No vaccine, no cure: HIV and AIDS in the United Kingdom - Select Committee on HIV and AIDs in the United Kingdom Contents
CHAPTER 2: The Scale of the Challenge
14. Human immunodeficiency virus (HIV) is a transmissible
virus which targets white blood cells in the body, affecting the
immune system. While it is predominantly sexually transmitted,
it can also be spread through the sharing of injecting drug equipment,
transmission from mother to child and through contaminated blood
and blood products. Unlike other sexually transmitted infections
(STIs), HIV cannot be cured. There is no vaccine to protect against
HIV. It is a lifelong, potentially life-threatening condition.
Untreated, HIV leaves an infected person more vulnerable to serious
infections and some cancers; and if a person develops one or more
of a specified range of these illnesses,
they are said to have progressed to Acquired Immmunodeficiency
Syndrome (AIDS), which was first described in 1981.
15. The success of the response to HIV and AIDS
in the 1980s was based partly on the profile of HIV and AIDS in
the public mind. Although HIV no longer has that same prominence,
the problem is more extensive and widespread than ever before.
There were an estimated 86,500 people living with HIV at the end
of 2009, the latest year for which figures are available.
By next year, this figure is likely to surpass 100,000.
16. Disturbingly, many of those living with HIV
do not know that they are infected. Surveillance systems operated
by the Health Protection Agency (HPA)
use anonymised blood samples from a number of sources to estimate
this 'undiagnosed fraction'.
The HPA estimated that 26 % of those living with the virus in
2009more than 22,000 peoplehad not been diagnosed.
Those undiagnosed are not receiving treatment and support which
could both improve their health and significantly reduce the chances
of them passing on the virus. Despite increased levels of testing,
leading to an increase in the prevalence of diagnosed infections,
the prevalence of undiagnosed HIV has not changed significantly
in the last 10 years.
17. There has also been a dramatic increase in
the yearly number of new HIV diagnoses since the late 1990s. This
peaked in 2005, with more than 7,800 new diagnoses (see Figure
1). In 2010, there
was a year-on-year increase for the first time since then, with
an estimated 6,750 people diagnosed.
At the same time, the impact of antiretroviral therapy has led
to a significant decline in the numbers of people progressing
from HIV to AIDS.
New HIV and AIDS diagnoses and deaths
Source: Health Protection Agency, Health Protection
Report Vol 5 No 22; 6 June 2011: http://www.hpa.org.uk/hpr/archives/2011/news2211.htm
The newly infected
18. Increasing numbers of new diagnoses in part
reflect efforts to increase levels of HIV testing. However, as
infections are often not diagnosed for a number of years,
the number of people diagnosed in a given year does not indicate
how many people actually acquired their infection in that yeara
measure known as the incidence. Calculating this is a more difficult
process, but the HPA uses a number of statistical processes in
an attempt to do so.
19. Dr Valerie Delpech, Consultant Epidemiologist
and Head of National HIV Surveillance at the HPA, estimated that
around 3,000 new infections occur amongst MSM per year.
A quarter of MSM newly diagnosed in 2010 probably acquired their
infection in the four to five months prior to diagnosis, with
higher recent rates amongst younger age groups.
For heterosexual men and women, Dr Delpech suggested that
each year there were at least 300 to 400 new infections;
Professor Noel Gill, Head of the HIV and STI Department in
the National Infectious Disease Surveillance Centre of the HPA,
estimated the true figure to be around 1,000.
Although new diagnoses are not the same as new infections, the
numbers of each appear to be broadly equivalent: in 2010, there
were 3,080 new diagnoses amongst MSM, and 1,150 new heterosexual
diagnoses acquired in the United Kingdom.
Who has HIV?
GROUPS AT HIGHEST RISK
20. In the United Kingdom, two groupsMSM
and those from black African communitiesare at highest
risk of acquiring HIV. Of those diagnosed in 2010, just over 3,000
(45%) were MSM, and just over 1,700 (26%) identified as black
African. The majority
of infections diagnosed in 2010 amongst MSM were acquired within
the United Kingdom, whereas the majority of those newly diagnosed
in the black African community were infected abroad.
Of those diagnosed with HIV and seen for care in 2009 (the latest
year for which figures are available), 43% were MSM, and 33% were
from black African communities.
21. Those two groups, however, are not the only
ones at risk. More than 11,300 people from outside black African
communities, who acquired their infection through heterosexual
sexual contact within the United Kingdom, accessed care in 2009.
The same group accounted for around 700 cases of UK-acquired infections
diagnosed in 2010.
Sharing of injecting drug equipment and mother-to-child transmission
are also means by which infection can spread, but both make up
a small proportion of overall cases. Only 160 people who acquired
HIV through injecting drug use were diagnosed in 2010,
and only 5,500 people have been so diagnosed since the epidemic
first emerged in 1981.
Similarly, only 77 cases of mother-to-child transmission were
diagnosed in 2010, with fewer than 2,000 diagnoses since 1981.
22. The age profile for HIV diagnoses is older
than for STIs generally. Young people accounted for 57% of those
diagnosed with the five most common STIs
in England in 2009.
In the same year, 10% of diagnoses for HIV were amongst those
aged between 15 and 24 years old,
whilst half of those diagnosed were aged between 25 and 40.
The older profile is partly due to the often long delay between
infection and diagnosis.
