Africans and HIV in the UK: an epidemiological perspectiveNov 2006

Tim Chadborn

On behalf of the HIV Reporting Section with special thanks to Julia Abernethy and Bela Vatsa

HIV & STI Department, Health Protection Agency Centre for Infections

What I will cover…

UK epidemiology

Access to treatment and care

Access to services

Access to treatment

AIDS and death

Late diagnosis

Preventable mortality

Key messages

New HIV diagnoses

0

1000

2000

3000

4000

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Year

Nu

mb

er

of

dia

gn

os

es

an

d d

ea

ths

HIV diagnoses

AIDS diagnoses

Deaths

HIV and AIDS diagnoses and deaths in HIV-infected black Africans, E,W&NI

Widespread

introduction of

HAART

1 Numbers will rise, for recent years, as further reports are received; reports from the Channel Islands excluded

Data Source: HIV/AIDS and death reports. Reports received by the end of September 2006.

HIV diagnoses of black Africans by exposure category

0

500

1000

1500

2000

2500

3000

3500

4000

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Year

Nu

mb

er

of

dia

gn

os

es

Men who have sex with men

Heterosexual contact

Injecting drug use

Mother to infant

Recipients of Blood/Blood Products

Undetermined

Heterosexual Women

1 Numbers will rise, for recent years, as further reports are received; reports from the Channel Islands excluded

Data Source: HIV/AIDS and death reports. Reports received by the end of September 2006.

0

50

100

150

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Year

Nu

mb

er

of

dia

gn

os

es

Men who have sex with men

Injecting drug use

Mother to infant

Recipients of Blood/Blood Products

1 Numbers will rise, for recent years, as further reports are received; reports from the Channel Islands excluded

Data Source: HIV/AIDS and death reports. Reports received by the end of September 2006.

HIV diagnoses of black Africans by exposure category – excluding heterosexuals

HIV diagnoses of infections that were probably acquired in Africa among non-black Africans

1 Numbers will rise, for recent years, as further reports are received; reports from the Channel Islands excluded

Data Source: HIV/AIDS and death reports. Reports received by the end of September 2006.

0

20

40

60

80

100

120

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Year

Nu

mb

er

of

dia

gn

os

es

White

Black Caribbean

Black - other

Indian/Pakistani/Bangladeshi

Other/mixed

HIV prevalence in adults HIV prevalence in adults in sub-Saharan Africa, end 2005in sub-Saharan Africa, end 2005

20% − 34%

10% − <20%

5% − <10%

1% − <5%

0% − <1%

trend data unavailable

outside region

Countries in the Commonwealth

HIV diagnoses of infections acquired through heterosexual contact

>75%

1 Numbers will rise, for recent years, as further reports are received; reports from the Channel Islands excludedData Source: HIV/AIDS reports. Reports received by the end of September 2006.

Acquired in UK -Partners’ region of infection

Acquired in Africa -African region of infection2005

Africa

UK

Other Europe

Rest of world

Not reported

Central

Eastern

Northern

South Eastern

Southern

Western

Not reported

Africa

Europe

Rest of world

Not reported

1996

Afric

aUK Ot

her E

urop

eRe

st o

f wor

ldNo

t rep

orte

d

Central

Eastern

Northern

South Eastern

Southern

Western

Not reported

Africa

Europe

Rest of world

Not reported

Acquired in Africa -African region of infection

Afric

a

UK Othe

r Eur

ope

Rest

of w

orld

Not r

epor

ted

Central

Eastern

Northern

South Eastern

Southern

Western

Not reported

Africa

Europe

Rest of world

Not reported

Key

Patients region of infection Patients region of infection

n 840

n 130

n 559

n 553

n 4049

n 2760

Acquired in UK -Partners’ region of infection

People seen for HIV care

HIV-infected individuals accessing care by ethnic group, 1996 and 2005 (E, W, NI)

38%

n= 11 356

77%

2%

16%

1% 4%

White

Black Caribbean

Black African

Asian/ Oriental

Other/Mixed

n= 44 553

50%

3%

39%

3%5%

Note: excluded from figure are 1736 from 1996 and 792 individuals from 2005 for whom no ethnicity was reported

17 330

1788

Percentage of ethnic groups diagnosed as HIV-infected: 2005

Source: SOPHID and ONS

Black African Black CaribbeanIndian/Pakistani/

BangladeshiWhite

Number aged 15-59 diagnosed with HIV infection and receiving care

(SOPHID)16,355 1,206 483 21,448

Population, aged 15-59

(ONS 2004 estimates)442,300 384,600 1,522,400 26,977,300

Percentage aged 15-59 living with diagnosed HIV 3.7% 0.3% 0.03% 0.08%

Undiagnosed infection

Undiagnosed HIV infections

One in 3 persons living with HIV are undiagnosed (approx 20 000 people)

- Persons unaware are at increased risk of:

presenting late/ AIDS preventable death transmitting HIV to sexual partners

- varies with different groups:

