Katy Sinka

The late diagnosis and consequent short-term mortality of HIV-infected heterosexuals (England and Wales, 2000-2004).

Objectives:To describe the proportion of HIV-infected heterosexual individuals diagnosed late and estimate how much mortality could have been prevented by earlier diagnosis. Design:A population-based study using surveillance reports from England and Wales. Methods:Calculation of proportions diagnosed late (CD4 cell count < 200 cells/μl) and short-term mortality (death within a year of diagnosis). Results:A total of 16 375 heterosexual individuals were diagnosed with HIV (2000–2004): 10 503 with CD4 cell counts available at that time; 42% (4425) were diagnosed late. Late diagnosis increased with age (P < 0.01). One fifth of women diagnosed antenatally were diagnosed late compared with 42% of other women and 49% of men; 70% of all heterosexuals diagnosed were black Africans, born and infected in Africa. Of those, at least 40% were recent arrivals to the UK, and twice as many were diagnosed late as black-African heterosexuals infected in the UK. Short-term mortality was 3.2% (491/15 523); 6.1% among those diagnosed late and 0.7% among others (P < 0.01). Short-term mortality was lower among black-African compared with white heterosexuals (3.1 versus 4.5%; P < 0.01) because of diagnosis at a younger age. Earlier diagnosis would have reduced short-term mortality by 56% (249 fewer deaths) and all mortality by 32% between 2000 and 2004. Conclusion:Groups at high risk of late diagnosis should be targeted for health promotion activities, opportunistic screening, and removal of any barriers to testing. HIV testing in a variety of settings would reduce missed diagnoses and costs. New patient checks in primary care may provide the earliest opportunity to diagnose HIV infection among recent arrivals to the UK.

No time to wait: how many HIV-infected homosexual men are diagnosed late and consequently die? (England and Wales, 1993-2002).

Objectives:To present national trends of the estimated number and proportion of late HIV diagnoses and short-term mortality following diagnosis among men who have had sex with men (MSM). To determine separately risk factors for late diagnosis and short-term mortality. Methods:Analysis of national HIV/AIDS case reports of new diagnoses linked to CD4 cell counts from the CD4 Surveillance Scheme. Inverse probability weighting adjusted for individuals with no CD4 cell count at diagnosis. Outcomes were late diagnosis (CD4 cell count <200 × 106 cells/l at diagnosis) and short-term mortality (death within 1 year of diagnosis). Results:Of 14 158 new diagnoses, 31% were estimated as late diagnoses. Despite a decreasing trend (P trend <0.01) an estimated 430 (25%) MSM were still diagnosed late in 2001. Late diagnosis disproportionately affected individuals diagnosed outside London, of non-white ethnicity, and of older age. There were 710 (5.0% of 14 158) deaths within a year of HIV diagnosis. Estimated short-term mortality was 14% for MSM diagnosed late and 1% for other MSM (adjusted odds ratio, 10.8; 95% confidence interval, 7.7–15.9). Short-term mortality declined concurrently with availability of highly active antiretroviral therapy and was independently associated with age and diagnosis outside London but not ethnicity. Conclusions:The continued late diagnosis of one in four MSM means these individuals lose the option to start therapy early, miss opportunities to prevent further transmission and are approximately 10 times more likely to die within a year of diagnosis. Early diagnosis of all MSM in 2001 could have reduced short-term mortality by 84% and all mortality in that year by 22%.

Epidemiology of HIV among black and minority ethnic men who have sex with men in England and Wales.

Objectives: To examine the epidemiology of HIV among black and minority ethnic (BME) men who have sex with men (MSM) in England and Wales (E&W). Methods: Ethnicity data from two national HIV/AIDS surveillance systems were reviewed (1997–2002 inclusive), providing information on new HIV diagnoses and those accessing NHS HIV treatment and care services. In addition, undiagnosed HIV prevalence among MSM attending 14 genitourinary medicine (GUM) clinics participating in the Unlinked Anonymous Prevalence Monitoring Programme and having routine syphilis serology was examined by world region of birth. Results: Between 1997 and 2002, 1040 BME MSM were newly diagnosed with HIV in E&W, representing 12% of all new diagnoses reported among MSM. Of the 1040 BME MSM, 27% were black Caribbean, 12% black African, 10% black other, 8% Indian/Pakistani/Bangladeshi, and 44% other/mixed. Where reported (n = 395), 58% of BME MSM were probably infected in the United Kingdom. An estimated 7.4% (approximate 95% CI: 4.4% to 12.5%) of BME MSM aged 16–44 in E&W were living with diagnosed HIV in 2002 compared with 3.2% (approximate 95% CI: 2.6% to 3.9%) of white MSM (p<0.001). Of Caribbean born MSM attending GUM clinics between 1997 and 2002, the proportion with undiagnosed HIV infection was 15.8% (95% CI: 11.7% to 20.8%), while among MSM born in other regions it remained below 6.0%. Conclusions: Between 1997–2002, BME MSM accounted for just over one in 10 new HIV diagnoses among MSM in E&W; more than half probably acquired their infection in the United Kingdom. In 2002, the proportion of BME MSM living with diagnosed HIV in E&W was significantly higher than white MSM. Undiagnosed HIV prevalence in Caribbean born MSM was high. These data confirm the need to remain alert to the sexual health needs and evolving epidemiology of HIV among BME MSM in E&W.

