Debate on the HIV Action Plan Annual Update, 2022-23

Background

Human immunodeficiency virus (HIV) damages cells in the immune system and weakens a person’s ability to fight everyday infections and disease. HIV is distinct from acquired immune deficiency syndrome (AIDS) – a term used to describe a range of infections and illnesses which can result from a weakened immune system caused by HIV. If HIV is left untreated, it can lead to AIDS.

HIV can be transmitted from one person to another through bodily fluids, including semen, vaginal and anal fluid and blood. HIV can also be transmitted through sharing needles, syringes or other injecting equipment, or from mother to baby during pregnancy, birth or breastfeeding. HIV cannot be transmitted through sweat, urine or saliva. In the UK, the most common way of getting HIV is through having anal or vaginal sex without a condom.

Some groups of people are at higher risk of becoming infected with HIV. These include:

• People with a current or previous partner with HIV.
• Men who have unprotected sex with men, people who inject drugs and share equipment.
• People who have received a blood transfusion, transplant or other risk-prone procedures in countries that do not have strong screening for HIV.

HIV is treated using antiretroviral medicines. These stop the virus replicating in the body and allow the immune system to repair itself and prevent further damage. The aim of HIV treatment is for the affected person to have an ‘undetectable viral load’, meaning the level of HIV in the body is too low to be detected by a test.

Pre-exposure prophylaxis (PrEP) describes a practice where a HIV-negative person takes antiretroviral medication to reduce the likelihood of contracting HIV from an infected partner. PrEP can be taken regularly, or alternatively, immediately before and after sex. PrEP comes as tablets that contain 2 medicines called tenofovir disoproxil and emtricitabine. People at higher risk of contracting HIV can obtain PrEP from sexual health clinics.

The NHS website provides information about HIV and AIDS, treatment and prevention and PrEP.

In England, local authorities are responsible for providing HIV testing and other public health services. Each local authority receives an allocation from the Government’s ring-fenced public health grant.

In 2022/23, the Department for Health and Social Care (DHSC) made £3.417 billion available to local authorities via the grant.

The HIV Action Plan for England

In 2019, the Government set out an ambition to achieve zero new HIV infections, AIDS and HIV-related deaths in England by 2030.

Welcoming this ambition, three national charities, Terrence Higgins Trust, National AIDS Trust and Elton John AIDS Foundation established the HIV Commission to support its delivery. The Commission, which has been endorsed by government, considered how the Government could achieve the 2030 target and published its recommendations in a December 2020 report, including that:

• England should take the necessary steps to be the first country to end new HIV transmissions, by 2030, with an 80% reduction by 2025.
• National government must drive and be accountable for reaching this goal through publishing a comprehensive national HIV Action Plan in 2021.
• HIV testing must become routine – opt-out, not opt-in, across the health service.

In December 2021, the Department for Health and Social Care (DHSC) published Towards Zero: HIV Action Plan for England 2022 to 2025.

Principally, it set out how the Government intends to achieve the interim ambition, set by the HIV Commission, of reducing new HIV transmissions in England by 80%, by 2025. It also sets out progress the Government hopes to make by 2025, towards its 2030 ambition of zero new HIV infections, AIDS and HIV-related deaths in England:

1. To reduce the number of people first diagnosed in England from 2,860 in 2019, to under 600 in 2025.
2. To reduce the number of people diagnosed with AIDS within 3 months of HIV diagnosis from 219 to under 110.
3. To reduce deaths from HIV/AIDS in England from 230 in 2019 to under 115.

The plan sets out how the Government intends to do this through four overarching objectives:

• Objective 1: ensure equitable access and uptake of HIV prevention programmes
  • Key actions to facilitate this include £3.5 million of funding to deliver a National HIV Prevention Programme over 2021 and 2024. The Government also committed to continuing to invest £23 million, via the Public Health Grant, in HIV pre-exposure prophylaxis (PrEP). The Government also said it would work to improve PrEP access for key population groups and monitor progress through a monitoring and evaluation framework.

• Objective 2: scale up HIV testing in line with national guidelines
  • Key actions include expanding opt-out testing in emergency departments in the highest prevalence local authority areas, supported by £20m over three years. The UK Health Security Agency (UKHSA) and the Office for Health Improvements and Disparities (OHID) would also work on understanding HIV testing uptake in sexual health services.

• Objective 3: optimise rapid access to treatment and retention in care
  • Key actions include reducing the number of people newly diagnosed with HIV who are not promptly referred to care and improving support to increase the number of people retained in care and receiving effective treatment.

• Objective 4: improving the quality of life for people living with HIV and addressing stigma
  • Key actions include the development of an audit tool to enable local areas to understand provision of availability and accessibility of HIV services and support, and addressing stigma and improving knowledge across the health and care system about HIV transmission, treatment and prevention.

The plan was developed jointly by OHID and UKHSA, and it forms part of the Government’s 2022 Sexual and Reproductive Health Strategy.

The Annual Update

On 7 June 2023, the DHSC published the first of its annual updates to Parliament on progress made towards the HIV Action Plan, which highlights key achievements under each of the Plan’s objectives.

It reports a 32% reduction in the number of new HIV diagnoses made in England, between 2019 and 2021. In the same period, the number of people diagnosed with AIDS fell by 21%.

In 2014, the Joint United Nations Programme on HIV/AIDS (UNAIDS) set the ’95-95-95’ target, where:

• 95% of all people living with HIV are aware of their status.
• 95% of those aware of their status are on antiretroviral treatment (ART).
• 95 % of those on ART achieve viral load suppression (meaning that they cannot transmit HIV to another person).

