Transcript Document

Africans and HIV in the UK:
an epidemiological perspective
Nov 2006
Tim Chadborn
On behalf of the HIV Reporting Section with special thanks to Julia Abernethy and Bela Vatsa
HIV & STI Department, Health Protection Agency Centre for Infections
What I will cover…
 UK epidemiology
 Access to treatment and care
 Access to services
 Access to treatment
 AIDS and death
 Late diagnosis
 Preventable mortality
 Key messages
New HIV diagnoses
HIV and AIDS diagnoses and deaths in
HIV-infected black Africans, E,W&NI
4000
HIV diagnoses
Number of diagnoses and deaths
AIDS diagnoses
Deaths
3000
2000
Widespread
introduction of
HAART
1000
0
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
Year
1
Numbers will rise, for recent years, as further reports are received; reports from the Channel Islands excluded
Data Source: HIV/AIDS and death reports. Reports received by the end of September 2006.
HIV diagnoses of black Africans by
exposure category
4000
3500
3000
Men who have sex with men
Heterosexual contact
Injecting drug use
Mother to infant
Number of diagnoses
Recipients of Blood/Blood Products
2500
Undetermined
Heterosexual Women
2000
1500
1000
500
0
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
Year
1
Numbers will rise, for recent years, as further reports are received; reports from the Channel Islands excluded
Data Source: HIV/AIDS and death reports. Reports received by the end of September 2006.
HIV diagnoses of black Africans by
exposure category – excluding heterosexuals
150
Men who have sex with men
Injecting drug use
Number of diagnoses
Mother to infant
100
Recipients of Blood/Blood Products
50
0
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
Year
1
Numbers will rise, for recent years, as further reports are received; reports from the Channel Islands excluded
Data Source: HIV/AIDS and death reports. Reports received by the end of September 2006.
HIV diagnoses of infections that were probably
acquired in Africa among non-black Africans
120
White
Black Caribbean
100
Number of diagnoses
Black - other
80
Indian/Pakistani/Bangladeshi
Other/mixed
60
40
20
0
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
Year
1
Numbers will rise, for recent years, as further reports are received; reports from the Channel Islands excluded
Data Source: HIV/AIDS and death reports. Reports received by the end of September 2006.
HIV prevalence in adults
in sub-Saharan Africa, end 2005
Countries in the Commonwealth
20% − 34%
10% − <20%
5%
− <10%
1%
− <5%
0%
− <1%
trend data unavailable
outside region
HIV diagnoses of infections acquired through
heterosexual contact
Key
Acquired in Africa African region of infection
2005
Eastern
No rthern
So uth Eastern
No rthern
a
Eastern
So uthern
So uth Eastern
So uthern
Western
Patients region of infection
No t repo rted
A f ric
Central
o pe
r Eur
Ot he
rld
w
f
o o
R es t
t ed
r
o
p
e
No t r
Central
Acquired in Africa African region of infection
UK
1996
Western
No t repo rted
Patients region of infection
n 559
n 2760
Africa
>75%
UK
Other Europe
Rest of world
Not reported
Acquired in UK Partners’ region of infection
No t repo rted
Rest o f wo rld
UK
A frica
n 840
Other Euro pe
n 4049
Acquired in UK Partners’ region of infection
A frica
A frica
Euro pe
Euro pe
A fri
Euro
Rest o f wo rld
Rest o f wo rld
No t repo rted
Res
No t repo rted
No t
n 130
n 553
1
Numbers will rise, for recent years, as further reports are received; reports from the Channel Islands excluded
Data Source: HIV/AIDS reports. Reports received by the end of September 2006.
People seen for HIV care
HIV-infected individuals accessing care by
ethnic group, 1996 and 2005 (E, W, NI)
3%
1% 4%
16%
5%
White
Black Caribbean
1788
Black African
2%
Asian/ Oriental
38%
39%
50%
17 330
Other/Mixed
77%
3%
n= 11 356
n= 44 553
Note: excluded from figure are 1736 from 1996 and 792 individuals from 2005 for whom no ethnicity was reported
Percentage of ethnic groups diagnosed as
HIV-infected: 2005
Number aged 15-59 diagnosed with
HIV infection and receiving care
(SOPHID)
Population, aged 15-59
(ONS 2004 estimates)
Percentage aged 15-59 living with
diagnosed HIV
Source: SOPHID and ONS
Black African
Black Caribbean
Indian/Pakistani/
Bangladeshi
White
16,355
1,206
483
21,448
442,300
384,600
1,522,400
26,977,300
3.7%
0.3%
0.03%
0.08%
Undiagnosed infection
Undiagnosed HIV infections
One in 3 persons living with HIV are undiagnosed (approx 20 000
people)
- Persons unaware are at increased risk of:
 presenting late/ AIDS
 preventable death
 transmitting HIV to sexual partners
- varies with different groups:
Among black Africans ca: 17,000 diagnosed, 6,000 not
Prevalence of previously undiagnosed HIV
infection
Prevalence of previously undiagnosed1 HIV
infection among heterosexuals attending
sentinel GUM clinics
6%
Sub-Saharan Africa-born
Caribbean-born
Asia-born
UK-born
5%
4%
3%
2%
1%
0%
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
Year
1Previously
undiagnosed HIV infection includes those diagnosed at the clinic attendance and those remaining undiagnosed.