The changing epidemiology of prevalent diagnosed HIV infections in England, Wales, and Northern Ireland, 1997 to 2003

Objectives: To present the current epidemiology of prevalent diagnosed HIV infections in England, Wales, and Northern Ireland (E, W, & NI) and describe trends over time. Methods: Descriptive analyses of the annual national Survey of Prevalent HIV Infections Diagnosed (SOPHID) for the period 1997 to 2003. Results: In 2003, 34 251 adults (15 years of age or over) were seen for HIV related care in E, W, & NI, representing a 17% increase in the prevalence of diagnosed HIV infections compared with 2002 and a 132% increase compared with 1997. Between 1997 and 2003, as a proportion of total prevalent cases, adults who acquired their infection through heterosexual sex increased from 26% to 49%; black African adults increased from 15% to 35% and diagnosed adults resident in London fell from 62% to 55% of the total. The male to female ratio declined from 5:1 to 2:1. The proportion of adults receiving combination antiretroviral therapy increased from 53% in 1998 to 64% in 2003. Conclusion: There has been a large increase in the number of adults with diagnosed HIV infection seen for care in E, W, & NI since 1997. Changes in the epidemiology of prevalent diagnosed HIV were seen by sex, route of infection, ethnicity, level of antiretroviral therapy, and areas of residence and treatment. In 2003, for the first time, prevalent diagnosed infections acquired through heterosexual sex overtook those acquired through sex between men. These increases have serious implications for the planning and financing of HIV services in the United Kingdom.

Men who have sex with men who are born abroad and diagnosed with HIV in England and Wales: an epidemiological perspective

Relatively little is known about the sexual health needs of men who have sex with men (MSM) born abroad who reside in the UK. We describe here the epidemiology of HIV among MSM born outside the UK and diagnosed with HIV in England and Wales. Reports of HIV diagnoses in England and Wales received at the Health Protection Agency Centre for Infections were analysed. Between 2000 and 2003, 6386 MSM were diagnosed with HIV in England and Wales. Country of birth was recorded for 3571 (56%). Of those with country of birth reported, 2598 (73%) were born in the UK and 973 (27%) abroad. Of those born abroad (973), 424 (44%) were born in Europe, 141 (15%) in Africa, 104 (11%) in South/Central America and the remainder in other regions. Where reported (949), 69% of MSM born abroad were White, 12% other/mixed, 9% Black Caribbean and 7% Black African. Probable country of infection was reported for 612 MSM born abroad: 52% were infected in the UK, 43% in their region of birth and 5% in another region. Men born abroad represent a significant proportion of HIV diagnoses among MSM in England and Wales. More than half probably acquired their HIV infection in the UK, strengthening the call for targeted HIV prevention and sexual health promotion among MSM who are not born in England and Wales.

Late diagnosis of HIV infection among individuals with low, unrecognised or unacknowledged risks in England, Wales and Northern Ireland

Abstract A small number of UK nationals who have a low, unrecognised or unacknowledged risk for HIV present late in the course of HIV infection; often after frequent attendances to primary care physicians. Information from in-depth interviews with individuals diagnosed with HIV in England, Wales and Northern Ireland (EW&NI) was analysed. Those diagnosed because of HIV-related symptoms (late diagnoses) were compared with those diagnosed for other reasons. Of the 286 individuals interviewed, 157 (55%) had HIV-related symptoms at the time of diagnosis, and 129 were tested for other reasons. A greater proportion of those diagnosed late were male and older. Of the 157 late diagnoses, 77 were considered to have acquired HIV heterosexually in the UK, 19 heterosexually abroad, 16 through ‘high-risk’ behaviours, 15 heterosexually by a ‘high-risk’ partner, four through blood transfusion and the remainder through an unusual or unknown route. A significantly higher proportion of those diagnosed late had had a long-standing relationship. None had been informed by a current or ex-partner of their HIV status. Primary care physicians should consider HIV as a possibility when patients without an apparent risk for HIV-infection present with symptoms indicative of possible immune suppression. Sensitive partner notification practices that enable a greater number of individuals to inform their partners should be explored.

Prevalent diagnosed HIV in England, Wales and Northern Ireland: adjusted totals 1996 to 2001 and extrapolations to 2004.

Objective: To predict trends in diagnosed HIV prevalence by extrapolation to 2004 using data from the annual surveys of individuals receiving HIV-related care in England, Wales and Northern Ireland from 1996 to 2001. Methods: Data from the annual surveys of prevalent HIV infections diagnosed (SOPHID) were adjusted for under-reporting and non-attendance and separately extrapolated for infections acquired homosexually, heterosexually and by other routes. The data were extrapolated using negative binomial and linear regression models based on the 1996 to 2001 annual surveys. Results: The negative binomial model predicted an increase of 56% in diagnosed HIV prevalence in England, Wales and Northern Ireland between 2001 and 2004. The linear model predicted an increase of 25% for the same time period. The predicted increases are mostly driven by the large rise in the number of new diagnoses, in particular in individuals infected heterosexually. Conclusion: Increases in HIV prevalence in England, Wales and Northern Ireland have diverged from a linear trend. Negative binomial modelling of the data predicts that large rises in prevalence will continue during the early 2000s.