Among black Africans ca: 17,000 diagnosed, 6,000 not

Prevalence of previously undiagnosed1 HIV infection among heterosexuals attending sentinel GUM clinics

1Previously undiagnosed HIV infection includes those diagnosed at the clinic attendance and those remaining undiagnosed. Data source: Unlinked Anonymous prevalence monitoring, England, Wales and Northern Ireland

0%

1%

2%

3%

4%

5%

6%

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

Year

Pre

va

len

ce

of

pre

vio

us

ly u

nd

iag

no

se

d H

IV

infe

cti

on

Sub-Saharan Africa-born Caribbean-born

Asia-born UK-born

Epidemiology summary

Black Africans living with HIV in the UK

• 17,206 black Africans living with diagnosed HIV in 2005 (22,521 white)

• Over 3500 new diagnoses each year (approx 20,000 total)

• 2/3 are women

• Most HIV-infected black Africans were born in Africa and infected through heterosexual sex in Africa (small number of MSM)

• Most came to the UK during the last ten years and were diagnosed in the UK within a few years of arrival

• around 100 children (<15 years) 97% infected MTCT

• Two-fifths of black-African adults were diagnosed late in 2005 (CD4<200)

• >10% have AIDS at the time of HIV diagnosis

• Almost all active TB identified at HIV diagnosis is among black Africans

Black Africans living with HIV in the UK

• About 1 in 40 women giving birth who were born in SSA are HIV positive.

1 in 30 of those born in Central and Eastern Africa

1 in 80 of women born in Southern or Western Africa

(1 in 2500 women born in the UK)

• In 2005, 3036 women newly diagnosed with HIV

• 18% reported being tested antenatall

• Other reasons: symptoms (28%), routine screening at GUM clinics (25%) and known positive partner (10%).

• <10% die aged 50 years or more and many die shortly after HIV diagnosis (MSM: 30% and relatively few)

Access to services (2004 study using 2003 data)

2003 HIV treatment centres (red dots) and patients (blue dots)

© Crown Copyright. All rights reserved (Health Protection Agency – 10016969 2005)

Distance to and use of local centre

Out of London London (25km radius)

Distance to local centre (Km)

% using local centre

Total% using local

centreTotal

         

<=5 69 7,304 (69%) 43 16,299 (98%)

       

6 to 10 49 1,741 (17%) 19 344 (2%)

       

11 to 20 35 1,114 (11%) - 0

       

20+ 51 395 (4%) - 0

         

Total 61 10,554 (100%) 42 16,643 (100%)

Individuals accessing HIV care: SOPHID 2003

0

1000

2000

3000

4000

5000

6000

Nu

mb

er o

f in

div

idu

als

non-local centre local centre

Summary of findings

• Half of all individuals used their local services (<1km – 90km).

• Majority of individuals live within 5km of an HIV service.

• Local service use is greatest in those living very near to the service.

• There is much greater local service use outside of London.

• There are some differences by population sub-group.

• E.g. Those requiring specialist services use non-LS (paediatrics & haemophiliacs).

Access to treatment

BHIVA guidelines on ARV treatment initiation (relating to CD4 cell counts)

CD4 cell count (per mm3) before starting therapy

General recommendation for asymptomatic individuals

<200 All patients should be on ARV

201-350 ARV commencement

350+ ARV not recommended

Number of individuals on ARV by CD4 cell count category

0

5000

10000

15000

20000

25000

<200 200-350 350+

CD4 count category

Nu

mb

er

of

ind

ivid

ua

ls

on ARV Not on ARV

Percentage with CD4<200 that were not on ARV

0

10

20

30

40

50

60H

ete

rosexual M

ale

*

Sex b

etw

een m

en

Hete

rosexual F

em

ale

*

Oth

er

(inc N

K)

White

Bla

ck-A

fric

an

Oth

er

(inc N

K)

15-2

4

25-3

4

35-4

4

45+

Asym

pto

matic

Sym

pto

ms p

re-A

IDS

AID

S

Death

in a

patient

with A

IDS

Oth

er

(inc N

K)

Route of infection Ethnicity Age Group Most advanced clinical stage everreached

% n

ot

on

AR

V

0

5

10

15

20

25

30

35

40

45

50

East M

idlan

ds

Easte

rn

Lond

on

North E

ast

North W

est

Norther

n Ire

land

South

Eas

t

South

Wes

t

Wale

s

Wes

t Midl

ands

Yorks

hire

& H

umbe

rsid

e

Region & SHA of treatment

% n

ot

on

AR

TPercentage with CD4<200 that were not on ARV by region where treated

n = 215

499287

2734

89

37532

70

190

219

224

Summary of 2005 findings

• 92% of adults not on ART had CD4>=200 and so did not require ART according to guidelines

• Among severely immunocompromised individuals (CD4<200), 20% were not receiving ART

• Some may be expected to start ART consequently

• Little variation by ethnicity or exposure category

• Some variation by region

AIDS and death

0

1000

2000

3000

4000

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Year

Nu

mb

er

of

dia

gn

os

es

an

d d

ea

ths

HIV diagnoses

AIDS diagnoses

Deaths

HIV and AIDS diagnoses and deaths in HIV-infected black Africans, E,W&NI

Widespread

introduction of

HAART

1 Numbers will rise, for recent years, as further reports are received; reports from the Channel Islands excluded

Data Source: HIV/AIDS and death reports. Reports received by the end of September 2006.