Data source: Unlinked Anonymous prevalence monitoring, England, Wales and Northern Ireland
Epidemiology summary
Black Africans living with HIV in the UK
• 17,206 black Africans living with diagnosed HIV in 2005 (22,521 white)
• Over 3500 new diagnoses each year (approx 20,000 total)
• 2/3 are women
• Most HIV-infected black Africans were born in Africa and infected through
heterosexual sex in Africa (small number of MSM)
• Most came to the UK during the last ten years and were diagnosed in the
UK within a few years of arrival
• around 100 children (<15 years) 97% infected MTCT
• Two-fifths of black-African adults were diagnosed late in 2005 (CD4<200)
• >10% have AIDS at the time of HIV diagnosis
• Almost all active TB identified at HIV diagnosis is among black Africans
Black Africans living with HIV in the UK
• About 1 in 40 women giving birth who were born in SSA are HIV
positive.
1 in 30 of those born in Central and Eastern Africa
1 in 80 of women born in Southern or Western Africa
(1 in 2500 women born in the UK)
• In 2005, 3036 women newly diagnosed with HIV
• 18% reported being tested antenatall
• Other reasons: symptoms (28%), routine screening at GUM clinics (25%) and
known positive partner (10%).
• <10% die aged 50 years or more and many die shortly after HIV
diagnosis (MSM: 30% and relatively few)
Access to services
(2004 study using 2003 data)
2003 HIV treatment centres (red dots) and
patients (blue dots)
© Crown Copyright. All rights reserved (Health Protection Agency – 10016969 2005)
Distance to and use of local centre
Out of London
Distance to
local centre
(Km)
London (25km radius)
% using local
centre
Total
% using local
centre
Total
<=5
69
7,304 (69%)
43
16,299 (98%)
6 to 10
49
1,741 (17%)
19
344 (2%)
11 to 20
35
1,114 (11%)
-
0
20+
51
395 (4%)
-
0
Total
61
10,554 (100%)
42
16,643 (100%)
Individuals accessing HIV care: SOPHID 2003
non-local centre
local centre
Number of individuals
6000
5000
4000
3000
2000
1000
0
od
o
l
B
te
He
la
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ex
ros
an
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er
h
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lla
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o
o
r
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te
te
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a
Bl
ite
h
W
ID
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MS
-
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h
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c
W
to
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e
M
h
t
MS
Mo
er
Oth
Summary of findings
• Half of all individuals used their local services (<1km – 90km).
• Majority of individuals live within 5km of an HIV service.
• Local service use is greatest in those living very near to the
service.
• There is much greater local service use outside of London.
• There are some differences by population sub-group.
• E.g. Those requiring specialist services use non-LS
(paediatrics & haemophiliacs).
Access to treatment
BHIVA guidelines on ARV treatment initiation
(relating to CD4 cell counts)
CD4 cell count (per mm3)
before starting therapy
General recommendation for
asymptomatic individuals
<200
All patients should be on ARV
201-350
ARV commencement
350+
ARV not recommended
Number of individuals on ARV by
CD4 cell count category
on ARV
Not on ARV
Number of individuals
25000
20000
15000
10000
5000
0
<200
200-350
CD4 count category
350+
0
Route of infection
Ethnicity
Age Group
Other (inc NK)
Death in a patient with AIDS
AIDS
Symptoms pre-AIDS
Asymptomatic
45+
35-44
25-34
15-24
Other (inc NK)
Black-African
White
Other (inc NK)
Heterosexual Female*
Sex between men
Heterosexual Male*
% not on ARV
Percentage with CD4<200 that were
not on ARV
60
50
40
30
20
10
Most advanced clinical stage ever
reached
Percentage with CD4<200 that were
not on ARV by region where treated
50
45
40
89
30
25
190
n=
215
224
2734
20
15
287
70
499
375
219
32
10
5
M
sh
ire
&
es
t
W
Yo
rk
Region & SHA of treatment
de
si
Hu
m
be
r
id
la
nd
s
al
es
W
es
t
W
So
ut
h
Ea
st
So
ut
h
I re
la
nd
t
W
es
No
rth
er
n
No
rth
Ea
st
No
rth
Lo
nd
on
er
n
Ea
st
M
id
la
nd
s
0
Ea
st
% not on ART
35
Summary of 2005 findings
• 92% of adults not on ART had CD4>=200 and so did
not require ART according to guidelines
• Among severely immunocompromised individuals
(CD4<200), 20% were not receiving ART
• Some may be expected to start ART consequently
• Little variation by ethnicity or exposure category
• Some variation by region
AIDS and death
HIV and AIDS diagnoses and deaths in
HIV-infected black Africans, E,W&NI
4000
HIV diagnoses
Number of diagnoses and deaths
AIDS diagnoses
Deaths
3000
2000
Widespread
introduction of
HAART
1000
0
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
Year
1
Numbers will rise, for recent years, as further reports are received; reports from the Channel Islands excluded
Data Source: HIV/AIDS and death reports. Reports received by the end of September 2006.
