Highlights from the BHIVA Satellite Symposium, IAS Conference, Paris, France, July 2017: 'Tougher times: adapting to increasing demand with declining resources'.

The British HIV Association and the International AIDS Society ran the first joint symposium in an IAS conference. It covered a range of clinical and epidemiological topics and examined the current challenges and opportunities in implementing services within financial constraints. Four outstanding speakers gave overviews that are summarised below.

UK epidemiology and treatment cascade

Valerie Delpech

Public Health England

The United Kingdom provides free healthcare for all people diagnosed with HIV infection through 200 or so specialised HIV outpatient clinics. Monitoring of HIV care is undertaken by Public Health England using comprehensive data routinely collated from all HIV clinics.

In 2015, an estimated 101,200 people (95% credible interval (CrI) 97,500–105,700) were living with HIV in the UK. This is equivalent to an HIV prevalence of 1.6 per 1000 individuals, or 0.16% (Figure 1). Of concern, 13,500 (95% CrI 10,200–17,800), or 13% (95% CrI 10–17%) people remain unaware of their infection and are at risk of passing on the virus to others. The new diagnosis rate remains high, driven by ongoing transmission and sustained testing. In 2015, 6095 people were diagnosed with HIV: this represents a new diagnosis rate of 11.4 per 100,000 individuals, which is higher than most other countries in Western Europe, the average being 6.3 per 100,000 people in 2015.

Figure 1.

Diagnosed HIV prevalence (per 1000 population aged 15–59 years): England, 2015. Overall prevalence rate: 2.26 (2.24–2.27) per 1000. (From Public Health England).

Over 95% of all people living with HIV (PLWH) in the UK have most likely acquired their infection through sexual contact, around half of whom are heterosexuals and half were gay/bisexual men. Although less common as a route of HIV exposure, transmission continues among people who inject drugs (PWID).

Overall in 2015, 47,000 (95% CrI 44,200–50,900) gay, bisexual and other men who have sex with men (GBM) were estimated to be living with HIV, of whom 5800 (95% CrI 3200–9600), or 12% (95% CrI 7–19%) remained undiagnosed. HIV incidence (the number of new infections) remains particularly high in this group. In England an estimated 2800 (95% CrI 1700–4400) gay/bisexual men acquired HIV in 2015, with the vast majority acquiring the virus within the UK.

HIV care in the UK is of a high standard for all. In 2015, 88,769 people received HIV care, up 73% from a decade ago (51,449 in 2006). This reflects the longer life expectancy conferred by effective antiretroviral therapy (ART), as well as consistent numbers of people newly diagnosed. Nearly all (97%) of the 6095 people diagnosed with HIV in 2015 were linked to specialist HIV care within 3 months of diagnosis, similarly to previous years. Furthermore, the vast majority (94%) of people accessing HIV care in 2015 were receiving ART and as a result have undetectable virus in blood and body fluids and are, therefore, very unlikely to transmit HIV to others. These indicators are monitored at the trust level on the National Health Service in England (NHSE) HIV clinical dashboard and indicate high quality of service throughout the country. Furthermore, epidemiological markers show that there is no indication of inequalities in HIV care received through the NHS by gender, ethnicity or HIV exposure. All subpopulations of PLWH have reached the UNAIDS targets of 90% diagnosed on ART and 90% with viral load suppression for those on ART. However, late presentation at diagnosis remains high and highlights the need for increased and expanded HIV testing. In 2015, 39% of adults were diagnosed at a late stage of infection.

New diagnoses in 2016 were considerably lower than in 2015, particularly among gay and bisexual men. This was due to high volumes of testing, initiation of early treatment following BHIVA treatment as prevention recommendations and the use of internet-based pre-exposure prophylaxis. We need to consolidate the scaling-up of testing and early commencement of ART across all parts of the country for all groups at greatest risk of HIV.

Prevention: supporting generic PrEP access and offering monitoring – legalities and practicalities. Efficiencies viewed through 90:90:90

Nneka Nwokolo

56 Dean Street, Chelsea and Westminster Hospital

No single HIV prevention initiative has proved to be effective so far. The most successful strategies have been where a combination of interventions has been adopted.

HIV pre-exposure prophylaxis (PrEP), in association with other modalities such as treatment as prevention (TasP), have been shown to be the likely reasons for reductions in new HIV infections seen in San Francisco [1] and London [2].

However, PrEP is not available on the NHS in England, thereby forcing individuals to purchase generic tenofovir disoproxil fumarate (TDF)/emtricitabine (FTC) online. Generic formulations purchased via www.iwantprepnow.co.uk have been established to be genuine [3]; however, it is crucial that individuals purchasing PrEP online are screened appropriately for HIV, hepatitis B and C, and sexually transmitted infections (STIs) as well as undergoing assessment of their renal function.

The 56 Dean Street Clinic has provided monitoring for individuals purchasing generic PrEP since February 2016. With 336 person-years of follow-up, no new HIV or hepatitis infections have been diagnosed, although there was a 10% increase in STIs at follow-up. No significant deteriorations in renal function were seen [4].

In areas where PrEP is unavailable, it is crucial that HIV and sexual health services support individuals on generic PrEP by ensuring that they have access to monitoring. Several international PrEP guidelines exist and clinicians should familiarise themselves with guidance relevant to their clinical circumstances/country.

Concerns remain about STI risks in individuals on PrEP. However, data on risk compensation are conflicting [5-7] and efforts should continue to address these issues.