The United Kingdom (UK) has a relatively small HIV epidemic, with an estimated 101,200 people living with HIV in 2015. This equates to an HIV prevalence of 1.6 per 1,000 people aged 15 and over.1 In the same year, 6,095 people were newly diagnosed with HIV and 594 people died of AIDS-related illnesses.2
In 2015, 96% of people living with HIV were receiving antiretroviral treatment (ART).3However, late diagnosis of HIV remains a key challenge in this country, despite declining rates.
Although the figure for undiagnosed cases has fallen by 11% since the estimate of 24% in 2014, it still means that around 13,500 people are unaware of their infection, despite testing and treatment for HIV being free and universally available in the UK.
The annual number of new diagnoses – 6,095 people – represents a notably high rate of 11.3 per 100,000 people. Western Europe’s average is 6.3 per 100,000.
The epidemic in the UK mainly affects men who have sex with men and black African women. But in its 2016 report, Public Health England emphasised the diversity of people living with HIV in the UK. In 2015, for the first time since the 1990s, the proportion of people diagnosed with HIV who were born in the UK (52%) exceeded the proportion born abroad (48%).[4
Key affected populations in the UK
Men who have sex with men
Since the 1980s, men who have sex with men have remained the group most at risk of HIV in the UK. In 2014, the most recent data available, an estimated 45,000 men who have sex with men were living with HIV. This means roughly 1 in 20 men who have sex with men aged 15 to 44 are living with the virus.5 The prevalence rate is 4.9% nationally among this group, rising to 9% in London.6
The number of men who have sex with men newly diagnosed with HIV continues to rise, from 2,860 in 2010, to 3,320 in 2015.7
In 2014, men who have sex with men aged between 25 and 44 years old accounted for two-thirds of new diagnoses. 6% were over 55 at the time of their diagnosis. Over half (51%) of these new diagnoses were made in London. Four out of five men who have sex with men newly diagnosed with HIV were white (81%), 2% were black African, 2% black Caribbean and 14% described as other/mixed race.8
Increases in HIV diagnoses can be partly explained by increased HIV testing as well as ongoing HIV transmission. 14% of men who have sex with men living with HIV in the UK are believed to be unaware of their infection.9 Those living in London have a lower rate of late diagnosis (23%) than those who live outside of the capital (36%).10
Heterosexual men, women, and black Africans
In 2014, an estimated 21,300 heterosexual men and 32,700 heterosexual women were living with HIV in the UK. Of this number, 55% of men and 62% of women were of black African ethnicity (much higher than the percentage of black Africans in the UK population). Indeed, the number of black Africans living with HIV continues to rise.11
In 2015, there were 2,360 new HIV diagnoses as a result of heterosexual sex – 1,350 among heterosexual women and 1,010 among heterosexual men.12. This is about half the diagnoses made ten years ago when this figure stood at 4,340. The fall is largely due to changing migration patterns, with fewer people born in sub-Saharan Africa being diagnosed with HIV in the UK.
Of the 88,769 people accessing HIV treatment in the UK in 2015, 41,945 were men and women who had acquired HIV through heterosexual sex and 41,016 were men who had acquired HIV through homosexual sex.13
Of those who acquired HIV via heterosexual sex, 16,291 men and 25,654 women were accessing care. Among this group, 60% of people were black African, 24% white, 4% black Caribbean, 4% Asian and 3% of other black ethnicity.14
Just over half (51%) of the heterosexual men and 60% of the heterosexual women living with HIV were aged 25 to 44.15 As with other groups in the UK, the proportion of heterosexual people diagnosed at an older age has increased. The median age of HIV diagnosis for heterosexuals has risen from 34 in 2005 to 40 in 2014. 24% of all heterosexual men and 18% of heterosexual women living with HIV were unaware of their HIV status. This difference is largely due to the effectiveness of the UK’s antenatal screening programme.16
Among the black African population living with HIV, roughly 16% of men and 12% of women were living with an undiagnosed infection. HIV prevalence is comparatively higher among this group. For example, nearly 18 (17.9) out of 1,000 black African heterosexual men and nearly 44 (43.7) out of 1,000 black African women were living with HIV in 2014 compared to 0.5 per 1,000 non-black African men and nearly 1 (0.7) per 1,000 non-black African women.17
People who inject drugs
The HIV epidemic among people who inject drugs (sometimes referred to as PWID) in the UK has remained relatively low with an estimated 2,160 living with HIV in 2014.18
