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  • Of the estimated 6,840 (95% confidence intervals 6,600-7,050) persons newly diagnosed with HIV in the UK in 2007, an estimated 56% (3,860 [3,700-4,000]) acquired their infection heterosexually and an estimated 38% (2,630 [2,500-2,750]) were men who have sex with men (MSM). In recent years there has been a decline of new HIV diagnoses in HIV-infected heterosexuals from sub-Saharan Africa who were probably infected in their country of origin. In contrast, there was no evidence of a fall in the current high rate of HIV transmission among MSM within the United Kingdom, which has remained at epidemic level.
  • Among MSM newly diagnosed in 2006, 83% probably acquired their infection in the UK. Among white MSM this percentage was 84% compared to 74% among MSM of all other ethnic groups. There is evidence that MSM born abroad are also at risk of acquiring HIV infection within the UK. Among heterosexuals, 17% probably acquired their infection in the UK. A greater percentage of heterosexuals of white ethnicity probably acquired their infection in the UK (50%) compared to those of black African ethnicity (8%) and those among other ethnic groups (30%). Migration is a major cause of late diagnosed and reduce access to testing and treatment in many countries, including the UK Following earlier steep increases in UK, there is a levelling off in diagnoses among black-African individuals largely due to changes in immigration Small but important increases in number of heterosexually acquired infections acquired in the UK, particularly among black-African individuals HIV prevalence in UK amongst black-African populations greatly exceeds that amongst other ethnicity groups.
  • There have been 2 major NHS reorganisations since the Sexual Strategy in England Shifting the Balance of Power (abolition of health authorities) And Changes in commissioning to Patient-led NHS (2006) Our health, our care, our say (2006) – deliver of care in partnership Changes in commissioning (2006) offer the opportunity to have more specialist care support for commissioning but consequent changes in personnel and population configuration may present challenges to local service development Practice based commissioning should facilitate patient pathways and closer working between acute and community based services. Our health, our care, our say (2006) – provides an opportunity for innovative methods for providing services to tackle hepatitis and HIV
  • Since the National Strategy for Sexual Health (England) in 2001, we have seen increase testing of HIV offered to all GUM attendees as part of STI screen, o ver 700 000 screens in 2007 with a High uptake >80% Additionally there is since 1999 routine HIV testing in the antenatal setting with >85% uptake TB clinics- routine in most clinics across London Up to 20% co-infection rates among BA TB patients
  • There were 35,242 individuals reported to SOPHID in 2004 with both a CD4 count and level of ARV reported (88% of a total 40,000 reported). 14% of these – almost 5,000 – had CD4 counts less than 200 *Click* Of those 5,000 individuals, 19% - almost 1000 (950) – were not receiving ARV.
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    1. 1. Tackling HIV and co-infections The UK experience AIDS conference Mexico City, 2008 Dr Valerie Delpech Centre for Infections Health Protection Agency
    2. 2. Acknowledgments The Public Health Agency of Canada (PHAC) CDC colleagues at HPA, Department of Health and The Terence Higgins Trust
    3. 3. Outline <ul><li>Background epidemiology </li></ul><ul><ul><li>How serious is the problem? </li></ul></ul><ul><ul><li>Infection specific data, HIV co-infection data </li></ul></ul><ul><li>Response </li></ul><ul><ul><li>Strategies, policies and guidelines </li></ul></ul><ul><ul><li>Enhanced surveillance </li></ul></ul><ul><ul><li>Public Health interventions/ Health promotion </li></ul></ul><ul><li>Future Actions </li></ul>
    4. 4. National Health Service, (NHS) <ul><li>Patients receive free and accessible care </li></ul><ul><ul><li>GUM (STI) clinics </li></ul></ul><ul><ul><ul><li>test bulk of HIV and STIs, sexual screens, treatment of STIs (240+) </li></ul></ul></ul><ul><ul><li>HIV clinics </li></ul></ul><ul><ul><li>TB clinics </li></ul></ul><ul><ul><li>Drug dependence Units </li></ul></ul><ul><ul><li>Antenatal clinics – test for HIV, Hepatitis B and other infections </li></ul></ul>
