The United Kingdom (UK) has a relatively small HIV epidemic, with an estimated 103,700 people living with HIV in 2014. This equates to an HIV prevalence of 1.9 per 1,000 people aged 15 and over.1 In the same year, 6,151 people were newly diagnosed with HIV and 613 people died of AIDS-related illnesses.2
Access to antiretroviral treatment in the UK has improved significantly over the past decade. In 2014, 91% of people living with HIV were receiving antiretroviral treatment (ART).3 However, late diagnosis of HIV remains a key challenge in this country, despite declining rates.
Moreover, evidence suggests that levels of HIV knowledge among the general population have fallen. This is due at least partly to a lack of public awareness campaigns and the absence of HIV from sexual and reproductive health education in schools.
The epidemic in the UK mainly affects men who have sex with men and black Africans.
Key affected populations in the UK
Men who have sex with men
Since the 1980s, men who have sex with men (MSM) have remained the group most at risk of HIV in the UK. In 2014, an estimated 45,000 MSM were living with HIV meaning roughly one in twenty MSM aged 15 to 44 are living with the virus. The number of MSM newly diagnosed with HIV continues to rise from 2,860 men in 2010, to 3,360 in 2014.4
Two-thirds of new HIV diagnoses among MSM in 2014 were between 25 and 44 years old and 6% were over 55 at the time of their diagnosis. Over half (51%) of these new diagnoses were made in London. Four in five MSM newly diagnosed with HIV were white (81%), with 2% black African, 2% black Caribbean and 14% described as other/mixed race. The majority (60%) were born in the UK with 20% from the rest of Europe, 3% born in Africa and 6% in Asia.5
Increases in HIV diagnoses can be partly explained by increased HIV testing as well as ongoing HIV transmission. 14% of MSM living with HIV in the UK are believed to be unaware of their infection.6
Heterosexual men and women and black Africans
In 2014, an estimated 21,300 heterosexual men and 32,700 heterosexual woman were living with HIV in the UK. Of this number, 55% of men and 62% of women were of black African ethnicity. Indeed, the number of black Africans living with HIV has continued to rise.7 In the same year, there were 2,186 new HIV diagnoses as a result of heterosexual sex – 1,218 among heterosexual women and 986 among heterosexual men.8
Almost half (48%) of all people accessing HIV care (40,842) acquired HIV via heterosexual sex (15,383 men and 25,459 women). Among this group, 60% of people were black African, 24% white, 4% black Caribbean, 3% other black ethnicity, 2% Indian/Pakistani/Bangladeshi, and 2% of other Asian ethnicity.9
51% of heterosexual men with HIV were aged 25 to 44 compared to 60% of women. 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.10
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 much higher among this group. For example, 17.9 per 1,000 black African heterosexual men and 43.7 per 1,000 black African women were living with HIV in 2014 compared to 0.5 per 1,000 non-black African men and 0.7 per 1,000 non-black African women.11
People who inject drugs
The HIV epidemic among people who inject drugs (PWID) in the UK has remained low with an estimated 2,160 PWID living with HIV in 2014 – an HIV prevalence of 2.2 per 1,000 among PWID aged 15 to 44. 11% of all PWID were unaware of their HIV status.12
There were 150 new HIV diagnoses as a result of sharing injecting drug equipment in 2014 – 101 men and 49 women. Nearly a third (30%) of these diagnoses were made in London. Almost three-quarters (73%) of new diagnoses among PWID were between 25 and 44 years old and 6% were aged 55 or above.13
Other key affected populations
In 2014, 29 children were newly diagnosed with HIV – down from 131 in 2005. Two-thirds of these children were born abroad and arrived in the UK at an elder age. Three children born in 2014 were known to have acquired HIV from their mothers.14
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%). MSM were most likely to have an HIV test (87%) compared with 77% of heterosexual men and 62% of heterosexual women.15
While testing coverage among MSM 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.16
179 out of 223 health clinics achieved the recommended testing coverage of 80% among MSM, consistent with British Association for Sexual Health and HIV (BASHH) recommendations for this group.17 44 clinics achieved optimal testing coverage (90%) among eligible MSM. However, 85% of clinics (190/223) did not achieve 80% testing coverage among heterosexual men and women.18
Where black Africans are concerned, one survey detected an annual HIV testing rate of just 36.8%.19 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.20
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.21 22 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.23
Late diagnoses were highest among PWID (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.24
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.25
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.26 The service began in November 2015 as part of National HIV Testing Week.27
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."28
HIV prevention programmes in the UK
Prevention programming for MSM
CHAPS has been England's main HIV prevention programme working to prevent the sexual transmission of HIV among MSM. 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 MSM by:
- getting the peers of MSM 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.30
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.31
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.32
- 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.33
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).34
- 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."35
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.36
HIV education and awareness
- School education
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.37
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"38 and that SRE is an "important and necessary part of all pupils’ PSHE education."39
"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.”40
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.41
- Public awareness
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 utilised television and sent an information leaflet to every household.42