0

2

4

6

8

10

12

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

Calendar year of follow-up

Inci

den

ce r

ate

(per

100

PY

FU

)

Overall incidence of death

Incidence of death within 6 months of HIV diagnosis

Incidence of death more than 6 months after HIV diagnosis

Incidence of death (all causes)

Widespread introduction of HAART

Late diagnosis

Late diagnoses by exposure category, 2005

Data source: CD4 Surveillance and CD4 Monitoring

22%

28%

37%

47%

34%

7%11% 10%

19%

11%

0%

10%

20%

30%

40%

50%

MSM IDUs Femaleheterosexuals

Maleheterosexuals

Overall

Exposure category

Per

ce

nta

ge

of

ne

w H

IV d

iag

no

ses

d

iag

no

se

d l

ate

Patients with CD4 count under 200 cells/mm3 within 30 days of diagnosis.

Patients with a clinical AIDS diagnosis within 3 months of HIV diagnosis.

47% 44% 44% 43% 41% 41% 40% 39% 36% 34%

0%

10%

20%

30%

40%

50%

South W

est

North W

est

London

South E

ast

East M

idla

nds

Wal

es

Easte

rn

York. &

Hum

b.

Wes

t Mid

land

s

North E

ast

Percentage diagnosed late: region of diagnosis

All significantly

different to London

20% 21%

49%44% 44%

0%

10%

20%

30%

40%

50%

Black African White White Black African White

n = 256 291 124 7,270 221

Infected in the UK Infected in the UK Infected in Africa

partner infected outside EU partner infected within EU

Percentage diagnosed late : profile by ethnicity,region of infection and region of infection of partner

Preventable mortality

3.0

0.67

6.12

0

2

4

6

8

10

Overall Not diagnosed late Diagnosed late

Sh

ort

-te

rm m

ort

alit

y (

%)

Short-term mortality: univariable analysis

(Short-term mortality = Percentage who died within a year of diagnosis)

OR = 9.6p = <0.01

Short-term mortality as a percentage of all deaths

0%

10%

20%

30%

40%

50%

60%

70%

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

Year of death

Pe

rce

nta

ge

of

de

ath

s w

ith

in a

ye

ar

of

dia

gn

os

is

0

100

200

300

Nu

mb

er

of

de

ath

s

Total number of deaths

Percentage of deaths within a year of diagnosis

Crude estimation of preventable deaths 2000-2004

Black Caribbeans

White

1 in England and Wales, 2000-2004, excluding those previously diagnosed abroad

650

1,630

No. new diagnoses 1

2 those arrived in UK less than 2 years before diagnosis (data only available from clinician reports)

15% (98)

4% (65)

Percentage recent

arrivals 2

3 only individuals with both a clinician report and a CD4 count at HIV diagnosis

33% (32)

38% (25)

Percentage of recent arrivals

diagnosed late 3

4 assuming short-term mortality of those diagnosed late is 6.12%

2

2

Est. no. deaths: recent

arrivals diagnosed

late 4

5 assuming short-term mortality of those not diagnosed late is 0.67%

4

11

Est. no. deaths: other

individuals 5

6 / 19 (32%)

13 / 73 (18%)

Est. deaths/ Obs. deaths

35

184

Total deaths

Black Africans 11,525 37% (4,264) 43% (1,834) 112 68 180 / 356 (51%) 550

Key messages

• Late diagnosis is considerable among heterosexuals

Summary of results

• Substantial mortality within the first year after diagnosis

continues in the HAART era

• Individuals diagnosed late were about 10 times more likely to

die within a year of diagnosis

• Almost 50% of all deaths now occur within a year of diagnosis

• Early diagnosis could prevent deaths

• Groups at high risk of late diagnosis should be targeted for

appropriate health promotion activities, opportunistic

screening, and removal of any barriers to testing - stigma

Conclusions

• HIV testing in a variety of settings would reduce missed

diagnoses, numbers with AIDS at HIV diagnosis, and costs.

• New patient checks in primary care may be the earliest opportunity

to diagnose infection among recent arrivals to the UK.

Acknowledgements

The continuing collaboration of clinicians, nurses, microbiologists, health advisors and data managers who contribute to HIV surveillance in the UK is gratefully acknowledged. Without their generosity, time and effort, the current level of understanding of the epidemic could not have been attained.

Nov 2006