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[21], 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.[22] By next year, this figure is likely to surpass 100,000.[23]

16.  Disturbingly, many of those living with HIV do not know that they are infected. Surveillance systems operated by the Health Protection Agency (HPA)[24] use anonymised blood samples from a number of sources to estimate this 'undiagnosed fraction'.[25] The HPA estimated that 26 % of those living with the virus in 2009—more than 22,000 people—had not been diagnosed.[26] 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.[27]

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).[28] In 2010, there was a year-on-year increase for the first time since then, with an estimated 6,750 people diagnosed.[29] 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.[30]

FIGURE 1

New HIV and AIDS diagnoses and deaths since 1981[31]

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[32], the number of people diagnosed in a given year does not indicate how many people actually acquired their infection in that year—a 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.[33]

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.[34] 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.[35] For heterosexual men and women, Dr Delpech suggested that each year there were at least 300 to 400 new infections[36]; 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.[37] 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.[38]

Who has HIV?

GROUPS AT HIGHEST RISK

20.  In the United Kingdom, two groups—MSM and those from black African communities—are 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.[39] 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.[40] 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.[41]

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.[42] The same group accounted for around 700 cases of UK-acquired infections diagnosed in 2010.[43] 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[44], and only 5,500 people have been so diagnosed since the epidemic first emerged in 1981.[45] Similarly, only 77 cases of mother-to-child transmission were diagnosed in 2010, with fewer than 2,000 diagnoses since 1981.[46]

AGE RANGE

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[47] in England in 2009.[48] In the same year, 10% of diagnoses for HIV were amongst those aged between 15 and 24 years old[49], whilst half of those diagnosed were aged between 25 and 40.[50] 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.[51] It must be stressed, though, that increasing numbers of diagnoses are being made across all age groups.[52]

NATIONAL SPREAD

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.[53] 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.[54] Other urban centres, such as Manchester and Brighton, also have a comparatively high prevalence of HIV.[55]

The dangers of late diagnosis

25.  Late diagnosis is one of the most serious problems we face.[56] 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[57]). This is because HIV attacks the body's immune system, reducing levels of these cells in the body.[58]

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[59], and life expectancy is 10 years lower compared to those receiving prompt treatment.[60] Of those who died because of HIV during 2009, 73% had been diagnosed late.[61] Delaying treatment misses a chance to reduce the risk of onward transmission (see para 175). It also means more complex[62] and expensive[63] 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%.[64] Being diagnosed can also reduce risk behaviours amongst those infected.[65]

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%).[66] Late diagnosis is also a problem amongst those aged over 50, for whom two-thirds of diagnoses were late.[67]

29.  A very late diagnosis[68] 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.[69] Given that a late diagnosis indicates that a patient may have gone undiagnosed for up to eight years[70], this is deeply disturbing.

FIGURE 2

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.[71] Then, around 22,000 people were accessing care. In 2009, this had risen to more than 65,000.[72] 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 years—16 years longer than somebody in the same position in 1996.[73] 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.[74]

FIGURE 3

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.[75] 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.[76] 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[77] to more than £500m in 2006/07.[78] Newer and more expensive drug regimes have contributed to this rise.[79] Given the high number of new diagnoses, the costs of HIV treatment are only likely to rise further over time.

Conclusion

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.


21   These conditions are known as AIDS-defining illnesses. Back

22   Health Protection Agency, HIV in the United Kingdom (2010 Report), op. cit. Back

23   HAUK 68 (Health Protection Agency). Back

24   See Appendix 8. Back

25   HAUK 97 (Health Protection Agency)-"The estimates of undiagnosed infections rely on data from unlinked anonymous (UA) serological surveys conducted in four selected adult populations: pregnant women, injecting drug users attending drug agencies, sexual health clinic attendees tested for syphilis and MSM attending community venues recruited through the Gay Men's Sexual Health Survey (conducted in collaboration with University College London)." Back

