Research and analysis

HPR volume 8 issue 39: news

Updated 23 December 2014

1. Trends in late HIV diagnoses and in persons accessing HIV-related care in the UK: data to December 2013

On 6 October 2014, Public Health England (PHE) published national HIV data tables on numbers accessing HIV care in the United Kingdom to the end of 2013 [1]. This information release precedes the launch of the 2014 HIV Surveillance Overview in the week commencing 17 November 2014, in advance of National HIV Testing Week (21-28 November 2014) [2].

There were 6,000 people newly diagnosed with HIV infection in the UK in 2013. Three quarters of them were men (4,477). This is a slight decrease following 6,245 diagnoses reported in 2012, and is consistent with the overall declining trend observed since a peak in 2005 (7,892). The decline is largely due to a reduction in the number of new HIV diagnoses among men and women born abroad. Reports of AIDS and all-cause deaths among persons with diagnosed HIV have remained low since the introduction of effective antiretroviral therapy (ART) in the mid-1990s, with 319 and 527 reports in 2013, respectively. Of note is the changing age distribution among persons newly diagnosed; in 2013 nearly one in six (n=974) adults were 50 years or older, compared to one in fourteen (n=587) in 2004.

There has been a modest reduction in the proportion and the number of HIV diagnoses made at a late stage of infection. Over the past five years, late HIV diagnoses in the UK have fallen from 52% (3,450/6,634) in 2009 to 42% (1,058/6,000) in 2013 (data adjusted for missing information). Defined as having a CD4 count <350 cells/µl within three months of HIV diagnosis, late HIV diagnoses represent a key indicator of the public health response to HIV. Late HIV diagnosis by Local Authority is published each February as one of the Public Health Outcome Indicators [3]. People who are diagnosed with HIV late have a ten-fold increased risk of death within a year of diagnosis compared to those diagnosed promptly. Prompt diagnosis also provides the opportunity for behaviour change and access to anti-retroviral therapy (ART) both of which reduce the risk of onward transmission.

The number of persons accessing HIV-related care has nearly doubled over the last decade, from 41,157 in 2004 to 81,512 in 2013 (see figure). This is due to on-going new diagnoses and an ageing cohort effect as people are living longer with HIV. The number and proportion of persons accessing HIV-related care aged 50 and over continues to rise. In 2013, one in four adults (≥15 years) were aged 50 and over, compared with one in five adults in 2009 and one in eight in 2004. It is vital that those living with diagnosed HIV continue to receive appropriate care as they age and have effective and integrated management of their co-morbidities alongside their HIV infection.

Coverage of ART continues to rise with 87% (70,570/81,512) of persons seen for care in 2013 receiving ART compared to 68% (27,799/41,157) in 2004. Coverage of ART among people with a CD4 count <350 cells/µl has increased from 83% (12,519/15,113) in 2009 to 90% (11,351/12,631) in 2013.

London had the largest number of residents living with diagnosed infection accounting for 42% (33,863/81,512) of diagnosed persons. The PHE centres that saw the largest proportional increases over the past 10 years were the West Midlands and Yorkshire and The Humber, which each saw a tripling in the number accessing care from 2,720 in 2004 to 5,552 in 2013 and from 1,706 to 4,298, respectively.

National testing guidelines recommend that, where the prevalence of diagnosed HIV infections is two or more per 1,000 among persons aged 15-59, an HIV test should be offered to persons newly registering in general practice and being admitted to a general medical ward. In 2013, 66 Local Authorities (LAs) had a diagnosed prevalence above the two per 1,000 threshold, nearly half of which were in London (32/66). All but one of the 33 London LAs had prevalence above this threshold. Outside London, the five LAs with the highest prevalence above the two per 1,000 threshold were: Brighton and Hove, Salford, Manchester, Slough and Luton.

Persons seen for HIV care by prevention group and ethnicity: United Kingdom, 2004–2013

1.1 Notes

1. HIV data tables are available at: https://www.gov.uk/government/statistics/hiv-data-tables.
2. The 2014 HIV Surveillance Overview will include estimates of undiagnosed HIV infection, HIV incidence trends, the impact of treatment as prevention and the monitoring of HIV care quality.
3. See: http://www.phoutcomes.info/public-health-outcomes-framework#gid/1000043/pat/6/ati/102/page/0/par/E12000004/are/E06000015.

2. English Surveillance Programme for Antimicrobial Utilisation and Resistance first report

PHE has been charged with delivering on four of the seven key areas of the UK antimicrobial resistance strategy for 2013-2018 [1]. The English Surveillance Programme for Antimicrobial Utilization and Resistance (ESPAUR) was established by PHE in response to the strategy. ESPAUR, which works towards aspects of the four key areas, has produced its first annual report, presenting “baseline” data on useage of key antibiotics and an assessment of the extent of proliferation of resistant strains associated with those drugs.

The key aims of ESPAUR are to develop surveillance systems to measure both utilisation and resistance, to measure the impact of the former on the latter, and assess the implications for patient/public safety.

It is a given that consumption of antibiotics is a major driver for the development of resistance in bacteria and ESPAUR data outputs are seen as essential to the reduction of unnecessary prescribing. The data in the new report provide, for the first time, information on national and regional antibiotic resistance and use trends from 2010 to 2013, and provide a baseline against which changes in prescribing practices and resistance can be compared [2]. The focus is on susceptibility data for bacteria/drug combinations chosen because they encompass particularly hard-to-treat infections.

On consumption, the ESPAUR report states that, in 2013, 66 different antibiotics were prescribed in both general practice and hospital settings, of which the top 15 accounted for 98% and 88% of consumption respectively. From 2010 to 2013, total antibiotic consumption increased by 6%: general practice consumption increased 4%, prescribing to hospital inpatients increased by 12% and other community prescriptions (eg dentists) increased by 32%. The predominant antibiotics consumed in England were penicillins, tetracyclines and macrolides. The report dedicates sections on trends in consumption to these other key drug categories

On antibiotic resistance, the report dedicates sections to trends in resistance for the following key pathogen categories: Escherichia coli, Klebsiella pneumoniae, Pseudomonas spp. and Streptoccus pnemoniae. It notes, for example, that (according to voluntary reporting data) there was an increase of 12% in bloodstream infections caused by E.coli between 2012 and 2013, with varying levels of resistance to key antibiotics for this infection of between 10 and 19%.

Data from the first year of ESPAUR provides a baseline measure of antimicrobial resistance and use. This will allow PHE to determine the impact of future behaviour and educational strategies developed with both the public and healthcare professionals. As part of this, PHE have established the Antibiotic Guardian pledge campaign where everyone in the UK, the public and the medical community can choose one simple pledge about how they make better use of antibiotics and help save these vital medicines from becoming obsolete [3].

2.1 References

1. “UK five-year antimicrobial resistance strategy 2013 to 2018”, DH website, 10 September 2013.

2. English surveillance programme antimicrobial utilisation and resistance (ESPAUR) 2014 report, 10 October 2014. See also: “New report reveals increase in use of antibiotics linked to rising levels of antibiotic resistance”

3. The Antibiotic Guardian website, where pledges can be made is at: http://antibioticguardian.com/