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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