26   Health Protection Agency, HIV in the United Kingdom (2010 Report), op.cit. Back

27   HAUK 97 (Health Protection Agency). Back

28   Health Protection Agency, United Kingdom; New HIV diagnoses data to end of December 2010, op. cit. Back

29   ibidBack

30   ibid. Back

31   Note: In this figure, HAART refers to 'highly active antiretroviral therapy'. Back

32   See, for example, Q 833 (Dr Valerie Delpech) and Q 839 (Professor Noel Gill). Back

33   See HAUK 97 (Health Protection Agency). Such techniques use new diagnosis levels, CD4 counts (see Appendix 8), undiagnosed fraction estimates and recent infection algorithm data to produce an estimate of those infected each year. See also Q 833 (Dr Valerie Delpech). Back

34   Q 833. Back

35   Health Protection Agency, Health Protection Report Vol 5 No 22; 6 June 2011. Back

36   Q 834. Back

37   Q 837. Back

38   Health Protection Agency, United Kingdom; New HIV diagnoses data to end of December 2010. op. cit. Back

39   ibidBack

40   ibid. Back

41   Health Protection Agency, HIV in the United Kingdom (2010 Report), op. cit. Back

42   ibidBack

43   Personal correspondence with the Health Protection Agency. Back

44   Health Protection Agency, United Kingdom: New HIV diagnoses data to end of December 2010, op. cit. Back

45   Health Protection Agency, Health Protection Report, 6 June 2011, op. cit. Back

46   Health Protection Agency, United Kingdom: New HIV diagnoses data to end of December 2010, op. cit.  Back

47   Chlamydia, herpes, warts, gonorrhoea and syphilis. Back

48   HAUK 97 (Health Protection Agency).  Back

49   HAUK 68 (Health Protection Agency). Back

50   Health Protection Agency, United Kingdom: New HIV diagnoses data to end of December 2010, op. cit. Back

51   Health Protection Agency, HIV in the United Kingdom (2010 Report), op.cit. Back

52   See Health Protection Agency, United Kingdom: New HIV diagnoses data to end of December 2010, op. cit. Back

53   Health Protection Agency, Survey of Prevalent HIV Infections Diagnosed (SOPHID), Data tables 2009: http://www.hpa.org.uk/web/HPAwebfile/HPAweb_c/1221482342808 Back

54   ibidBack

55   ibidBack

56   See, for example, QQ 235-236 (Dr Ian Williams and Dr Keith Radcliffe). Back

57   See Appendix 8. Back

58   When the CD4 count falls below the level at which treatment is recommended to begin (350 cells per mm3 of blood), the diagnosis is considered to be late. If the count falls further, to below the level at which treatment was recommended under previous guidelines (200 cells per mm3 of blood), the diagnosis is said to be very late (see Appendix 8).  Back

59   Q 32 (Dr Valerie Delpech). Back

60   HAUK 53 (British HIV Association). Back

61   Health Protection Agency, HIV in the United Kingdom (2010 Report), op.cit. Back

62   HAUK 64 (Terrence Higgins Trust), HAUK 47 (National AIDS Trust).  Back

63   HAUK 51 (London Specialised Commissioning Group), HAUK 36 (Association of Directors of Public Health), HAUK 67 (Health Protection Agency). Back

64   Cohen MD et al., Prevention of HIV-1 infection with Early Antiretroviral Therapy, New England Journal of Medicine, July 2011. Back

65   Q 331 (Professor Mike Kelly), HAUK 50 (Halve It Coalition). Back

66   Health Protection Agency, HIV in the United Kingdom (2010 Report), op.cit. Back

67   ibidBack

68   See footnote 59. See also Appendix 8. Back

69   Health Protection Agency, HIV in the United Kingdom (2010 Report) op. cit. Back

70   Q 32 (Dr Valerie Delpech). Back

71   Health Protection Agency, HIV in the United Kingdom (2010 Report), op.cit. Back

72   ibidBack

73   May M et al., Impact on life expectancy of late diagnosis and treatment of HIV-1 infected individuals: UK CHIC, 2010. Back

74   Health Protection Agency, HIV in the United Kingdom (2010 Report), op.cit. Back

75   Department of Health, Programme budget, 2009-10, op. cit. Back

76   HAUK 94 (Department of Health). Back

77   Mandalia et al., Rising Population Cost for Treating People Living with HIV in the UK, 1997-2013, 2010 Back

78   Department of Health, Programme budget 2009-10, op. citBack

79   HAUK 82 (Sarah Stephenson, Greater Manchester Sexual Health Network), Q 724 (Simon Williams and Claire Foreman), Q 725 (Claire Foreman). Back


 
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