    5. 5. Background <ul><li>UK . </li></ul><ul><li>No. of diagnoses per year (approx) </li></ul><ul><ul><li>7000 HIV </li></ul></ul><ul><ul><li>7000 TB </li></ul></ul><ul><ul><li>7000 HCV </li></ul></ul><ul><ul><li>250 000 acute STIs </li></ul></ul><ul><ul><li>Prevalence </li></ul></ul><ul><ul><li>250,000 HCV infected individuals </li></ul></ul><ul><ul><li>73,000 HIV infected individuals </li></ul></ul><ul><li>2.3 million persons infected with HIV in WHO Europe, 30% undiagnosed </li></ul><ul><li>UK has one of highest rates of new diagnoses in Europe, </li></ul><ul><li>driven by migration and new infections among MSM </li></ul>
    6. 6. Response Preventing new infections and minimising burden <ul><li>Strategy/ Policy </li></ul><ul><li>National Sexual Health Strategy (SHS), England (2001) and Action Plan (2002) </li></ul><ul><li>Chief Medical Officer’s Getting ahead of the Curve (2002) </li></ul><ul><li>Similar Strategies and action plans for TB, and Hepatitis C (2002 & 2003) </li></ul><ul><li>Clinical guidelines eg: BASSH/BHIVA/TB guidelines </li></ul><ul><li>Public Health – eg: outbreak response to syphilis and LGV </li></ul><ul><li>Health promotion – THT, local PCTs </li></ul>
    7. 7. HIV in the UK
    8. 8. New HIV diagnoses in the UK by exposure category: 1998 – 2007 Data reported to December 200795% confidence intervals provided for estimates
    9. 9. New HIV diagnoses in the UK by prevention group and probable world region of infection: 2006 Data reported to December 2007
    10. 10. Estimated late diagnosis 1 of HIV infection and AIDS at HIV diagnosis by prevention group, UK: 2006 1 CD4 cell count less than 200 cells/mm3 within 30 days of diagnosis among adults (aged >14 years) HIV/AIDS diagnoses and death reports, and surveillance of CD4 cell counts in HIV-infected persons TB is the most important cause of AIDS in migrant populations
    11. 11. Pattern of diagnosis and associated short-term mortality rate among BME adults Late diagnosis CD4 count <200 cells/mm 3 ; prompt diagnosis ≥200 cells/mm 3 . Short-term mortality rate: percent of patients known to have died within a year of diagnosis. Reports of HIV diagnosis, deaths and CD4 cell counts Number diagnosed Short-term mortality rate Diagnosed promptly Diagnosed late
    12. 12. STIs in the UK
    13. 13. STIs diagnosed in GUM clinics, UK
    14. 14. Proportion of STIs among MSM 2000 & 2006, UK Syphilis Gonorrhoea Chlamydia Herpes Warts NSU MSM 0% 100% 2000 2006 2000 2006 2000 2006 2000 2006 2000 2006 2000 2006 50% 2000 2006 HIV 3.3% <ul><li>Increases in STIs last 5 years </li></ul><ul><li>20% in HIV </li></ul><ul><li>117% in syphilis </li></ul><ul><li>21% in gonorrhoea </li></ul><ul><li>35% in genital herpes and warts </li></ul>49% 59% 2% 6% 6% 7% 5% 7% 7% 8% 22% 33% 39% 34% 80% UK Acquired
    15. 15. LGV in MSM, England
    16. 16. What are we doing about HIV co-infections? <ul><ul><li>Surveillance </li></ul></ul><ul><ul><li>Strategies & Policies </li></ul></ul><ul><ul><li>Public Health interventions </li></ul></ul><ul><ul><li>Health promotion </li></ul></ul>
    17. 17. Surveillance Methods for HIV co-infections <ul><li>1. Enhanced surveillance </li></ul><ul><ul><li>Gonorrhoea (GRASP), </li></ul></ul><ul><ul><li>Syphilis </li></ul></ul><ul><ul><li>LGV </li></ul></ul><ul><ul><li>HCV (new) </li></ul></ul><ul><li>2. Data linking exercises </li></ul><ul><ul><li>HIV New diagnoses and deaths </li></ul></ul><ul><ul><li>Survey of Prevalent HIV infections diagnosed (SOPHID) </li></ul></ul><ul><ul><li>Enhanced Tuberculosis case reporting System (ETS) </li></ul></ul><ul><ul><li>Enhanced Pneumococcal Surveillance scheme (EPS) </li></ul></ul><ul><ul><li>Hepatitis C sentinel laboratory reporting </li></ul></ul>
    18. 18. Proportion of infections among HIV+ MSM in 2006 Syphilis Gonorrhoea LGV 0% 100% MSM HIV+ MSM HIV+ MSM HIV+ 50% 99% HCV MSM - HIV+ 7.5% 33% 59% HIV+ 34% 75% 28% 99%
    19. 19. In-depth Analyses Enhanced Syphilis Surveillance among MSM <ul><li>HIV positivity associated with </li></ul><ul><ul><li>Being non white </li></ul></ul><ul><ul><li>Born outside UK </li></ul></ul><ul><ul><li>Presenting later </li></ul></ul><ul><ul><li>Greater number of sexual contacts </li></ul></ul><ul><ul><li>Diagnosed in London </li></ul></ul><ul><ul><li>Meeting sexual contacts in Sauna and on the Internet </li></ul></ul><ul><ul><li>Being older – peak in 40-44 and 45-49 </li></ul></ul>
