Overall, the number of people living with HIV in the UK continues to increase and the number living with undiagnosed HIV remains high

In 2014, an estimated 103,700 people (95% credible interval (CrI) 97,500-112,700) were living with HIV (PLWH) in the UK, of whom 69,200 (CrI 65,000-75,100) were men and 34,400 (CrI 31,700-39,100) were women. This compares to an estimated 100,000 PLWH in 20131. The overall HIV prevalence in the UK in 2014 was 1.9 per 1,000 people aged 15 and over. In 2014, an estimated 18,100 (17%) PLWH were unaware of their infection and at risk of unknowingly passing on HIV if having sex without a condom, and this is similar to revised estimates from 2013 (18,219 (18%)). The estimated number and proportion of people living with undiagnosed HIV have declined since 2010 (from 22,800 and 25% respectively), with the majority of this decline happening before 2012.

Despite a decline in undiagnosed HIV infections among men who have sex with men there is evidence that rates of ongoing HIV transmission remain high

An estimated 45,000 (CrI 41,900-49,500) men living with HIV in the UK in 2014 had acquired their infection through sex with other men (MSM), up from 43,000 in 2013. Among MSM aged 15-44, one in 20 is estimated to be living with HIV (48.7 MSM (CrI 41.2-58.1) per 1,000). An estimated 6,500 (CrI 3,500-10,900), 14%) MSM were unaware of their infection in 2014, a decline from 8,500 (CrI 4,600-13,900, 22%) in 2010. HIV testing coverage among MSM attending sexual health (STI) clinics has increased over this period and is likely to be the reason for the estimated decline in undiagnosed infections and observed increases in new diagnoses. Despite this there remains a high HIV incidence in MSM, with an indication of a small sequential increase in 2013 and 2014.

HIV testing in STI clinic attendees continues to increase throughout most of England with high coverage particularly among MSM

In England, 1.43 million people attended a STI clinic in 2014, with 69% of eligible attendees having an HIV test. Testing coverage was highest among MSM (87%, 90,719/104,028) and 179/223 (80%) of STI clinics across England achieved the British Association for Sexual Health and HIV (BASHH) standard . Coverage was less comprehensive for eligible heterosexual men (77%, 382,743/497,455) and women2 (62%, 504,249/814,459), and only 33/223 (15%) STI clinics achieved 80% HIV test coverage.

Prompt diagnosis remains a priority for heterosexuals living with HIV

Among the 54,100 (CrI 49,000-62,400) people (men (21,300), women (32,700)) living in the UK who had acquired HIV through heterosexual sex, more than one in five (21% (11,200 (CrI 6,200-18,900) were unaware of their HIV infection, with a higher proportion of those living outside London unaware (24% out of London undiagnosed compared to 12% in London). Among heterosexuals aged 15-44 in the UK, almost one in every 1,000 is estimated to be living with HIV (0.9 per 1,000 (CrI 0.7-1.1), with higher prevalence’s among black African heterosexual men (one in 56) and women (one in 22). Late diagnosis remains a significant problem among heterosexuals with 55% (1,381/2,490) newly diagnosed at a late stage of infection in 2014, of whom 51% (700/1,381) were black African. There is a need for expanded and scaled up HIV testing across the UK to reduce undiagnosed infection and late diagnosis in line with national HIV testing guidance.

The ongoing high rates of HIV transmission and acquisition among men who have sex with men emphasise the need for high impact, appropriately tailored combination prevention strategies and programmes

Despite high and increasing rates of HIV testing by MSM coupled with high levels of effective ART treatment coverage for those diagnosed positive, there remains evidence of ongoing HIV transmission among MSM. Ensuring optimal implementation of effective prevention interventions such as condom use is required to reduce infections, in addition to addressing the wider determinants of poor sexual health among MSM which are closely linked to HIV infection.

The evidence for efficacy and effectiveness of antiretroviral agents to reduce onward transmission from people who are HIV positive as well as prevent HIV acquisition in those who are HIV free (HIV – Pre Exposure Prophylaxis HIV – PrEP) continues to expand, making important additions to the prevention toolkit.

