HIV (human immunodeficiency virus) infection is easily prevented, yet despite remarkable advances in our understanding of the condition, the number of people who are acquiring HIV in the UK remains stubbornly high.
In 2013 around 108,000 people were estimated to be living with HIV, 6,000 of whom were newly diagnosed. Among men who have sex with men (MSM) there has been a steady increase in HIV infection, with the highest ever number of new HIV diagnoses (3,250) reported in 2013.
Around a quarter, 26,100, of the people estimated to be living with HIV in the UK are unaware that they have the virus and are at risk of unknowingly passing it on to others. The incidence, or number of new cases every year, is continuing at a high rate in England especially among certain groups, such as MSM. While the large majority of black Africans do not have HIV, one-third of the 40,000 black African heterosexual men and women living with the virus in the UK are unaware they have the infection.
Improved treatment options mean that for those with HIV who are diagnosed early, HIV has changed from being fatal into a chronic condition - with a life expectancy almost matching that of people who are HIV free.
Nevertheless, there is still no cure, complications of infection occur and without daily medication HIV is a life threatening infection. The costs of HIV infection are high – to an individual’s physical health, their wellbeing and mental health affected by stigma and discrimination, and their relationships with other people.
In addition, there are direct financial costs to health care and to the wider economy, with the medical lifetime cost of care associated with each new infection estimated to be around £360,000.
The benefits of effective therapy reach beyond the individual person, having a beneficial impact on wider HIV prevention. People with HIV who are on successful therapy are far less infectious and therefore much less likely to pass the virus on to other people.
Encouragingly, although still high, the proportion of people diagnosed with a late stage of HIV infection - when clinical complications can be serious and unawareness means they are more likely to unknowingly infect others - has begun to decline, falling from 57% in 2004 to 42% in 2013.
Knowing the risks
Testing programmes for HIV, ensuring that people know their HIV status, is a crucial intervention.
It is the key to beginning effective treatment and better long-term health outcomes for people testing positive, as well as reducing transmission.
It may also motivate some people who test negative to change their behaviour to avoid acquiring the infection. PHE’s data and evidence supports Local Authorities who have the responsibility for commissioning HIV prevention initiatives and testing as part of their public health role.
Through indicating which groups of people in their communities are at particular risk of HIV, initiatives can be tailored for maximum impact. For example:
- Men who have sex with men are advised to have an HIV and STI screen at least annually, and every 3 months if they’ve had unprotected sex with new or casual partners
- Black African men and women are advised to have an HIV test and a regular HIV and STI (sexually transmitted infections) screen if having unprotected sex with new or casual partners
Reducing the risk
Condoms remain a highly effective method for reducing transmission of HIV and other STIs. In fact, without condom use in the UK, estimates suggest that HIV rates among MSM alone would have resulted in a 400% increase in new infections. But we cannot rely solely on consistent condom use to stem the epidemic.
A comprehensive, combined approach to prevention must be a priority, particularly as evidence shows the positive impact to both the individual and wider preventative benefits of the use of antiretroviral therapy (ART) in people living with HIV.
The evidence is clear: if condoms are not used consistently, the amount of HIV virus in a person’s body (the HIV viral load) is the single biggest risk factor for passing on the infection to sexual partners.
Effective therapy lowers the amount and activity of the virus, making the person with HIV less infectious. In fact, data from the START and TEMPRANO studies, which will go to inform international approaches (WHOs revised guidelines on ART), again confirm the wider health benefits of early ART for reducing the risk of serious illnesses and other infections in people with HIV.
The use of ART to prevent as well as to treat HIV infection (Treatment as prevention or TasP) has recently been approved by NHS England (NHS England’s response to a public consultation “investing in specialised services”, June 2015).
To support this development of preventative approaches in NHS practice, PHE has worked in partnership with NHS England’s HIV Clinical Reference Group (CRG) to develop, formalise and implement the clinical commissioning policy on Treatment as Prevention.
This policy builds on existing clinical guidelines produced by the British HIV Association (BHIVA), and World Health Organisation (WHO).
Matthew Day, who led PHE’s input into the NHS England policy, notes that this brings England in line with other developed countries in ensuring immediate access to ART for people diagnosed with HIV and at risk of passing on the infection to their sexual partners. PHE modelling undertaken for NHS England estimated that up to 1,800 new infections of HIV could be prevented over a 6 year period alone, with even longer term benefits in terms of population health and costs to NHS.
To be most effective, TasP must be part of a coordinated care plan that is agreed between the individual patient and their clinician. Critically, this needs to be supported by other prevention strategies including access to condoms and interventions aimed to reduce risky behaviour.
PHE, the NHS, Local Authorities, professional bodies and third sector partners need to work together for effective leadership and advocacy for all of these approaches.
What about PrEP?
Pre-exposure prophylaxis (PrEP) is the use of antiretroviral drugs by people who are HIV free, to avoid acquiring the virus. There is strong evidence to show that PrEP can be an effective way of preventing HIV infection provided the drug is taken appropriately.
The results of a recent two-year study (the PROUD study), jointly funded by the Medical Research Council and PHE, showed that PrEP was highly protective for MSM who engage in condomless sex. The issues to be resolved before deciding whether or not to introduce a PrEP programme, including eligibility and cost-effectiveness, are currently under consideration by the NHS England HIV CRG.
The importance of tailored interventions
Both regular testing for HIV and access to high quality treatment and care are important factors in addressing the high rates of HIV. We also know that well-tailored local initiatives have a critical role to play.
Certain groups within populations are at higher risk of acquiring HIV and it is important that local areas adapt their approaches according to their particular populations and landscape, whether that is through nightclubs or community groups, or targeting those most at risk.
Our evidence and action plan ‘promoting the health and wellbeing of gay, bisexual and other men who have sex with men’ supports a more holistic integrated and tailored approach to improving the health outcomes for these groups.
There is a wealth of evidence based opportunities, supported by cross system leadership, to turn the tide of the HIV epidemic. To capitalise on these opportunities it is vital for organisations to work together as part of a coordinated cross-system approach towards HIV prevention.
This whole-system view underpins PHE’s work, ranging from our funding of HIV Prevention England to our support for local innovation, which includes:
- the newly established national HIV innovation fund, which will support work with voluntary organisations through funding for innovative HIV prevention projects;
- a national HIV self-sampling service set up by PHE with Local Authorities, which will be a crucial additional way for people to access HIV testing;
- partnership between PHE and the Elton John AIDS Foundation to support Local Authorities with innovative programmes to tackle late stage diagnosis of HIV;
- Making it work: a guide to whole system commissioning for sexual health, reproductive health and HIV produced by PHE in partnership with NHS England, the Local Government Association, Association of Directors of Public Health and the Department of Health, which is designed to help local teams bring the whole system together through effective partnership working, which in turn will secure the best outcomes for people and for populations.
Effective treatment and effective prevention are two sides of the same coin. Ensuring that HIV remains a priority while delivering a joined up, collaborative approach to HIV prevention, diagnosis, treatment and care is essential across national and local health systems if the best is to be achieved for the individual and the public.