    20. 20. SNAHC pilot S urveillance of N ewly A cquired hepatitis C in MSM <ul><li>Objectives </li></ul><ul><li>To assess the burden of disease, behavioural and other risk factors </li></ul><ul><li>To develop information systems for public health actions </li></ul>Crude HCV incidence in HIV+ MSM, London and Brighton , 2002- June 2006 Surveillance Case definition Definite Case: Documented anti-HCV sero-conversion HCV antibody positive and has a documented negative HCV antibody within the previous 36 months. Probable Case HCV RNA positive AND HCV antibody negative or equivocal
    21. 22. Linking Exercises TB HCV Pneumococcal
    22. 23. TB co-infections
    23. 24. Incidence of Invasive Pneumococcal Disease in HIV-diagnosed individuals England and Wales: 1996-2005 Source SOPHID & EPS incidence estimate of 141/100,000, 10 times higher than background adult population
    24. 25. Changes since 2001 <ul><li>Major NHS reorganisations since Strategy </li></ul><ul><ul><li>Shifting the Balance of Power (abolition of health authorities) </li></ul></ul><ul><ul><li>Changes in commissioning to Patient-led NHS (2006) </li></ul></ul><ul><ul><li>Our health, our care, our say (2006) – deliver of care in partnership </li></ul></ul><ul><li>Changes in the Epidemiology of HIV, TB, HCV </li></ul><ul><ul><li>Increased STI among MSM, black Caribbean communities </li></ul></ul><ul><ul><li>Increased HIV/TB in black Africans linked to late diagnosis </li></ul></ul>
    25. 26. Review of Sexual Health Strategy, MedFash for the SHIAG July 2008 <ul><li>Prioritising sexual health as a key public health issue and sustaining high level leadership at local, regional, and national level </li></ul><ul><li>Designated accountability, active performance management at PCT and SHA level </li></ul><ul><li>Delivering modern sexual health services (increasing the level and quality of services, networks and improving workforce planning and training) </li></ul><ul><li>Incorporating sexual health and long-term care for people with HIV </li></ul><ul><li>Building strategic partnerships (treatment, public health, community sector), more integrated cross- government approach </li></ul><ul><li>Commissioning for improved sexual health, including investing more in prevention, and dissemination of evidence that works </li></ul>
    26. 27. Improving our response to HIV co-infections <ul><ul><li>We need to better address needs of MSM, Black communities and IDUs </li></ul></ul><ul><ul><li>Improved surveillance and monitor tools </li></ul></ul><ul><ul><li>Better commissioning of services & prevention interventions </li></ul></ul><ul><ul><li>Better integrate health services to improve early diagnosis, treatment and ongoing care </li></ul></ul><ul><ul><ul><li>Eg: New HIV testing guidelines (Sept 2008) </li></ul></ul></ul>Resources for positive HIV MSM, THT
    27. 28. Better integration of services Sexual Health & HIV Screens in GUM clinics, UK
    28. 29. Improving Surveillance <ul><ul><li>1. Improve & integrate enhanced surveillance systems </li></ul></ul><ul><ul><ul><li>shift from disease focus to at risk populations </li></ul></ul></ul><ul><ul><ul><li>standardising surveillance tools across system </li></ul></ul></ul><ul><ul><ul><li>better collection of behavioural information </li></ul></ul></ul><ul><ul><li>2. Develop key indicators for monitoring infection, treatment and care, and prevention efforts, for example </li></ul></ul><ul><ul><ul><li>% late diagnosed </li></ul></ul></ul><ul><ul><ul><li>% not on ARV <200 ?<350 </li></ul></ul></ul><ul><ul><ul><li>% of STI patients screened for HIV </li></ul></ul></ul><ul><ul><ul><li>% positive MSM tested for HCV </li></ul></ul></ul>
    29. 30. Proportion of late diagnosed in London Percentage of patients diagnosed with CD4<200 by PCT of residence >45% (4) 40-45% (6) 35-40% (8) 30-35% (6) 25-30% (6) <25% (1)
    30. 31. Proportion of HIV-infected persons not on ARV by CD4 category: UK, 2006 CD4 cell count category 31% 19% 31% Proportion not on ARV Annual survey of HIV-infected persons accessing care n = 5,144 2,407 18% 30% 31% 11,595 4,983 29,165 9,894
    31. 32. Conclusions <ul><ul><li>Co-infections are a significant problem among HIV infected individuals </li></ul></ul><ul><ul><li>We can do more to reduce co-infection in affected populations (screening and earlier testing, integrated care, targeted health promotion intervention) </li></ul></ul><ul><ul><li>We can improve our surveillance and develop key indicators to monitor our progress </li></ul></ul><ul><ul><li>We welcome the opportunity of an international collaboration to share best practice, lessons learnt and innovative approaches to reducing co-infections </li></ul></ul>
    32. 33. THANK YOU Acknowledgments The Public Health Agency of Canada (PHAC) CDC colleagues at HPA, Department of Health and The Terence Higgins Trust