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Volume 6 No 16; 20 April 2012

New HIV and AIDS diagnoses and deaths in the United Kingdom in 2011

New data - based on surveillance reports received as at end-December 2011 - indicate that a total of 5,600 people (4,050 men and 1,550 women) were diagnosed with HIV in the United Kingdom in 2011 [1]. This provisional figure is likely to rise to 6,150 after adjustment for reporting delays (see table). The 2011 total is a slight decrease on 2010 and continues the year-on-year decline from the peak of 7,820 diagnoses reported in 2005.

For the first time since 1998, the number of new HIV diagnoses in men who have sex with men (MSM) has surpassed new diagnoses in heterosexuals. Half of those diagnosed in 2011 (48%, 3,000) probably acquired their infection through sex between men and 47% (2,890) through heterosexual contact (data adjusted for undetermined risk) (see figure). The overall decline in new diagnoses is largely due to fewer reported cases among heterosexuals who probably acquired their infection abroad.

The number of new diagnoses among MSM in 2011 (2,475) is expected to reach 3,000 when all reports are received. This continues the slow but steady increase observed over the past decade. The majority of MSM diagnosed in 2011 are white (84%) and acquired their infection within the UK (84%). Analysis of data from each of the related surveillance systems strongly suggest that the continuing high annual numbers of new HIV diagnoses in MSM have been driven by an underlying high and unchanged HIV incidence.

The number of new diagnoses among those infected heterosexually within the UK has remained steady at around 1,100 per year since 2008. In contrast, the number of new diagnoses among heterosexuals infected abroad has halved since 2006, from 3,530 in 2008 to 1,850 in 2011. This is largely due to a decrease in new diagnoses among persons from sub-Saharan Africa.

Continued low numbers of HIV diagnoses were made in people who inject drugs (PWID) (140) and persons infected through other exposures (120), such as mother to child transmission and recipients of blood/tissue products. All infections acquired through receipt of blood/tissue products diagnosed since 2002 were acquired outside of the UK, including the 21 diagnosed in 2011.

A total of 375 deaths and 350 AIDS diagnoses among HIV-infected persons in 2011 were reported, and this number is likely to increase as further reports are received.

New HIV diagnoses by exposure group and year of diagnosis: United Kingdom, 2002 - 2011

Probable exposure group *

2002
2003
2004
2005
2006
2007
2008
2009
2010
2011**
Sex between men
Adjusted
1980
2170
2460
2640
2650
2880
2770
2800
2880
3000
Observed
1955
2137
2421
2609
2598
2811
2640
2612
2681
2475
Hetero-sexual - likely country of infection
All
Adjusted
4050
4800
4900
4830
4430
4110
4120
3470
3180
2890
Observed
4004
4723
4829
4763
4347
4004
3919
3240
2952
2350
In the UK
Adjusted
530
640
760
830
900
1010
1080
1070
1040
1040
Observed
402
490
595
660
701
733
774
766
744
572
Abroad
Adjusted
3530
4160
4140
4000
3530
3100
3040
2400
2140
1850
Observed
3526
4150
4072
3906
3396
2887
2644
2157
1814
1244
Injecting drug use
Adjusted
140
170
160
190
200
180
190
160
150
140
Observed
133
167
153
185
195
178
183
147
140
102
Other exposure groups
Adjusted
170
200
200
160
180
160
140
170
150
120
Observed
168
197
192
162
178
157
131
154
135
86
Not reported
77
110
110
105
134
182
347
431
448
581
Total
6337
7334
7705
7824
7452
7332
7220
6584
6356
6150
 * Adjusted by distributing proportionally those reports for which exposure group is not reported.
** Adjusted for reporting delay.

Note: The table shows actual numbers for the observed values.  Numbers presented in the text are rounded.

 

New HIV diagnoses by exposure group: United Kingdom, 2002 - 2011

Reference

1. United Kingdom new HIV diagnoses to the end of December 2011 (HPA, in collaboration with Health Protection Scotland and the UCL Institute of Child Health) (470 KB PDF). Downloadable from the HPA website: Home > Topics > Infectious Diseases > Infections A-Z > HIV > New HIV Diagnoses > New Diagnoses National Overview.

Expanded HIV testing in high prevalence areas: HPA resource published

The HPA has published a synthesis of evidence and resources to support current and future commissioners to introduce routine HIV testing in general medical services. The full document can be accessed on the HPA website, at: http://www.hpa.org.uk/expandedhivtesting2012.

National HIV testing guidelines published in 2008 recommended that in high prevalence areas, defined as those with a diagnosed HIV prevalence of more than two in 1,000 among 15 to 59 year olds, HIV testing should be expanded into general medical services such as hospital medical admissions and new registrants in general practice [1]. This recommendation has been corroborated by subsequent reports in 2011 from the HPA, the National Institute of Health and Clinical Excellence (NICE) [2] as well as the House of Lords select committee on HIV and AIDS report [3].

The HPA Time to Test for HIV report examined the results of eight Department of Health pilot projects and recommended that the routine offer of HIV testing should now be commissioned as a priority for all general medical admissions in high HIV prevalence areas in England [4]. In addition, the authors recommended that HIV testing by general practitioners should be widely promoted, especially in high prevalence areas, although they highlighted the need for further consideration of delivery models.