In England all anti-retroviral drugs, whether for treatment or prevention, are commissioned by NHS England. In June 2015 the use of ART by people who are HIV positive to both prevent as well as treat HIV infection (treatment as prevention or TasP) was approved by NHS England [20]. At present there is no publicly funded PrEP programme in any of the four UK nations. NHS England is currently working to make commissioning decisions about PrEP, with a outcome expected in the summer of 2016.

In England, 1.43 million people were reported to have attended an STI (also known as GUM) clinic in 2014, more than in 2013 (1.37 million). The proportion of eligible people tested for HIV infection (coverage) was 69% (991,816/1,439,212), a slight decrease from 71% in 2013.

HIV testing coverage remained highest among MSM (87%, 90,719/104,028), followed by heterosexual men (77%, 382,743/497,455) and women (62%, 504,249/814,459). Though overall increases in testing coverage in MSM and heterosexual men have continued since 2009 (rising from 78% in MSM and 72% in heterosexual men in 2009), coverage in women has decreased from 67% in 2013. This is despite an increase in eligible women testing (up from 482,443 in 2013) and may be due to attendances at integrated sexual and reproductive health clinics in which the population of women being seen may be at lower HIV risk.

There were 179 of 223 (80%) STI clinics in England where HIV testing coverage reached at least 80% among MSM attendees, consistent with BASHH recommendations for STI testing in MSM [5]. Of these, 44 clinics achieved optimal (90% or greater) testing coverage in eligible MSM attendees. However, coverage was lower among heterosexual men and women, where 85% (190/223) of clinics fell below 80%. In every PHE centre area of the country there were marked differences between local services in the levels achieved for HIV test coverage.

Despite improved coverage for MSM among STI clinic attendees, continued efforts to further increase HIV testing are needed, in line with national testing guidance. Expanded HIV testing outside of STI services should also be implemented in order to increase accessibility among populations not regularly presenting to STI clinics. STI clinic data from England in 2014 indicate that less than one quarter of people of black African or black British ethnicity presented to the same STI clinic at least once in the previous five years.

Pre-exposure prophylaxis (PrEP)

HIV Pre Exposure Prophylaxis (HIV – PrEP) is the use of antiretroviral agents by people who do not have HIV prior to a potential exposure to HIV to prevent acquisition of infection. Worldwide a number of research studies in different populations have shown that consistent use of HIV-PrEP can be an efficacious and effective prevention intervention. Two European studies of oral PrEP using a combination of tenofovir and emtricitabine coformulated as Truvada (t) among men who have sex with men (PROUD trial in the UK and the IPERGAY trial in France) have reported during 2015. Both trials demonstrated a reduction in HIV acquisition of 86% in intent to treat analyses. Existing and emerging data suggest that HIV – PrEP has the potential, within a combination prevention approach, to have a significant role in the control of HIV transmission.

In England use of anti-retroviral drugs, whether for treatment or prevention, is designated as a specialised service that is commissioned by NHS England. PHE is actively involved in supporting NHS England and local authorities as they prepare to make commissioning decisions about PrEP. Working within the PrEP Policy Working Group (of NHS England’s Clinical Reference Group) for HIV, PHE is supporting NHS England’s policy development through the delivery of data and intelligence, which includes a comprehensive evidence review and health economic analyses.

Impact of treatment on HIV prevention in the UK

People on effective ART with an undetectable viral load are very unlikely to pass on HIV to sexual partners In the UK, free and accessible HIV treatment and care has resulted in large-scale treatment coverage: in 2014, an estimated 75% of all PLWH (diagnosed and undiagnosed) were treated and 70% of all PLWH (72,800/103,700) had an undetectable viral load (less than 200 copies/UL). This figure is close to the ambitious UNAIDS target of 73% of all PLWH being virologically suppressed, as laid out in the 90-90-90 goals (90% of people living with HIV being diagnosed, 90% diagnosed on ART and 90% viral suppression for those on ART by 2020).