The update reports that England met this target in 2020 and 2021. The annual update also reports that England has seen the lowest ever number of people living with undiagnosed HIV.

The update acknowledges progress made so far as a “testament to the collective and ongoing efforts of many organisations across local government, the NHS and wider health system, statutory agencies, and the voluntary and community sector”.

However, it cautions that progress towards HIV elimination in England is unevenly distributed across different population groups:

While we have seen a sustained fall in new HIV diagnoses in gay, bisexual and other men who have sex with men (GBMSM) in London, which in the context of high numbers of HIV testing among this group, reflects a fall in incidence, we are not seeing the same fall among GBMSM outside London. For heterosexual men and women of all ethnicities, new diagnoses fell between 2019 and 2021, but the number having an HIV test remained below pre-COVID-19 levels. However, the estimated number of undiagnosed HIV infection plateaued, and late HIV diagnoses increased, suggesting no evidence of a fall in incidence in this population. Diagnosis rates remain disproportionately higher among GBMSM and black African heterosexuals in comparison to the overall population and non-black African heterosexuals.

Progress on improving diagnosis and reducing preventable deaths

In 2019, an estimated 105,200 people were living with HIV infection in the UK, of which 94% were diagnosed. This is the most recent estimate.

New HIV diagnoses first made in England in 2021

In 2021, 2,023 new HIV diagnoses were made in England (not including diagnoses first made abroad). This is 32% below the 2019 figure of 2,986. However, the number of people tested for HIV was also 20% lower in 2021 than in 2019.

The Government’s ambition is to reduce the number of annual diagnoses to 600 by 2025.

Just under half of those first diagnosed with HIV in England in 2021 had a ‘late diagnosis’, which means that they are estimated to have been unaware of their infection for at least three to five years. This increases the likelihood of death, serious illness, and onward transmission.

AIDS diagnoses in 2021

In 2021, 171 people were diagnosed with AIDS. This is 21% below the figure for 2019. The Government target is to reduce the annual number of diagnoses to 110 by 2025.

Preventable deaths from HIV

It’s estimated that 40% of deaths of people with HIV are HIV-related and are preventable. In 2021 this amounts to 289 preventable deaths from HIV.

The Government has a target to reduce this to 115 by 2025.

The figure has increased from 234 since 2019. However, the HIV Action Plan update notes that this is likely due to a higher number of deaths related to COVID-19, and is unlikely to be HIV-related.

Progress on the Plan’s main objectives

The update explained, in detail, the Government’s progress on work towards achieving the plan’s objectives. We have highlighted some of the key points below.

Objective 1: ensure equitable access and uptake of HIV prevention programmes

Key developments include 22,000 HIV testing kits having been ordered during National HIV Testing Week 2023 (February), supported by the ‘I test’ campaign which seeks to normalise HIV testing. UKHSA has produced a PrEP monitoring and evaluation framework, consisting of a series of indicators to inform service improvement in PrEP commissioning and delivery.

A PrEP Access and Equity Task and Finish Group has gathered evidence on barriers to PrEP access, and recommendations have been presented to the HIV Action Plan Implementation Steering Group to inform the development of a roadmap to improve PrEP access. The Government will consider its response to the recommendations.

Objective 2: scale up HIV testing in line with national guidelines

NHS England expanded the scope of opt-out emergency department testing in high prevalence areas to include hepatitis B and hepatitis C, as part of a blood borne viruses approach. NHS England has published a report examining the first 100 days of this expanded initiative. It includes an interim report, while a final report for 2022 to 2023 is expected to be published at the end of 2023.

Objective 3: optimise rapid access to treatment and retention in care

UKHSA has developed two new measures of retention in care; those not seen for at least 15 months, and those not seen within five years. The update reports that Covid-19 has exacerbated the number of people not retained in HIV care, and that the number of people not retained in care now exceeds the estimated number of people living with undiagnosed HIV. UKHSA is carrying out work to support care delivery, including a review of face to face and virtual consultations, which will consider patient demographics and clinical outcomes.

Objective 4: improving quality of life for people living with HIV and addressing stigma

The update notes that many actions under objective 4 are planned for commencement in 2023 and 2024, but also says progress has been made in several areas.

An internal scoping review of the effectiveness of peer support for people living with HIV in England and the UK is in progress. Commissioners will also engage with this work to consider as part of their support to people living with HIV.

Separately, a workforce task and finish group has been established by NHS England and the DHSC to assess and take action on HIV awareness among healthcare workers.

Governance

A national HIV Action Plan Implementation Steering Group has been established to lead on the implementation of the Plan. The Group is chaired by Professor Kevin Fenton, the Government’s Chief Advisor on HIV. The Group’s membership includes the UK Health Security Agency, NHS England and NHS Improvement, the British HIV Association, the National AIDS Trust, and the Terrence Higgins Trust.

Response to the update

Richard Angell, Chief Executive of the Terrence Higgins Trust, welcomed progress on new diagnoses identified through A&E department testing and called for the expansion of the programme to more emergency departments in high prevalence areas. He also called for PrEP to be made available in pharmacies and GP surgeries across England.

Deborah Gould, Chief Executive of the National AIDS Trust, welcomed the “encouraging updates” in the plan, but expressed concern about groups who are less likely to undergo routine HIV testing, and the number of people with a HIV diagnosis who are not engaged with treatment. She also called on the Government to make PrEP available in GP surgeries, community pharmacies and via online routes.