Decline in HIV transmission but progress slow in women

The UK Health Security Agency (UKHSA) has published the latest evaluation report into the government’s progress towards reducing HIV transmission. The report shows that there has been a continued decline in HIV transmission but progress has slowed particularly among women and ethnic minorities.

The number of new HIV diagnoses among gay and bisexual men fell by 42% from 1,239 to 724 between 2019 and 2022.

England also met the UNAIDS 2025 95-95-95 targets for the third time with 95% of all people with HIV being diagnosed, 98% of those diagnosed on treatment and 98% of those on treatment being virally suppressed and unable to pass on the virus.

This second report of the monitoring and evaluation framework (MEF) focuses on the interim ambitions of England’s HIV Action Plan 2022 to 2025 to reduce HIV diagnoses first made in England (by 80%), AIDS diagnoses (at the time of HIV diagnosis) (by 50%), and HIV-related deaths (by 50%) between 2019 and 2025.

Despite a significant fall in cases among white gay and bisexual men between 2019 and 2022, there are groups of ethnic minority gay and bisexual men in whom new HIV diagnoses are not decreasing at the same rate. In 2022, 42% (304 of 724) of diagnoses in gay, bisexual and other men who have sex with men (GBMSM) were among ethnic minority groups compared to 34% (417 of 1,239) in 2019.

Overall new HIV diagnoses first made in England fell by 13% from 2,819 in 2019 to 2,444 in 2022. However, between 2021 and 2022 diagnoses rose from 2,313 to 2,444. In order to achieve the 2025 transmission target, HIV transmission would need to fall by 627 per year.

This recent rise is partly due to a slowing of progress towards elimination in heterosexual women and ethnic minority groups. Cases in heterosexual women, which despite reducing from 589 in 2019 to 447 in 2021, rose by 26% from 447 to 564 in 2022.

Among white British women, diagnoses fell by 39% between 2019 and 2022, compared to 6% among black African women. Among heterosexual men, new HIV diagnoses fell by 25% from 458 in 2019 to 281 in 2022. 

Dr Alison Brown, Interim Head of HIV Surveillance at UKHSA, said:

England remains a world leader in efforts to reduce HIV transmission and ensure that those diagnosed have timely access to effective treatment.  

While there is much to celebrate, with numbers of HIV diagnoses continuing to decrease in certain groups, there is also much more to do. HIV diagnoses are increasing among heterosexual populations, particularly among women.

It is concerning that testing levels in these groups has not recovered to 2019 levels, prior to COVID-19. So please, no matter your gender or sexual orientation, get regularly tested, use condoms and get PrEP if you’re eligible, to protect you and your partners’ health.

Professor Kevin Fenton, government’s Chief Advisor on HIV and Chair of HIV Action Plan Implementation Steering Group, said: 

This week’s announcement to start new research on an expansion of the HIV opt-out emergency department testing programme,  demonstrates the government’s commitment to keep the momentum up to end new transmissions of HIV within England by 2030.

HIV opt-out testing is successful at reaching everyone, including women and those from ethnic minorities, who are living with HIV without knowing. It is a huge step in the right direction, and today’s research shows we need to do more to make sure these groups are effectively being targeted.

I believe we can meet our 2030 targets and thank the UKHSA for its research to point us in the right direction – and identify where more can be done.

Richard Angell, Chief Executive of Terrence Higgins Trust, said: 

We have all of the tools we need to end new HIV cases by 2030 and diagnose those out there who are unaware they’re living with HIV. But with just 6 years left to achieve that goal, we need to do more and do it faster. Crucially, we also need to ensure that the progress we’re making is felt by all of the groups impacted by HIV – without exception. That includes for women, heterosexual men and people from racially minoritised communities, where testing levels continue to lag both behind pre-COVID-19 levels and those seen among gay and bisexual men. 

The announcement of £20 million funding to expand opt-out HIV testing in A&Es to an additional 46 hospitals is great news as this approach is proven to help address inequalities, with the proportion of women, older people and those of Black ethnicity diagnosed in A&Es higher than those found in sexual health. But this landmark expansion is only part of the puzzle and needs to happen in parallel with the better utilisation and availability of HIV prevention drug PrEP, ramping up testing in a wide range of settings and, of course, tackling the highs levels of stigma still surrounding HIV.

Deborah Gold, Chief Executive of National AIDS Trust, said:

This period of time is absolutely crucial in our fight to end new HIV transmissions. Though the data shows some really encouraging progress, it also demonstrates how important it is to tackle inequalities across different communities as our key focus.

PrEP and opt-out testing are game-changers, but they’re not enough if they’re not reaching the right people. People who adhere to their medication cannot pass the virus on. This is also known as Undetectable = Untransmissible (U=U) and it is a vital message in the ongoing fight against stigma and discrimination, however, not enough people are aware of it. Tailored engagement and interventions which involve the communities that we are trying to reach must be the starting point to addressing inequalities.

The year 2022 also saw the highest ever number of tests in sexual health services among GBMSM, but numbers have remained lower than pre-pandemic levels for heterosexual men and women. 

In 2022, 40% of women attending sexual health services were not offered an HIV test compared to 27% in heterosexual men and 23% in gay and bisexual men. Women, and ethnic minority populations were also less likely start or continue PrEP.

UKHSA continues to work with DHSC and partners towards the HIV Elimination Action Plan, including supporting the evaluation of the opt-out testing programme to increase HIV diagnoses and also providing guidance to clinicians to help people with HIV access treatment. In addition, UKHSA will be working to understand why women are less likely to be offered a HIV test in an effort to tackle inequalities.