The number and proportion of people initiating ART at CD4 counts>350 cells/mm3 has increased between 2010 and 2014 (Figure 9). This is particularly seen for those with a CD4>500 cells/mm3 in which group 1,700 people (31% of all initiations) initiated ART in 2014 compared to 600 (11%) in 2010. This may reflect earlier prescribing and uptake of ART to prevent HIV transmission as per British HIV Association (BHIVA) guidelines.

Two methods are used to estimate the number of people living with HIV including those undiagnosed. The first, the multi-parameter evidence synthesis model (MPES), produces annual estimates for all most at risk populations, while the second is a CD4 back-calculation model that provides undiagnosed prevalence as well as incidence estimates restricted to MSM populations. These figures complement the data on diagnosed HIV prevalence presented in the HIV new diagnoses, treatment and care 2015 report.

In 2015, there have been significant revisions to the MPES used to estimate the number and proportion of people living with undiagnosed HIV (full methodology published in). This is due to changes to the sources of primary data used by the model over the past few years, including changes to the unlinked anonymous serosurveys and behavioural surveys (eg NATSAL) and a greater reliance on data from STI clinics. In this report, the revised MPES methodology was used to generate annual estimates and trend data for the years 2010 to 2014. Revisions to the methodology in 2015 mean that figures in this report may be different to previously published estimates.

In 2014, there were an estimated 103,700 people living with HIV (PLWH) in the UK (95% credible interval (CrI) 97,500-112,700). An estimated 18,100 (17%) (CrI 12,100-26,900) people were unaware of their infection, with differences between exposure groups (Figure 1 and Appendix 1). Since 2010 the number of PLWH has increased (from 91,900) while the number and proportion undiagnosed (22,800, 25%) declined before stabilising in recent years.

The HIV prevalence among those aged 15-44 years in 2014 in the UK was estimated to be 2.3 per 1,000 population (CrI 2.1-2.5), 2.8 per 1,000 men and 1.7 per 1,000 women. The HIV epidemic remains largely concentrated among gay, bisexual men and other MSM and men and women of black African ethnicity.

Early diagnosis of HIV infection enables better treatment outcomes and reduces the risk transmitting the infection to others. Have an HIV test if you think you may have been at risk.

• Men who have sex with men are advised to have an HIV and STI screen at least annually, and every three months if having 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 screen if having unprotected sex with new or casual partners.
• Always use a condom correctly and consistently, and until all partners have had a sexual health screen
• Reduce the number of sexual partners and avoid overlapping sexual relationships.
• Unprotected sex with partners believed to be of the same HIV status (serosorting) is unsafe. For the HIV positive person, there is a high risk of acquiring other STIs and hepatitis. For the HIV negative person, there is a high risk of acquiring HIV infection (over 7,000 of MSM and 13,000 black-African heterosexuals remain unaware of their HIV infection) as well as of acquiring STIs and hepatitis.

Early diagnosis of HIV infection enables better treatment outcomes and reduces the risk transmitting the infection to others.

Have an HIV test if you think you may have been at risk.

Always use a condom correctly and consistently, and until all partners have had a sexual health screen.

Reduce the number of sexual partners and avoid overlapping sexual relationships.

Men who have sex with men are advised to have an HIV and STI screen at least annually, and every three months if having unprotected sex with new or casual partners.

Unprotected sex with partners believed to be of the same HIV status (serosorting) is unsafe. For the HIV positive person, there is a high risk of acquiring other STIs and hepatitis. For the HIV negative person, there is a high risk of acquiring HIV infection (6,500 of MSM remain unaware of their HIV infection) as well as of acquiring STIs and hepatitis.
Black African men and women are advised to have an HIV test and a regular HIV and STI screen if having unprotected sex with new or casual partners.

How to get an HIV test: Go to an open-access sexually transmitted infection (STI) clinic (some clinics in large cities are offering ‘fast-track’ HIV testing) or go to a community testing site.

Ask your GP for an HIV test – nowadays there is no need for a lengthy discussion about the test, it just involves having blood taken, or even a finger prick.

Ask online for a self-sampling kit.