Incidence of death (all causes)
Overall incidence of death
Incidence of death within 6 months of HIV diagnosis
Incidence rate (per 100 PYFU)
12
Incidence of death more than 6 months after HIV diagnosis
10
8
6
4
2
Widespread
introduction
of HAART
0
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
Calendar year of follow-up
Late diagnosis
Late diagnoses by exposure category, 2005
Patients with CD4 count under 200 cells/mm3 within 30 days of diagnosis.
Percentage of new HIV diagnoses
diagnosed late
Patients with a clinical AIDS diagnosis within 3 months of HIV diagnosis.
50%
47%
40%
37%
34%
28%
30%
22%
19%
20%
11%
10%
11%
10%
7%
0%
MSM
IDUs
Female
heterosexuals
Male
heterosexuals
Exposure category
Data source: CD4 Surveillance and CD4 Monitoring
Overall
Percentage diagnosed late: region of diagnosis
All significantly
different to London
50%
40%
30%
47%
44%
20%
44%
43%
41%
41%
40%
39%
36%
34%
10%
st
Ea
N
or
th
es
tM
id
l
H
W
&
rk
.
Yo
an
ds
b.
um
rn
st
e
Ea
st
M
Ea
al
es
id
la
Ea
h
ut
So
W
nd
s
st
n
nd
o
Lo
es
t
W
N
or
th
So
ut
h
W
es
t
0%
Percentage diagnosed late : profile by ethnicity,
region of infection and region of infection of partner
n=
256
291
124
7,270
221
50%
40%
30%
49%
20%
10%
20%
21%
Black African
White
44%
44%
Black African
White
0%
Infected in the UK
White
Infected in the UK
partner infected outside EU partner infected within EU
Infected in Africa
Preventable mortality
Short-term mortality: univariable analysis
(Short-term mortality = Percentage who died within a year of diagnosis)
OR = 9.6
p = <0.01
Short-term mortality (%)
10
8
6.12
6
4
3.0
2
0.67
0
Overall
Not diagnosed late
Diagnosed late
Short-term mortality as a percentage of all deaths
Total number of deaths
Percentage of deaths within a year of diagnosis
300
60%
50%
200
40%
30%
100
20%
10%
0%
0
1995
1996
1997
1998
1999 2000
Year of death
2001
2002
2003
2004
Number of deaths
Percentage of deaths within a year of
diagnosis
70%
Crude estimation of preventable deaths 2000-2004
No. new
diagnoses 1
Black Africans
Black Caribbeans
White
Percentage
recent
arrivals 2
11,525 37% (4,264)
Percentage
of recent
arrivals
diagnosed
late 3
43% (1,834)
Est. no.
Est. no.
deaths: recent
deaths:
arrivals
other
diagnosed
individuals 5
late 4
Est. deaths/
Obs. deaths
Total
deaths
112
68
180 / 356 (51%)
550
650
15% (98)
33% (32)
2
4
6 / 19 (32%)
35
1,630
4% (65)
38% (25)
2
11
13 / 73 (18%)
184
1
in England and Wales, 2000-2004, excluding those previously diagnosed abroad
2
those arrived in UK less than 2 years before diagnosis (data only available from clinician reports)
3
only individuals with both a clinician report and a CD4 count at HIV diagnosis
4
assuming short-term mortality of those diagnosed late is 6.12%
5
assuming short-term mortality of those not diagnosed late is 0.67%
Key messages
Summary of results
• Late diagnosis is considerable among heterosexuals
• Substantial mortality within the first year after diagnosis
continues in the HAART era
• Individuals diagnosed late were about 10 times more likely to
die within a year of diagnosis
• Almost 50% of all deaths now occur within a year of diagnosis
• Early diagnosis could prevent deaths
Conclusions
• Groups at high risk of late diagnosis should be targeted for
appropriate health promotion activities, opportunistic
screening, and removal of any barriers to testing - stigma
• HIV testing in a variety of settings would reduce missed
diagnoses, numbers with AIDS at HIV diagnosis, and costs.
• New patient checks in primary care may be the earliest
opportunity to diagnose infection among recent arrivals to the
UK.
Acknowledgements
The continuing collaboration of clinicians, nurses, microbiologists,
health advisors and data managers who contribute to HIV
surveillance in the UK is gratefully acknowledged. Without their
generosity, time and effort, the current level of understanding of
the epidemic could not have been attained.
Nov 2006