For those who test positive, minimising time from diagnosis to initiation of treatment will reduce the time people are living with a detectable viral load (Figure 12). Enabling individuals to remain on treatment with an undetectable viral load reduces overall transmissible levels of virus and the opportunity for onwards transmission to sexual partners. This includes ensuring that individuals already diagnosed with HIV are linked to, engaged in, and where relevant, re-engaged in care so that they can access effective treatment and achieve viral suppression. Figure 12. Flowchart for theme 3: reduce the number of people with transmissible levels of virus An accessible text version of this flowchart is also available. A summary of current and provisional indicators for theme 3 can be found in Table 6. Table 6. Provisional indicators for theme 3: reduce the number of people living with transmissible levels of virus
CodeTheme 3: indicator201920202021 PT3AEstimated number of people living with transmissible levels of virus in England12,93212,18411,985 PT3A(i)Number of people not linked to care within calendar year of diagnosis342259147 PT3A(ii)Number of people on treatment and no evidence of viral suppression3,6081,2222,762 PT3BNumber of people not linked to care within 15 days of HIV diagnosis1,9101,3571,525 PT3CNumber of people not linked to care within 28 days of HIV diagnosis2,2441,5781,742 PT3DNumber and proportion of people starting treatment within 90 days of diagnosis2,2791,4461,538 PT3ENumber of people seen for HIV care and not on treatment1,6271,1191,195 PT3FNumber (and proportion) of people treated who are not virally suppressed (viral load over 200 copies)2,096 (2.4%)1,874 (2.2%)1,799 (2.0%) PT3GNumber of people not attending care for at least 15 months (‘not retained in care’)2,5194,9804,444 PT3HNumber of people who had not attended care for at least 15 months and have attended a new appointment5,2593,6264,939 PT3INumber of people effectively re-engaged in care – people who had not attended care for at least 15 months, reattended and who have undetectable viral load within 6 months4,0942,301Not available PT3JNumber of late HIV presentations among those previously diagnosed abroad160106112 PT3KNumber of people who had not attended care for >15 months and have attended a new appointment following opt-out testing in ED
ProvisionalProvisionalProvisional Estimated number of people with transmissible levels of virus in England (PT3A) In 2021, a lower-level estimate of 11,985 people living with HIV had transmissible levels of virus, equivalent to 13% of people living with HIV. The equivalent numbers for 2019 and 2020 were 12,184 and 12,932 respectively. Of the 11,985 people (lower level estimate) with transmissible levels of virus, an estimated 4,400 (37%) (95% CrI 3,500 to 6,100) remained undiagnosed in 2021 while 7,585 were living with diagnosed HIV, of which: 147 (1.2%) were first diagnosed in 2021 and not linked to care by end of the year, 4,444 (37%) were not retained in care (not seen in care for at least 15 months since last HIV care appointment between October 2019 and September 2020), 1,195 (10%) attended care in 2021 but were not receiving treatment, and 1,799 (15%) were on treatment in 2021 but were not virally suppressed (viral load below 200 copies per mL) (Figure 13). In a higher-level estimate, the number of people living with transmissible levels could reach up to 32,829, if we include the 2,618 people who were on treatment in 2021 but had no evidence of viral suppression (95% of whom had missing viral load data for 2 consecutive years) and the additional 18,226 people who had been seen once from January 2015 to September 2019 but not seen for at least 15 months by end of 2021. For 2019 and 2020, the higher-level estimates were 23,613 and 25,239, respectively. Figure 13. Lower-level estimates for the number of people living with HIV with transmissible levels of virus, England, 2021 Linkage to HIV care (PT3B and PT3C) Linkage to HIV care is defined as having a first CD4 count result, viral load result or HIV clinic attendance within a specific number of weeks or months of the HIV diagnosis date. In 2021, 79% (1,525 of 1,935) of adults first diagnosed with HIV in England were linked to HIV care within 2 weeks, 90% (1,742 of 1,930) within 1 month and 97% (1,857 of 1,923) within 3 months. This compared to 67% (1,910 of 2,831), 79% (2,244 of 2,826) and 86% (2,426 of 2,820) within 3 months respectively, in 2019 (Figure 14). Figure 14. Linkage to HIV care within 2 weeks, one month and 3 months among adults first diagnosed with HIV in England: 2019 to 2021 Prompt HIV treatment (PT3D) Among those diagnosed with HIV in England in 2021, 78% (1,583 of 2,023) started HIV treatment within 90 days of diagnosis, compared to 73% (1,446 of 1,987) in 2020 and 76% (2,279 of 2,986) in 2019. Treatment coverage (PT3E) The proportion of people receiving anti-retroviral therapy (ART) amongst people in HIV care remains high, at 98% (88,352 of 89,982) in 2019 and 98% (89,583 of 91,083) in 2021. In 2021, there were 1,195 people living with HIV and attending care who were not receiving ART and 305 people with a missing ART status recorded. Viral suppression (PT3F) ART not only prevents illness and death in people living with HIV but achieving viral suppression also prevents transmission of HIV. This is referred to as TasP and also promoted as undetectable=untransmissible or U=U (39). In England, 98% of people on treatment and with viral load results available were virally suppressed (79,951 of 81,750) in 2021. In 2021, 1,799 people on ART had a reported detectable viral load, compared with 1,874 in 2020 and 2,096 in 2019. In addition, 2,618 people on treatment did not have any viral load recorded in 2021 and either no viral load reported or a detectable (over 200 copies per mL) viral load reported in 2020. This is an increase compared with 1,071 in 2020 but lower than 2019 (3,500). Retention in care (PT3G, PT3H) During the COVID-19 pandemic, fewer people were seen in HIV care compared to previous years due to the impact of the public health measures to control COVID-19 on HIV care access and delivery (2). People not retained in care are not receiving the treatment and support needed to remain healthy and virally suppressed. Current BHIVA guidelines recommend that people living with HIV should attend care on a yearly basis (40). Though most people are seen within 12 months, some delays may occur. Therefore, people not retained in care are those not seen within 15 months of their last attendance for the below measures. Among the 94,695 people seen for HIV care between 1 October 2019 and 30 September 2020, 4,444 people were not retained in care that is were not seen for care again for at least 15 months, and up until the end of 2021. Similar measures for 2019 and 2020 were 2,519 and 4,980, respectively. It is worth noting that of the 91,083 people seen for HIV care in 2021, 4,939 people had returned after a care gap of over 15 months since January 2015. Future analyses will include as a proxy for reintegration into care, an assessment of the extent to which people with a history of over 15 months’ absence from care attain an undetectable viral load. Late HIV presentations among those diagnosed abroad (PT3J) Amongst those diagnosed at a late stage of infection in England are individuals who were previously diagnosed outside the UK, and who present at a late stage of infection. Overall, those previously diagnosed abroad constitute approximately one quarter of new HIV diagnoses made each year in England (25%, 669 of 2,692 in 2021), but only 13% (112 of 866 in 2021) of all diagnoses made at a late stage of infection. From 2019 to 2021, the proportion of those previously diagnosed abroad who presented at a late stage of infection remained stable, at 20% (160 of 788 in 2019, 106 of 525 in 2020, and 112 of 547 in 2021). Meanwhile the proportion of those who were diagnosed late increased (41%, 857 of 2,101 in 2019; 44%, 667 of 1,520 in 2020; 46%, 754 of 1,630 in 2021).