HIV infected pregnant women diagnosed before delivery

Antenatal HIV screening introduced

3


Sexual health screens and HIV tests at GUM clinics, E, W & NI

STI data from genitourinary medicine clinics

0

100,000

200,000

300,000

400,000

500,000

600,000

700,000

2004 2005 2006 2007 2004 2005 2006 2007 2004 2005 2006 2007

Num

ber

of c

ases

STI screen with HIV test

HIV test - no STI screen

STI screen with HIV test

Women Heterosexual men

MSM


Median CD4 count at diagnosis by prevention group, UK: 1998-2007

0

50

100

150

200

250

300

350

400

450

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Year seen for HIV related care

Med

ian

CD

4 C

oun

t (c

ells

/mm

3)

MSM Heterosexual Men Pregnant Women

Non-pregnant women Injecting Drug Use All Women


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

0%

10%

20%

30%

40%

50%

60%

70%

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Pro

port

ion

of a

tten

dees

rem

ainin

g un

dia

gnose

d

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Pro

port

ion

of a

tten

dees

hav

ing

an H

IV tes

t

HIV positive heterosexuals attending GUM remaining undiagnosed

Proportion of all heterosexuals attending GUM receiving an HIV test


The proportion of MSM attending sentinel GUM clinics receiving an HIV test and the fraction of HIV-infected MSM remaining undiagnosed, UK


0%

10%

20%

30%

40%

50%

60%

70%

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Pro

port

ion

of a

tten

dees

rem

ainin

g un

dia

gnose

d

0%

10%

20%

30%

40%

50%

60%

70%

80%

Pro

port

ion

of a

tten

dees

hav

ing

an H

IV tes

t

Proportion of HIV positive MSM attending GUM remaining undiagnosed

Proportion of all MSM receiving HIV test


Undiagnosed Infection& late diagnosis


Estimated number of adults (15 to 59 years) living with HIV (both diagnosed and

undiagnosed) in the UK: 2007

0

5,000

10,000

15,000

20,000

25,000

MSM Heterosexualmen born in

Africa

Heterosexualwomen born in

Africa

Heterosexualmen bornelsewhere

including UK

Heterosexualwomen bornelsewhere

including UK

IDU men IDU women

Es

tim

ate

d n

um

be

r o

f p

ers

on

s li

vin

g w

ith

HIV

Diagnosed Undiagnosed

550

13,250

Total 73,300(68,800 – 78,500)

22,950

2,650

6,300

3,6503,750 2,850 4,600 2,850

1,200

450 150

7,850

MPES


Prevalence of previously undiagnosed HIV infection, UK: 2007


0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

4.0%

4.5%

London Elsewhere in UK UK overall

Pre

va

len

ce

MSM

Heterosexuals - sub-Saharan African-born

Heterosexuals - UK-born

Heterosexuals - born elsewhere


* Estimates of median time from infection to each CD4 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/annualreport2003/notime.htm

Estimated time between infection and diagnosis: people diagnosed in London in 2006

0%

10%

20%

30%

40%

50%

Men who have sexwith men

White Heterosexuals Black AfricanHeterosexuals

8.5 years

6.2 years

4.2 years

2 years


Late HIV diagnosis and mortality in London: 2006

0

10

20

30

40

50

Homosexual & bisexual men Black Africans/black Caribbeans

Pro

po

rtio

n d

iag

no

sed

late

(%

)

0

2

4

6

8

10

Pe

rcen

tag

e d

yin

g w

ith

in a

yea

r (%

)

late diagnoses

death within a year of HIV diagnosis (others)

death within a year of HIV diagnosis (late diagnosis)


HIV prevention indicator

Each PCT to reduce late diagnosis of HIV to 15% by 2010-11

Definition: CD4<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 and analysed by the HPA for NHS London

No differential targets by ethnic group/risk group


Map of proportion diagnosed late by PCT for 2007 (CD4 <200 cells per mm3)

Data for London SHA to performance manage London PCTs on late HIV diagnosis (the HIV

Prevention Indicator)


Expanding HIV testing


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 test monitoring: New Testing guidelines


Data source: SOPHID

Rates of diagnosed HIV-infected adults (15+) seen for HIV-related care in the

UK, by PCT of residence: 2007

London


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)

EvaluationFeasibilityAcceptabilityCost effectivenessEfficacy


Funded Projects

Leicester Routine testing 15-59 year olds3 hospitalsMedical admission units

Brighton and SussexRoutine testing 15-59 year oldsAcute general medicineUA arm

LondonRoutine testing 15-65 year olds3 hospitalsEmergency department, selected outpatients departments, acute medical unit

Brighton and HoveRoutine testing 15-59New GP registrations


Projects cont.

London (Lewisham)Comparison of 2 modelsHIV testing in GP practices

SheffieldPiloting home samplingIncludes 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 communitiesPeer-led and nurse lead initiatives for MSM testing


Preventing Onward Transmission


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

WRONG!!!

WRONG!!!


Disproportionate HIV transmission from those unaware

of their infection

~25% Unaware

of Infection

~75% Aware of Infection

Accounting for: ~54% of New

Infections

~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.


Treatment as prevention

EvidenceSerodiscordant studies (on ART & not)Models (CA: need to increase persons on ART up to 75%)

ConcernsEthics and feasibility Treatment accessART resistanceAdverse events (bio & behavioural)Undiagnosed or ‘false negatives’ still drive the epidemic

BUT in line with Clinical guidelines


0%

5%

10%

15%

20%

25%

30%

35%

<200 200-350 >350

other Black African

Proportion of HIV-infected persons not on ARV by CD4 category: UK, 2006

CD4 cell count category

31%19% 31%Pro

port

ion

not

on

AR

V

Annual survey of HIV-infected persons accessing care

n = 5,144 2,407

18% 30% 31%

11,595 4,983

29,165 9,894


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


Thank you

Surveillance – Needs to guide and monitor prevention efforts

hiv and sti department - centre for infections reducing the burden of undiagnosed hiv infection dr...

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