There are on going concerns about the increase in injection of methamphetamine and mephedrone in recent years. Certain populations of men who have sex with men are thought to be increasingly engaging in this during sex (known as ‘chemsex’), with the sharing of equipment and low condom use reported. 19
The number of people newly diagnosed with HIV in 2015 who acquired it through injecting drugs remains low overall (210 or 2%). However, the number of diagnoses reported in this group rose from 160 in 2014 to 210 in 2015. This is mainly due to a localised outbreak among people who inject drugs in Glasgow.20
In 2014, nearly a third (30%) of HIV diagnoses among people who inject drugs were made in London and almost three-quarters (73%) of those diagnosed were aged between 25 and 44.21
Other key affected populations
In 2015, 23 children were newly diagnosed with HIV – down from 131 in 2005. Of these, 17 were born abroad and arrived in the UK at an older age. Of the 860 children born in 2015 to women living with HIV, just one was known to have acquired the virus.22
HIV testing and counselling (HTC) in the UK
In 2014, 1.43 million people in England attended a sexual health (or GUM) clinic. 69% of people eligible for an HIV test had one – down on 2013 figures (71%). Men who have sex with men were most likely to have an HIV test (87%) compared with 77% of heterosexual men and 62% of heterosexual women.23
While testing coverage among men who have sex with men and heterosexual men has increased since 2009, it has fallen among heterosexual women. This is thought to be due to attendance at integrated sexual and reproductive health clinics in which this population is routinely tested for HIV.24
179 out of 223 health clinics achieved the recommended testing coverage of 80% among men who have sex with men, consistent with British Association for Sexual Health and HIV (BASHH) recommendations for this group.25 44 clinics achieved optimal testing coverage (90%) among eligible men who have sex with men. However, 85% of clinics (190/223) did not achieve 80% testing coverage among heterosexual men and women.26
Where black Africans are concerned, one survey detected an annual HIV testing rate of just 36.8%.27 Another study indicated that only one quarter of black African or black British ethnicity attended the same sexual health clinic at least once in the previous five years. By contrast, there was a 97% uptake of HIV testing among women attending antenatal clinics.28
In the UK, many people are diagnosed at a late stage of HIV infection - this is defined as having a CD4 count under 350 within three months of a diagnosis. One study found that even though some of its participants had self-identified as being potentially at risk of HIV, only 14% of these participants had actively tested to know their status.29 30 Although late diagnosis of HIV has declined in the last decade, from 56% in 2005 to 40% in 2014, this figure remains unacceptably high and further work to expand HIV risk awareness, testing and diagnosis is needed.31
Late diagnoses were highest among people who inject drugs (65%), followed by heterosexual men (61%) and black Africans (58%). London has the lowest proportion of people diagnosed late (33%) compared to 48% in the North of England and over 50% in both Wales and Northern Ireland.32
Many groups continue to push for a move from ‘opt-in testing’ to ‘opt-out testing’ (where patients are given an HIV test alongside routine checks unless they decline it). The National Institute for Health and Clinical Excellence (NICE) has advocated for expanding testing outside clinical settings by engaging community organisations, developing local strategies to increase testing, and by providing rapid HIV tests.33
Two programmes provided free HIV self-sampling kits online to use at home during National HIV Testing Week in 2013 and 2014. The pilot’s success led to the establishment of a national self-sampling service co-commissioned by Public Health England (PHE) and 89 local authorities.34 The service began in November 2015 as part of National HIV Testing Week.35
In response to this initiative, Professor Kevin Fenton, Director of Health and Wellbeing at PHE said:
"I would encourage all those at higher-risk of HIV, such as men who have sex with men or people from black African communities, to seriously consider testing, especially as they are now able to order a home-sampling kit free online."36
HIV prevention programmes in the UK
HIV prevention programming in the UK is largely run by HIV Prevention England (HPE) which is coordinated by the Terrence Higgins Trust and focusses primarily on the needs of men who have sex with men and black Africans.37
Prevention programming for men who have sex with men
CHAPS has been England's main HIV prevention programme working to prevent the sexual transmission of HIV among men who have sex with men. Funded by the Department of Health and led by the Terrence Higgins Trust, CHAPS produces various research-informed campaigns through interventions in the media.
