Changing HIV strategy

Changed international migration means we need a change of approach.

This is the first joint post on this substack.

• Caroline Johnson is a former public health minister and is MP for Sleaford and North Hykeham. She is also a practicing NHS paediatric consultant. She graduated from medical school in 2001 and became a consultant in 2012.

• Neil O’Brien is also a former public health minister and had responsibility for policy on HIV.

Background

The improvements in care for those with HIV over the last few decades have been remarkable.

30 years ago HIV progressed inevitably to AIDS, a fatal illness; today, when diagnosed early and treated with antiretrovirals, the majority of people with HIV in the UK can expect a near-normal life expectancy.

The vast majority of those diagnosed are on high-quality treatment and, with consequent undetectable viral loads, are unable to pass on the virus.

After years of progress the last Government announced a realistic ambition to end new HIV transmissions, new AIDS diagnoses and new HIV-related deaths in England by 2030. 

The UK had been making very good progress towards ending HIV transmission under the HIV Action Plan. Amongst other things the UK has been a leader in: 

• Introducing opportunistic “opt out” testing in emergency departments in the local authority areas across the country with the highest prevalence of HIV; 

• Driving up the use of Pre-Exposure Prophylaxis treatment (PrEP);

• Driving up testing, including through mailing out kits which enable instant at-home results.

There is much, much more to do, but based on 2021 data, the government was able to hail significant progress.

The challenge

Numbers of newly diagnosed patients had fallen consistently since 2005. However, data for 2022 and now recently published data for 2023 show that progress has been thrown into reverse:

This is driven by a growth in numbers of newly diagnosed individuals who were born outside the UK and Europe - particularly among people from Africa. Within Africa the largest growth has come from people from East Africa, followed by southern Africa.

The share of new HIV diagnoses to people born outside the UK has gone up across the country. Until two years ago it was significantly higher in London than elsewhere, but now the share of diagnoses to people born outside the UK is higher in other regions: 91% in Yorkshire, and 88% in the East Midlands and East of England last year. People from Africa accounted for around three quarters of new diagnoses in these three regions in 2023.

We can also look at the total population of people with diagnosed HIV, rather than the flow of new cases. According to a recent Parliamentary Question we asked, a majority of those living with HIV in Great Britain, 57%, are people who were born outside the UK. In some regions this is much higher: 62% in the East Midlands and East of England, and 70% in London:

Background

The number of non visitor visas issued to people from Sub-Saharan Africa has been much higher under the new immigration system, with around 330,000 visas issued in 2023, compared to about 50,000 a year in the 2010s. Though there are signs visa numbers are falling as a result of changes to eligibility criteria, numbers are not expected to return to previous levels.

Sadly the share of people aged 15-49 living with HIV is high in much of Africa. It is above 10% in Namibia, Zambia, Mozambique and Zimbabwe. It was 18% in Botswana and 21% in South Africa in 2021. But the share is also high in east and west Africa.

An unevenly distributed challenge

International migration is not evenly distributed around the country. The regional statistics above don’t necessarily fully express the load that this changing demographic mix is putting on HIV services in some places.

Because of the rapid growth in the number of HIV cases among people born outside the UK, many of the places that have seen the largest increases in the total number of new HIV diagnoses are outside London.

While the capital still sees the largest total number of new diagnoses every year, the proportional increase is higher in every other region - and the absolute increase over the last two years is higher in the East Midlands and South East.

We can also look at the total population of patients as well as new diagnoses. Local authorities with large increases in numbers living with HIV between 2021 and 2023 included places like Nottingham, Newcastle and Basingstoke. While these are not the highest prevalence areas in the country, the proportional increase in demand has been large.

What should be done?

The current HIV strategy is based on “ending new transmissions in the UK by 2030” - but this strategy becomes much more difficult to implement where a large number of new people are arriving into the country with HIV, and this is especially so if individuals are unaware of their diagnosis and therefore untreated.

We suggest one part of the answer is to test all people arriving from higher HIV prevalence countries as part of their visa requirements. For tuberculosis, the UK already requires all people applying for a visa from a list of 102 countries to have a TB test if they are coming for more than six months.

Around 18 countries require an HIV test for at least some visas. For example:

• If you’re applying for permanent residency in Australia, you must undergo an HIV test to meet the ‘Health Requirement’ for a visa. People on shorter visas also need to have an HIV test under various other circumstances.

• New Zealand requires HIV testing as a requirement for visa applicants intending to stay for more than 12 months.

DHSC is currently funding opportunistic HIV testing in hospitals in places like Swindon and North Northamptonshire where the HIV diagnosed prevalence rate was around 2 per 1,000 people aged 15-59.

This is a successful policy - but it also highlights why it would be proportionate to test people from countries such as South Africa where the prevalence rate is 210 per 1,000 – over a hundred times higher.

Official guidance from the Office for Health Improvement and Disparities (OHID) is that testing should be recommended to “all men and women known to be from a country of high HIV prevalence (>1%), including recently-arrived children.” But anecdotally it is unclear how often such tests are offered, or taken up.

Making HIV testing compulsory to get a visa from high prevalence countries would reduce the risk of transmission from undiagnosed people. This would be a more targetted approach than either Australia or New Zealand.

While there would be an additional cost for applicants, this would be small compared to visa fees, the Immigration Health Surcharge and the other costs of travel.

Normalising testing

Many people have not really followed the revolution in the treatment of HIV over recent decades. Those old enough to remember the hard-hitting “Don't Die of Ignorance” campaign of the 1980s will remember the chilly warning that there was “no known cure”. Such information campaigns shook people out of complacency about the new disease, but also have a lingering effect on perceptions.

As such, those working in the care and treatment of HIV are rightly highly sensitive to issues of stigma which can prevent people from testing or seeking treatment. For this reason people working in the field may be reluctant to suggest targeted testing. 

But the experience of Australia and New Zealand suggests this has not caused any issues.

Indeed, the UK government has been working hard to normalise the idea of testing through the “I test” advertising campaign, which “normalises HIV testing as routine, beneficial, and something that everyone can take personal responsibility for.”

Alongside more testing as part of the visa process, Government should also update work from 2022 on the dynamics of undiagnosed HIV. Between 2019 and 2021 the number of undiagnosed cases in England was thought to have fallen from 5,600 to 4,400.

The number of cases first diagnosed overseas rose from 20% in 2015 to 53% in 2023. But there is clearly a risk that greater numbers of people coming to the UK from countries with higher prevalence levels may reverse the positive trend towards fewer people with HIV being undiagnosed. This year’s HIV monitoring report noted that positivity rates not falling in the face of increased testing was “indicative of ongoing transmission.”

Conclusion

The dramatic turnaround in the number of new HIV diagnoses must prompt a reconsideration of the government’s current strategy to end HIV transmission by 2030. To summarise:

• The growth in the number of diagnosed HIV cases should prompt a reworking of previous estimates of undiagnosed HIV. 

• The government should look to introduce a targetted version of the testing for people seeking visas which Australia and New Zealand have, focussed on higher-prevalance countries. 

• Given the recent trend has been taking us away from the goal to end new transmissions, government should step up measures across the board, including home testing; opt-out testing, access to PrEP and more.