The publication of this evidence and resource document follows on from the NHS Public Health Outcome Framework earlier this year, which includes an indicator on reducing the proportion of people presenting with HIV at a late stage of infection (CD4 count less than 350 cells/mm3), which is associated with increased morbidity and mortality [5]. In 2010, half of all new HIV diagnoses were reported after the point at which treatment should have been initiated [6].

The document summarises the rationale for the introduction of routine HIV testing in high HIV prevalence areas, collates the latest cost and cost-effectiveness data and summarises some of the key results from pilot projects that have introduced HIV testing in different medical services. The estimated cost of introducing routine HIV testing into general medical admissions in areas of high prevalence nationally would be approximately £1.3 million and for an average high prevalence local authority would be £19,000 per 100,000 population. These figures should be viewed in the context of the substantial and increasing cost of providing HIV specialist treatment and care [7] and that individuals who are aware of their HIV positive status may also have reduced rates of onward transmission through a combination of subsequent reduction in risk behaviours and commencement of antiretroviral therapy.

References

1. BHIVA (2008). UK national guidelines for HIV testing, http://www.bhiva.org/documents/Guidelines/Testing/GlinesHIVTest08.pdf.

2. National Institute of Clinical Excellence (2011). Increasing the uptake of HIV testing to reduce undiagnosed infection and prevent transmission among men who have sex with men, http://guidance.nice.org.uk/PH34.

3. House of Lords Select Committee (2011). No vaccine, no cure: HIV and AIDS in the United Kingdom, http://www.publications.parliament.uk/pa/ld201012/ldselect/ldaids/188/188.pdf.

4. Health Protection Agency (2011). Time to test for HIV: expanded healthcare and community HIV testing in England, www.hpa.org.uk/timetotesthiv2011.

5. Department of Health (2012). Healthy lives, healthy people: improving outcomes and supporting transparency. A public health outcomes framework for England, 2013-2016, http://www.dh.gov.uk
/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_132358
.

6. Health Protection Agency (2011). HIV in the United Kingdom: 2011 Report, http://www.hpa.org.uk/Publications/InfectiousDiseases/HIVAndSTIs/1111HIVintheUK2011report/.

7. Beck EJ, et al (2011). The cost-effectiveness of early access to HIV services and starting cART in the UK 1996-2008. PloS one, 6(12), p.e27830.

Public consultation on the role of the health workforce in tackling health inequalities

University College London's Institute of Health Equity (IHE) has published a draft report suggesting that the health services professionals - including frontline clinicians, managers and decision-makers at local and national level - could play a more active role in positively influencing the social determinants of health and in tackling health inequalities in England [1].

The report is not concerned with access to healthcare (although it acknowledges that access is a social determinant), rather it suggests that those who work in and for the health system, particularly those involved in direct patient care (ie doctors, midwives, health visitors, school nurses, dentists, primary care staff, etc) could exploit their unique access to the population, who "they see . at key points across the life-course . before, during and after birth . during schooling . and at times of illness", so as to further implement the recommendations of the 2010 report of the independent review of strategies for reducing health inequalities in England, chaired by professor Sir Michael Marmot, published in 2010 [2,3].

The 2010 review, commissioned by the Department of Health, applied the same analysis to England as had been applied in professor Marmot's earlier 2008 report for the WHO [4]. The Marmot Review for England demonstrated not only marked differences in average life expectancy between the most and least deprived parts of the country (particularly when disability-free life expectancy are considered) but also that "finely-graded social gradients" were apparent in the public health epidemiological data (similar to those first identified in Marmot's earlier work on the health of civil servants begun in the late 1960s). The implication of the social gradient, the English review concluded, was that focusing solely on the most disadvantaged will not reduce health inequalities sufficiently; "it is necessary to reduce the steepness of the social gradient in health through actions that are universal at the same time as having a scale and intensity that is proportionate to the level of disadvantage".

The new report makes recommendations in three main areas: what health services professionals can do in practice (as clinicians or commissioners, as employers/managers, and as members of associations working across sectors); how education, training and ongoing professional development might be refocused; and how incentives, monitoring and directives might better promote action on social determinants.

The radical reorganisation of the health system currently under way in England should not prevent these recommendations being implemented, the draft report suggests; indeed it states that "In a time of systemic and organisational change, there will need to be closer partnership working between Public Health England and the NHS at the national level, and between local government, directors of public health, and clinical commissioning groups at the local level". The report includes many short summaries of exemplary, already-operating schemes involving cross-sector and partnership working.

Comments on the consultation version/draft report are requested before a deadline of 18 May [1].

References

1. Institute of Health Equity (2012). "The role of the health workforce in tackling health inequalities: action on the social determinants of health (consultation version report and questions)".

2. Fair society, healthy lives: a strategic review of health inequalities in England post-2010 (February 2010).

3. The social determinants of health are "the conditions in which people are born, grow, live, work and age. What happens within an individual's social context, during the early years, education, income, skills development, employment and work and within communities all impact on their health and length of life. The Marmot Review demonstrated that there is a gradient in health outcomes, the lower a person's social economic status the worse their expected health".

4. Closing the gap in a generation: health security through action on social determinants of health (2008). Report of the WHO Commission on Social Determinants of Health (CSDH).