It works on the principle that people are influenced more by their peers than government and health agencies. For example, one campaign, ‘Clever Dick/Smart Arse’ aimed to increase condom use among men who have sex with men by:
- getting their peers to endorse condom use
- distributing free condoms in gay venues and encouraging people to buy discounted condoms online
- helping men judge their risk of HIV through an online survey
- increasing knowledge about correct condom use through the provision of online information.38
Prevention programming for black Africans
The National African HIV Prevention Programme (NAHIP) is another country-wide HIV prevention campaign funded by the Department of Health. It conducts a range of HIV interventions and provides structural services that target black Africans, while other activities try and reach a general audience.39
One of its campaigns, 'Beyond Condoms' aims to reduce the number of new HIV infections by promoting a safer sex culture within African communities in England. The campaign’s literature targets different religious groups and is available in five different languages.40
Needle and syringe programmes (NSPs)
The last measure of needle and syringe programme coverage in the UK was in 2006. At the time, 80% of NSPs were pharmacy-based while the remainder were specialist centres. In 2014, the NICE released new guidance on the provision of NSPs calling for a better mix of services.41
While the UK has reached the recommended World Health Organisation target of 200 syringes distributed per PWID per year, only a third of PWID in England receive more needle and syringes than the number of times they inject. Likewise, in Scotland, even though the number of needles and syringes distributed increased from 2.6 million in 2004/5 to 3.7 million in 2009/10 (equating to 200 per person), this was still well below the average number of injections per person (465).42
Opioid substitution therapy (OST)
In England and Wales, progress in the provision of OST is being threatened by a drive towards abstinence-based treatment. The potential government policy, 'Putting Full Recovery First', views the goal of drug treatment as "independence from any form of chemical."43
This has been disputed by many groups who say this is only a realistic target for a minority of drug users and that many would finish treatment too early, leading to a relapse.44
HIV education and awareness
In the UK, state schools have to provide Sex and Relationship Education (SRE) but independent schools do not. Parents also have the right to withdraw their children from SRE, though few do so.45
In a review of the National Curriculum in 2013, the UK government said that all state schools "should make provision for personal, social, health and economic education (PSHE), drawing on good practice"46 and that SRE is an "important and necessary part of all pupils’ PSHE education."47
"It is compulsory for pupils in secondary schools to have sex education that includes HIV/AIDS and STIs and sex education is statutory in science at key stages 1-3.”48
However, in the same year, a report by Ofsted - the official body that regulates schools in England – reported that curriculum provision for this subject area was only ‘good’ or ‘better’ in two-thirds of schools.49
In the early years of the epidemic, there were a number of high profile public awareness campaigns in the UK warning people about how you get HIV and calling for people to adopt safer sex behaviours.
In 1987, the government ran a major public information campaign called 'AIDS: Don't Die of Ignorance' which used television adverts and sent an information leaflet to every household.50
Since then, there have been very few public HIV awareness campaigns. Even sexual health campaigns such as 'Condom Essential Wear' in 2009 made no reference to HIV.51
More recently, a government-funded initiative called 'National HIV Testing Week' that has been running since 2011, aims to increase HIV awareness and testing among key affected populations in England, particularly men who have sex with men and African people.52
Antiretroviral treatment in the UK
Over the last few years, the number of people living with HIV and accessing antiretroviral treatment (ART) in the UK has continued to increase, from 84% in 2010 to 91% (85,489 people) in 2014. 95% of those on ART in 2014 were also virally suppressed. This means that the UK now meets two of the three UNAIDS 90/90/90 targets.53
ART coverage across key affected populations is also high; black Africans (92%), men who have sex with men (90%) and people who inject drugs (90%). However, treatment coverage varies greatly between age groups. For example, only 74% of young people (aged 16-24) living with HIV were on ART.54
Between 2010 and 2014, the proportion of people initiating ART with a CD4 count over 350 increased. 1,700 people initiated ART with a CD4 count over 500 (31% of all initiations) in 2014 compared to 600 (11% of all initiations) in 2010. This reflects the earlier prescribing of ART recommended by the new WHO and British HIV Association (BHIVA) guidelines that call for the initiation of ART immediately after HIV diagnosis, regardless of CD4 count.55 56
Barriers to HIV prevention in the UK
Stigma and discrimination
As in many other parts of the world, HIV-related stigma and discrimination prevent many people in the UK from accessing the services they need.