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.43
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 MSM and African people.44
Antiretroviral treatment in the UK
Over the last few years, the number of people living with HIV and accessing 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.45
ART coverage across key affected populations is also high; black Africans (92%), MSM (90%) and PWID (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.46
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.47 48
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.49
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.50
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.51
- 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%).52
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.”53
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.54 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.55
Furthermore, many migrants living with HIV in the UK already encounter difficulties in accessing treatment, care and support.56 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.57
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.58
In reaction to these proposed cuts, Deborah Gold 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."59
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.60
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 MSM 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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- 2. Public Health England (PHE) (2015) 'HIV New Diagnoses, Treatment and Care in the UK 2015 report'
- 3. Public Health England (PHE) (2015) 'HIV New Diagnoses, Treatment and Care in the UK 2015 report'
- 4. Public Health England (PHE) (2015) ‘HIV in the UK: situation report 2015’
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- 16. Public Health England (PHE) (2015) ‘HIV in the UK: situation report 2015’
- 17. Public Health England (PHE) (2014) ‘Addressing Late HIV Diagnosis through Screening and Testing: An Evidence Summary’
- 18. Public Health England (PHE) (2015) ‘HIV in the UK: situation report 2015’
- 19. Sigma Research (2014) 'African Health & Sex Survey 2013-2014: headline findings'
- 20. Public Health England (PHE) (2015) ‘HIV in the UK: situation report 2015’
- 21. Clifton, S., et al (2015) ‘HIV testing, risk perception and behaviour: findings from the third British National Survey of Sexual Attitudes and Lifestyles’ AIDS Journal
- 22. aidsmap (2015) ‘Large UK study shows low rates of HIV testing, even among those who think they are at risk of HIV’
- 23. Public Health England (PHE) (2015) 'HIV New Diagnoses, Treatment and Care in the UK 2015 report'
- 24. Public Health England (PHE) (2015) 'HIV New Diagnoses, Treatment and Care in the UK 2015 report'
- 25. The National Institute for Health and Clinical Excellence (NICE) (2011) 'PH33 Increasing the uptake of HIV testing among black Africans in England: guidance'
- 26. Public Health England (PHE) (2015) ‘HIV in the UK: situation report 2015’
- 27. Public Health England (PHE) (2015, 18 November) 'Free HIV home sampling launched to increase HIV testing'
- 28. Public Health England (PHE) (2015, 18 November) 'Free HIV home sampling launched to increase HIV testing'
- 29. HIV Prevention England (HPE) ‘Who we are’ [Accessed 19 November 2015]
- 30. Terrence Higgins Trust (2011, 29 November) 'THT urges gay men to take three steps to reduce spread of HIV'
- 31. Aidsmap 'National African HIV Prevention Programme (NAHIP)' [Accessed 19 November 2015]
- 32. AHRF News (2005) 'Focus on NAHIP' 2(4)
- 33. National Institute for Health and Care Excellence (NICE) (2014) 'PH52 Needle and Syringe Programmes'
- 34. National AIDS Trust (NAT) (2013) 'HIV and Injecting Drug Use'
- 35. National AIDS Trust (NAT) (2013) 'HIV and Injecting Drug Use'
- 36. National AIDS Trust (NAT) (2013) 'HIV and Injecting Drug Use'
- 37. Department for Education (2014, December) 'National Curriculum in England: Framework for Key Stages 1 to 4'
- 38. Department for Education (2013, September) 'The National Curriculum in England: Key stages 3 and 4 framework document'
- 39. Department for Education (2013, September) 'Guidance: Personal, Social, Health and Economic (PSHE) Education'
- 40. Ofsted (2014, June) ‘Written evidence submitted by Ofsted’
- 41. Ofsted (2013) ‘Not yet good enough: personal, social, health and economic education in schools’
- 42. National AIDS Trust (NAT) (2011) 'The Need for Public Awareness and Understanding of HIV'
- 43. National AIDS Trust (NAT) (2011) 'The Need for Public Awareness and Understanding of HIV'
- 44. HIV Prevention England (2014) 'National HIV Testing Week' [Accessed 19 November 2015]
- 45. Public Health England (PHE) (2015) 'HIV New Diagnoses, Treatment and Care in the UK 2015 report'
- 46. Public Health England (PHE) (2015) 'HIV New Diagnoses, Treatment and Care in the UK 2015 report'
- 47. World Health Organisation (WHO) (2015) 'Guideline on when to start antiretroviral therapy and on pre-exposure prophylaxis for HIV'
- 48. British HIV Association (BHIVA) (2015) ‘British HIV Association guidelines for the treatment of HIV-1-positive adults with antiretroviral therapy 2015’
- 49. National AIDS Trust (NAT) (2014) 'HIV and Black African Communities in the UK'
- 50. Sigma Research (2009) 'What do you need? 2007-2008 Findings from a national survey of people with diagnosed HIV'
- 51. Family Planning Association (FPA) (2015) 'The People Living With HIV Stigma Index UK 2015'
- 52. National AIDS Trust (NAT) (2014) ‘HIV: Public Knowledge and Attitudes 2014’
- 53. National AIDS Trust (NAT) (2014, 1 December) ‘British public still in the dark about HIV 30 years on’
- 54. UK Border Agency (2012) 'Healthcare needs and pregnancy dispersal guidance'
- 55. National AIDS Trust (2009) 'Detention, removal and people living with HIV'
- 56. National AIDS Trust (NAT) and Terrence Higgins Trust (THT) (October, 2012) 'Will I have to pay?'
- 57. National AIDS Trust (NAT) (2012) 'Universal access to primary care: A gateway for HIV testing, treatment and prevention'
- 58. National AIDS Trust (NAT) (2015, 15 December) 'NAT opposes 50% cut to national HIV prevention funding for England'
- 59. National AIDS Trust (NAT) (2015, 15 December) 'NAT opposes 50% cut to national HIV prevention funding for England'
- 60. British HIV Association (BHIVA) (2015, 27 November) 'Saving lives saves money: preventing mother-to-child HIV infection saves NHS £3.1 billion'