23. A mixture of late diagnosis, continuing sexual
activity and increased life expectancy for those infected also
means that there is an increasing number of those aged over 50
being diagnosed with HIV. New diagnoses amongst that group doubled
in the previous decade, accounting for 13% of all diagnoses in
2009. It must be
stressed, though, that increasing numbers of diagnoses are being
made across all age groups.
24. HIV infection is a problem nationwide, but
it is concentrated in certain urban and metropolitan centres.
This is particularly so in London: of more than 65,000 people
accessing care for HIV in 2009, over 28,000 (more than 40%) were
based in London.
In the London Borough of Lambeth alone, the area with the highest
prevalence of HIV in England, more than 2,700 people accessed
care for HIV in 2009.
Other urban centres, such as Manchester and Brighton, also have
a comparatively high prevalence of HIV.
The dangers of late diagnosis
25. Late diagnosis is one of the most serious
problems we face.
The timeliness of a diagnosis is measured in relation to the levels
of a particular type of white blood cell, CD4+, in the blood (the
CD4 count). This
is because HIV attacks the body's immune system, reducing levels
of these cells in the body.
26. Late diagnosis means that antiretroviral
therapy has been delayed, which has grave health implications
for the person diagnosed. There is a 10-times higher chance of
dying within the first year after diagnosis,
and life expectancy is 10 years lower compared to those receiving
Of those who died because of HIV during 2009, 73% had been diagnosed
late. Delaying treatment
misses a chance to reduce the risk of onward transmission (see
para 175). It also means more complex
and expensive treatment
for those diagnosed.
27. Early diagnosis is overwhelmingly in the
interests of public health. Diagnosis allows access to treatment,
which one study found reduced the transmission risk amongst heterosexual
couples by as much as 96%.
Being diagnosed can also reduce risk behaviours amongst those
28. In 2009, the latest year for which figures
are available, 52% of adults diagnosed were diagnosed late, with
a lower proportion of late diagnoses among MSM (39%) compared
with heterosexual women (59%) and men (66%).
Late diagnosis is also a problem amongst those aged over 50, for
whom two-thirds of diagnoses were late.
29. A very late diagnosis
is of even greater concern, worsening the prognosis for the patient
even further. Yet this was the case for 30% (nearly 2,000 people)
of those newly diagnosed in 2009, a proportion again higher amongst
heterosexual men and women.
Given that a late diagnosis indicates that a patient may have
gone undiagnosed for up to eight years,
this is deeply disturbing.
Late* and very late** diagnosis of HIV
Infection by prevention group and age group, 2009
* Diagnosed with a CD4 cell count <350 per
mm3 (within 91 days of diagnosis)
** Diagnosed with a CD4 cell count <200 per
mm3 (within 91 days of diagnosis)
Source: Health Protection Agency, HIV in the United
Kingdom (2010 Report), op.cit.
How many are accessing care?
30. The number of those accessing treatment and
care has trebled since 2000.
Then, around 22,000 people were accessing care. In 2009, this
had risen to more than 65,000.
There are a number of reasons for this increase. Significant numbers
of new diagnoses are being made each year. At the same time, those
diagnosed have been living progressively longer as antiretroviral
therapies have developed. A person diagnosed at age 20 can now
be expected to live on average for a further 46 years16
years longer than somebody in the same position in 1996.
Furthermore, changes in treatment guidelines, encouraging treatment
at an earlier stage, meant that the proportion of those accessing
care who were receiving antiretroviral therapy increased from
70% in 2000 to 78% in 2009.
Cumulative numbers of those accessing
care by prevention and ethnic group, 2000-2009
Source: Health Protection Agency, Numbers accessing
HIV care, 2009 slide set: http://www.hpa.org.uk/web/HPAweb&HPAwebStandard/HPAweb_C/1203064766492
The growing costs
31. The striking increase in the numbers of those
accessing care has obviously impacted on the costs of providing
treatment and care. Of the £1.9bn spent by the Government
on infectious diseases in England in 2009/10, £762m (40%)
was spent on the treatment of HIV and AIDS.
This spending included hospital services and drug prescriptions,
but did not include spending on prevention or social care. It
is also not clear, as the data cannot be separated out, how much
of the cost of HIV testing is included.
Given these factors, the final total could be much higher.
32. Spending on HIV and AIDS has significantly
increased over time, rising from an estimated £104m in 1997
to more than £500m in 2006/07.
Newer and more expensive drug regimes have contributed to this
rise. Given the high
number of new diagnoses, the costs of HIV treatment are only likely
to rise further over time.
33. HIV remains a very significant public health
challenge. The number of people living with the virus continues
to increase with no signs of halting. Thousands of new infections
are occurring in the United Kingdom each year. Diagnosis, when
it comes, is often late, whilst more than a quarter of those living
with HIV simply do not know they are infected. This jeopardises
the health of those infected, and is associated with continued
risk of transmitting the virus to others. Meanwhile, increasing
numbers of people accessing care drive up treatment costs in England
towards £1bn. This makes HIV an increasing and increasingly
expensive public health challenge which cannot be ignored. Tackling
the issue should be a major priority for the Government.
34. The Government should recognise the scale
of the HIV and AIDS challenge in the United Kingdom. Not enough
is being done to respond to a steadily growing risk to public
health. There are potentially huge cost implications in both the
short- and long-term in failing to deal effectively with the epidemic.
At a time when public health in the United Kingdom is subject
to major reform, the Government should ensure that HIV and AIDS
is a key public health priority.