Could HIV transmissions in the UK really be reduced to almost zero by 2030? The latest report suggests that yes

90% viral suppression rate achieved in London; Most people who receive ART now have a lower mortality rate than the general population.

The latest annual report on HIV diagnosis, treatment and testing in the United Kingdom should have come out, as they normally do, before World AIDS Day, December 1S t last year. He did not, due to the embargo of government publications during the general electoral campaign.

Today, the largely positive findings of Public Health England (PHE) provide evidence, through several different indicators, that new HIV infections in the United Kingdom continue to decline at a rate such that the new diagnoses are surpassing In fact, if the new diagnoses continue at the same rate, they will exceed the total number of people with undiagnosed HIV in the United Kingdom by 2022, even if they add the same amount of new infections each year.

That will not happen, because most of the new diagnoses now come from the minority of people who have had HIV for some time and do not belong to populations that are frequently tested, or do not. They are often older people or have come from other countries.

Glossary

virological suppression

Stopping the function or replication of a virus. In HIV, optimal viral suppression is measured as the reduction of viral load (HIV RNA) to undetectable levels and is the goal of antiretroviral therapy.

self sampling

In HIV tests, when the person taking the test collects their own sample and sends it to a laboratory for analysis. The laboratory makes the results available by phone or text message a few days later.

self check

In HIV tests, when the person taking the test collects their own sample and performs the complete test on their own, including reading and interpreting the result.

trend

In everyday language, a general movement up or down (for example, every year there are more HIV infections). When talking about statistics, a trend often describes an apparent difference between results that is not statistically significant.

However, the fact that the rate of positivity among people who are tested for HIV, in most populations and in most settings, has halved in recent years shows that, if Progress is maintained, the United Kingdom could be a country of very low incidence. 2030

Public Health England cites, as measures that we must improve if we want to achieve this goal:

  • more tests in non-traditional environments, such as A&E departments, prisons and automatic tests;
  • more consistent tests of people who go to clinics with symptomatic STIs (more than a third of STI assistants who were within the HIV test criteria were not done last year); Y
  • institute the routine start-up of PrEP in England which, he says, can lead to a “rapid decline in new HIV diagnoses in those attending homosexual and bisexual STI clinics starting in 2019”.

The report says that 4453 people were diagnosed with HIV in the United Kingdom in 2018, a 29% drop from 6278 diagnoses in 2014. The decrease was most marked in gay and bisexual men, where there was a 35% drop, from 3480 to 2250, during the same period. The drop in diagnoses 7887 in the peak year of 2004 is 44%.

There has been a greater drop in diagnoses of recent HIV infection. The proportion of people for whom incidence trials suggest that HIV was acquired in the four months prior to diagnosis has decreased from 35% to 26%. This allows PHE to estimate that the incidence of HIV, the actual annual rate of new infections, diagnosed that year or not, has decreased by no less than 73% in gay and bisexual men since 2014, from approximately 2300 infections in 2014 to just 800 in 2018. It is estimated that the incidence in heterosexual men decreased by 55% during the same period, and in women by 22%.

This leads to an approximate total of new infections in the United Kingdom of approximately 1450 a year, about a third of the number of new diagnoses. Even if you take the current estimate that 7500 people were living with undiagnosed HIV in the United Kingdom in 2018, and add another 1450 new infections per year (a figure that probably decreases even more), then, if the same 4453 are diagnosed each year , comes to a situation where there are more diagnoses than people who have not yet been diagnosed by 2022.

This will not happen, of course, because the diagnoses will decrease as the incidence does; because infections of people outside the UK will continue to be diagnosed; and because the remaining undiagnosed people will be harder to find. But the new HIV will become relatively rare, as AIDS deaths are now.

The proportion of people diagnosed late, many of whom may be in that “ hardest to find ” category, has also declined, from 3353 in 2009 to 1883 in 2018 (‘late’ is defined as a CD4 count below of 350). However, because the diagnoses in the newly infected have also decreased, the proportion of people with late diagnosis has remained fairly stable at 43%, and is much higher among some groups, such as African black heterosexual men (65% ) and people over 50 years old. (59%).

In the latter case, this is partly due to the fact that people over 50 simply had more time on average to live without HIV diagnosis, but also because CD4 counts tend to decrease faster in people with HIV. treaty. The proportion of people diagnosed over 50 has increased from 13% to 21% in the last decade.

A new, or recently published, fact in this year’s report is that many people with late diagnosis who were born abroad may have been diagnosed before they arrived in the UK, but they probably had not been receiving treatment for some time. It is estimated that 21% of the new diagnoses, and 23% in homosexual and bisexual men, were made in people who had in fact been previously diagnosed abroad. It is estimated that this group represents approximately 13% of those diagnosed late.

In homosexual men, the general decline in HIV diagnoses echoed in migrants from other countries, although not so strongly: the decrease was 52% since 2014 in homosexual men born in the United Kingdom and 36% in Men born abroad. There is an exception: the new diagnoses among homosexual men born in Latin America (where the prevalence in homosexual men is very high) and the Caribbean have not followed this clear trend and have oscillated around 225 cases a year since 2014. This means that They have increased as a proportion of the total, forming approximately one in seven diagnoses in gay men in 2018.