One study among black Africans living with HIV reported that a third had been discriminated against because of their HIV status. Half of this number said they had been discriminated against by healthcare workers (including doctors, dentists and hospital staff). As a result, many do not trust in the confidentiality of health services.57
Living with HIV in the UK has also been found to reduce a person's ability to find work and impacts upon people's employment opportunities leading to financial difficulties.58
The ongoing 'UK Stigma Index 2015' aims to find out whether people living with HIV in the UK experience HIV-related stigma and discrimination, and to describe how this affects their daily lives.59
Lack of HIV knowledge
There is also evidence that levels of HIV knowledge among the UK public is low. A survey by the National AIDS Trust in 2014 found that only 45% of people could correctly identify all of the ways HIV is and is not transmitted, and an increasing proportion incorrectly believed it can be transmitted via routes like kissing (16%).60
Talking about the need to educate the general public about HIV, Deborah Gold, Chief Executive of the National AIDS Trust said:
“It is alarming to see just how many people believe you can get HIV from kissing, sneezing, or coughing. Lack of understanding leads to stigma and discrimination towards people living with HIV.”61
In 2012, HIV treatment was made free to people from overseas. Guidelines also now ensure that those with HIV are referred to treatment and are placed where there are appropriate facilities.62 For example, people who are newly diagnosed are referred to an HIV specialist and those who are removed from the UK are given a three-month supply of medication.63
Furthermore, many migrants living with HIV in the UK already encounter difficulties in accessing treatment, care and support.64 Undocumented migrants in particular find it difficult to register with a local General Practice (GP) and are often required to prove their identity and do not understand NHS entitlement rules or how to apply for treatment.65
Despite evidence that HIV diagnoses are on the rise among certain groups, and that public knowledge of HIV is very low in the UK, the national government intends to cut funding for HIV prevention by 50%. The £1.2 million allocated for 2015/16 is equivalent to less than £1 for each person targeted by existing prevention programmes.66
In reaction to these proposed cuts, Deborah Gold, Chief Executive of the National AIDS Trust said:
"This decision is simply staggering. HIV transmission shows no signs of decline, with the highest number of diagnoses among gay and bisexual men ever last year. Public knowledge of HIV is far too low, and myths about HIV are on the increase. We are at serious risk of going backwards on HIV if national-level investment is not made in HIV prevention. We urge the Government to think again."67
These cuts are being proposed even though investment in HIV prevention has saved long-term treatment costs. Between 2000 and 2014, the provision of ART to stop HIV transmission from mothers to their babies saved the National Health Service (NHS) an estimated £3.1 billion.68
The future of HIV and AIDS in the UK
Although the UK has made significant progress in the provision of antiretroviral treatment over the past decade, the rate of new HIV infections has not declined, with men who have sex with men and black Africans still at a heightened risk of HIV.
Late diagnosis rates are still too high and have an impact on public heath as people living with an undiagnosed infection are more likely to pass the virus on to others.
As well as better access to testing services, in order to prevent new infections, there needs to be renewed efforts to increase HIV knowledge across the country through both public campaigns and education in schools.
However, impending government cuts to national HIV prevention funding mean that maintaining existing efforts, let alone the scaling up these services, will be very challenging.
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- 46. Department for Education (2013, September) 'The National Curriculum in England: Key stages 3 and 4 framework document'
- 47. Department for Education (2013, September) 'Guidance: Personal, Social, Health and Economic (PSHE) Education'
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- 49. Ofsted (2013) ‘Not yet good enough: personal, social, health and economic education in schools’
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- 59. Family Planning Association (FPA) (2015) 'The People Living With HIV Stigma Index UK 2015'
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- 63. National AIDS Trust (2009) 'Detention, removal and people living with HIV'
- 64. National AIDS Trust (NAT) and Terrence Higgins Trust (THT) (October, 2012) 'Will I have to pay?'
- 65. National AIDS Trust (NAT) (2012) 'Universal access to primary care: A gateway for HIV testing, treatment and prevention'
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- 68. British HIV Association (BHIVA) (2015, 27 November) 'Saving lives saves money: preventing mother-to-child HIV infection saves NHS £3.1 billion'