This report presents data between 2019 and 2021, which predates the HIV Action Plan (published in 2021). The HIV Action Plan uses 2019 as the baseline year against which the ambitions are set. In this report, the figures for the baseline year, 2019 (4), differ from those published in the HIV Action Plan (1) as further HIV clinic reports have been received since and integrated into the HIV database retrospectively. The estimates of population living with HIV (including undiagnosed) were rounded to the nearest 100. Towards zero new HIV transmissions New HIV diagnoses first made in England New HIV diagnoses first made in England fell by 32% from 2,986 in 2019 to 1,987 in 2020, but numbers plateaued in 2021 (2,023) (Figure 2 and Table 3). This plateau is likely due to the COVID-19 pandemic affecting HIV testing access and health-seeking behaviours (10) with a proportion of people deferring their HIV test in 2020 and subsequently testing in 2021. To achieve the 2025 target of 600 new HIV diagnoses by 2025, a decrease of approximately 360 diagnoses first made in England, annually, from 2022 onwards, would need to be achieved. This plateau is likely due to the COVID-19 pandemic affecting HIV testing access and health-seeking behaviours with a proportion of people deferring their HIV test in 2020 and subsequently testing in 2021 (10). To achieve the 2025 target of 600 new HIV diagnoses by 2025, a decrease of approximately 360 diagnoses first made in England, annually, from 2022 onwards, would need to be achieved. Table 3. Summary of indicators for progress towards the HIV Action Plan ambitions and UNAIDS targets, England, 2019 to 2021
HIV Action Plan indicators2019 baseline20202021Percentage change (2019 to 2021)2025 ambitionAnnual decrease from 2022 to achieve ambition Number of new HIV diagnoses first made in England2,9861,9872,023-32%600360 Number of people diagnosed with AIDS
216169171-21%11016 Estimated number of HIV-preventable deaths233.6325.6289.2+24%11544
UNAIDS 95 95 95 targets94%-98%-97%95%-99%-98%95%-99%-98%Not applicableNot applicableNot applicable The fall in the number of people first diagnosed with HIV in England was not equal between groups. Among GBMSM first diagnosed in England, there was a 45% fall in new diagnoses between 2019 and 2020 from 1,262 to 699. Subsequently, among GBMSM living in London, new HIV diagnoses first made in England continued to decrease from 247 in 2020 to 204 in 2021. However, among GBMSM living outside London, numbers rose from 452 in 2020 to 517 in 2021. The sustained fall in GBMSM in London, which occurred in the context of high numbers of HIV testing, reflects a fall in incidence. Among heterosexual men in London, new diagnoses first made in England reduced from 156 in 2019 to 134 in 2020 and to 108 in 2021. Outside London, new diagnoses first made in England fell from 377 in 2019 to 233 in 2020 but rose to 261 in 2021. Among heterosexual women in London, new diagnoses first made in England fell from 176 in 2019 to 117 in 2020 and rose to 140 in 2021. Outside London, new diagnoses first made in England reduced from 400 in 2019 to 275 in 2020 and rose to 289 in 2021. Among heterosexual adults, in whom HIV testing has not recovered to pre-COVID-19 levels, this suggested incidence has not fallen in this group. Further work is needed to ensure the fall in new HIV diagnoses in London observed in GBMSM can also occur in GBMSM outside London, and among heterosexual men and women. New HIV diagnosis rates were calculated using population denominators derived from the Multi Parameter Evidence Synthesis (MPES) model, a complex statistical model fitted to census, surveillance and survey-type prevalence data (11, 12). Although new HIV diagnoses rates (among people first diagnosed in England) have decreased across all groups over time, they remain disproportionately higher among GBMSM and Black African heterosexuals in comparison to the overall population and non-Black African heterosexuals (Figure 3). Figure 2. Progress towards ending HIV transmission, AIDS and HIV-related, preventable deaths by 2025, England, 2010 to 2021 Figure 3. New HIV diagnoses rate (per 1,000) among people first diagnosed in England, by specific population groups, ages 15 to 74, 2017 to 2021 Estimating HIV transmission in gay, bisexual and other men who have sex with men An age-dependent CD4 back-calculation model which estimates newly acquired