A question that is often asked about people born abroad is whether they acquired HIV in their home country or in a new one. Here there have been approximately the same number of people who contracted HIV abroad and in the United Kingdom. However, and perhaps contrary to expectations, the number acquired in the United Kingdom has decreased, from approximately 600 in 2014 to 400 now, while the number acquired in the country of origin has remained stable at approximately 600 per year. . This may be due to a lower incidence in the United Kingdom in general.

Diagnostics have fallen faster in London than in other places. Until 2014, London accounted for approximately half of the new diagnoses in homosexual men; This has now fallen to 39%. Among heterosexuals, London is no longer the only region with the majority of HIV diagnoses: there were 461 among the people of Midlands and eastern England, followed by 416 in London. In addition, twice as many undiagnosed people live outside London (approximately 4500) than within London (approximately 2100).

Diagnoses in African men and women have declined since the early 2000s, reflecting lower immigration rates in high-prevalence countries and lower prevalence in those countries. However, the PHE report notes that for this group, the diagnoses seem to have stopped decreasing, or at least, in 2018, there were a little more of them than the previous year (643 in 2018 compared to 626 in 2017).

In addition to the incidence estimates derived from the trials, the positive rate of HIV tests is evidence of a sharp decrease in the incidence.

In 2018, about 1.1 million people who attended specialized health services were tested for HIV, 6% more than in 2017, representing 58% of the 1.9 million eligible for a test. Of the 42% who were not evaluated, 45% rejected a test. Heterosexual women (74% of those who were not tested or 24% of all women attending) were more likely to refuse a test compared to 12% of all heterosexual male men and 4% of those gay men.

The percentage of those who tested positive has decreased from 0.3% (one in 333) in 2014 to 0.13% (one in 770) in 2018. The positivity has decreased by approximately two thirds in all high prevalence groups. In gay men it has decreased by 65%, from 2% in 2014 to 0.7% now; in African heterosexual men from 0.9% to 0.3%; and in African heterosexual women from 1.3% to 0.4%. This shows that the positivity has decreased less in low prevalence groups, such as white heterosexuals born in the United Kingdom, although it has still declined. The positivity has do not It decreased only among people diagnosed in primary care in low prevalence areas in the United Kingdom, where the 0.2% positivity rate has remained stable.

The positivity has also decreased, while the total number of tests has increased, in other settings, such as the A&E departments (57,000 tests in 2018, 0.7% positive; hospitalized patients (120,000 evaluated, 0.42% positive); and prisons (58,000 tests, 1.2% positive).

Now there is also a significant absorption of self-sampling and self-testing in the United Kingdom. In 2018, 138,000 people ordered a self-sampling kit from their local sexual health services (eSHS) website; 24,000 of the national HIV self-sampling service at www.freetesting.hiv; and 56,000 bought a self-assessment kit online or at a pharmacy. In the national self-sampling service, the general “reactivity” was 0.9% and the strong reactivity suggests a probable positive result (all reactive results must be confirmed) was 0.5%. Local eSHS self-sampling services were mainly used by heterosexuals, and national ones by homosexual men, possibly due to how they were announced.

In 2018, it was announced that, according to 2017 figures, the United Kingdom had achieved UNAIDS target 90/90/90, which means that 72.9% of all people with HIV underwent tests, undergoing treatment and suppressed by virus, and that London had exceeded the target 95/95 / 95, or 85.7% of all people with HIV suppressed virally.

These trends continue, with 93% of people with HIV diagnosed in the United Kingdom in 2018, 97% of people being treated and 97% of people with viral suppression (85.7% of all people with HIV with suppression viral). It is estimated that London has reached, or is very close, the highly symbolic milestone of having more than 90% of its HIV positive population suppressed (95% diagnosed, 98% of people under treatment, 97% of people with viral suppression = 90.3%)

Of an estimated 13,100 people with detectable viral loads in the United Kingdom, 7,500 were not diagnosed, 2,800 were not being treated, and another 2,800 were under treatment but were not virally suppressed. In the latter case, some may have started treatment very recently.

With respect to PrEP, at the time the figures were collected in 2018, it was estimated that 12,000 people took PrEP in the United Kingdom through the IMPACT trial in English or through programs in Scotland, Wales and Northern Ireland. At least 5000 were buying PrEP online. The IMPACT test is in the process of expansion and by summer there should be 26,000 people accessing PrEP through that alone. PHE comments that, so far, PrEP does not appear to have had an additional effect in reducing the incidence of HIV, but that it could cause additional falls by this time next year.

Finally, the end result of all this is to further reduce deaths from HIV. The PHE report reveals that only 473 people with HIV died from all causes in the United Kingdom in 2018, with an average age of 55 years. It is estimated that between 22% and 47% of deaths could be due to AIDS, which implies that 104 to 222 deaths could have stopped, mainly by early diagnosis of people, since AIDS deaths now occur overwhelmingly in the First year in people receiving a late diagnosis.

The report confirms something that has been reported elsewhere: people under 60, who are diagnosed on time, with CD4 counts above 350, are now Less The general population in the same age group is likely to die, probably due to better medical care. In 2018, the mortality rate among this group was 0.119% (one person in every 840 deaths per year) compared to 0.161% in the general population (one person in every 621 per year). In men with HIV, annual mortality was one death in 714 a year compared to one in 507 in the general population; in women it was one in 1369 versus one in 806. This is a notable change for a disease in which, at the peak of AIDS, that annual figure was more like one in five.

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