HIV infections and probability of HIV diagnosis according to the number of new HIV diagnoses and the distribution of CD4 counts at or soon after diagnosis (13, 14) was used to generate point estimates and 95% credible intervals (CrIs) of HIV incidence among GBMSM. The number of new HIV infections in GBMSM in England was estimated to have declined from 750 (95% CrI 610 to 910) in 2019, to 660 (95% CrI 470 to 880) in 2020, and to 620 (95% CrI 390 to 910) in 2021. These estimates indicate that the trend of decreasing incidence seen in previous years has been maintained, with an 80% probability of a decline between 2019 to 2021. The extent of the decline varied between age groups, with incidence of HIV among GBMSM aged 15 to 24 declining from an estimated 170 (95% CrI 130 to 210) infections in 2019 to 90 (95% CrI 50 to 150) in 2021 (probability for decline 99.5%) (Figure 4). In comparison, incidence in GBMSM aged 35 to 44 was estimated to be stable, at 170 (95% CrI 130 to 210) in 2019, and 180 (95% CrI 100 to 290) in 2021 (probability for decline 34%). Figure 4. Estimated HIV incidence in GBMSM in England by age group, using a CD4 back-calculation method, England, 2016 to 2021 Towards zero AIDS diagnoses There were 171 AIDS diagnoses within 3 months of HIV diagnosis in 2021 compared to 216 in 2019. If we are to meet the HIV Action Plan ambition of fewer than 110 in 2025, we would need to reduce the number of AIDS diagnoses within 3 months of an HIV diagnosis by 16 each year from 2022 onwards. Towards zero preventable, HIV-related deaths In 2021, there were 723 deaths occurring in people with HIV, a 24% rise from 584 in 2019. An estimated 40% of all deaths in 2021 in people with HIV related, preventable deaths (15), this equates to 289 deaths. If the target of fewer than 115 preventable HIV-related deaths in 2025 is to be met, the number of deaths would need to reduce by 44 each year from 2022 onwards. Compared with 2019, there were 170 and 139 more all-cause deaths in 2020 and 2021, respectively. Spikes in mortality in people living with HIV coincided with peak COVID-19 mortality (4). This suggests excess mortality in 2020 and 2021 was partially due to direct impact of COVID-19 infection, as well as its indirect impact through disruption to healthcare services. However, people living with diagnosed HIV who were on treatment and virally suppressed did not have a higher risk of COVID-19 death compared to the general population prior to the start of the widescale COVID-19 vaccination programme in December 2020 (16). In addition to the impact of COVID-19 on mortality in 2020 and 2021, the national HIV mortality review (4) which was implemented in 2019 has also led to improved ascertainment of deaths reported in this period. Further work is underway to implement the pan-European definition of HIV-related and preventable mortality (17), which will replace the current 40% estimate of all-cause deaths occurring in people with HIV. This definition will be implemented in England in due course. Those first diagnosed late (CD4 count under 350 cells within 91 days of diagnosis) in England in 2020 were 13 times more likely to die within a year of their diagnosis, compared to those who were diagnosed earlier (with higher CD4 counts) (4). This figure is higher than the equivalent measure for 2019 (8 times) and may reflect again the direct and indirect impact of the COVID-19 pandemic (4). Towards zero stigma Measuring HIV stigma is challenging, and work is ongoing to develop consensus definitions and measures. Previous publications indicate that in 2015, 30% of respondents to the Stigma Survey UK (18) and in 2017, 19% of the participants in the 2017 Positive Voices survey (19) reported having ever been treated differently from other patients in healthcare settings (enacted stigma). The UNAIDS 2025 targets set an ambition for stigma to be experienced by under 10% of people living with HIV by 2025 (8).
UNAIDS 95-95-95 progress In 2021, England again achieved the UNAIDS 95-95-95 target nationally, with 95% of people living with HIV being diagnosed, 99% of those diagnosed being on treatment and 98% of those on treatment having an undetectable viral load (Figure 5). In London, the equivalent figures were 96%, 98% and 98% compared to 95%, 99% and 98% outside of London. Figure 5. Progress towards the UNAIDS 95-95-95 targets by population group, England, 2019 to 2021