Research and analysis

HIV Action Plan monitoring and evaluation framework 2024 report

Updated 28 November 2024

Applies to England

Foreword

In 2021, the government published the first HIV Action Plan for England which set an ambition between 2019 and 2025 to reduce the number of:

• people first diagnosed with HIV by 80%
• people diagnosed with AIDS within 4 months of HIV diagnosis by 50%
• HIV related deaths by 50%

As 2025 rapidly approaches, it is time to take stock of progress towards these aims, celebrate our successes and focus on the new and emerging challenges.

There is much to celebrate with England continuing to provide world class HIV care. Once again, the UNAIDS targets were met. In 2023, 95% of all people with HIV were diagnosed, 98% of people diagnosed were receiving treatment and 98% of people receiving treatment were virally suppressed and unable to pass on the virus, even if having sex without condoms or pre-exposure prophylaxis (PrEP). From 2022 to 2023, there has been an overall 8% increase in HIV testing in sexual health services and an 11% increase in the number of people starting or continuing PrEP. The bloodborne viruses (BBVs) opt-out testing in emergency departments (EDs) programme has been a huge success, identifying 201 people with undiagnosed HIV in 2023 and 391 since April 2022.

However, progress in reducing transmission has been more uneven. HIV diagnoses fell by 12% from 2,801 in 2019 to 2,451 in 2022 but rose again by 15% to 2,810 in 2023. In London, this increase between 2022 and 2023 is likely due to the contribution of the ED opt-out testing programme. However, outside of London and excluding the ED testing programme, new HIV diagnoses have risen by 21% and have been mainly among people exposed through sex between men and women. From 2019 to 2023, new HIV diagnoses decreased among white men exposed through sex between men by 44%. However, no equivalent decline has occurred in men from ethnic minority groups: 1 in 4 new HIV diagnoses were among ethnic minority men in 2019 compared to 1 in 3 in 2023.

The proportion of people starting treatment within 3 months of diagnosis in 2023 was higher among men exposed through sex between men than among people exposed through sex between men and women and lowest in people of black ethnicity. These widening inequalities highlight the need for improved access and culturally competent support to HIV interventions across the whole pathway.

While it is unlikely that we will meet the 2025 targets, the 2030 target of zero new HIV transmissions is within our reach. We have the tools to end HIV transmission and we know what works: regular HIV testing, accessible PrEP, prompt linkage to care, engagement in care and viral suppression. The UK Health Security Agency (UKHSA) are committed to working with stakeholders to deliver an evidence-driven HIV Action Plan for 2025 to 2030 and ensure that these interventions are scaled up, appropriately delivered and equitably accessed by all people affected by HIV in England.

Professor Susan Hopkins
Chief Medical Advisor at the UK Health Security Agency

Main messages

Progress towards the HIV Action Plan ambitions

The main findings are:

• substantial progress has been made to reduce new HIV diagnoses first made in England (hereafter ‘HIV diagnoses’) between 2019 and 2023, particularly among men exposed through sex between men; however, with the current trajectory it is highly unlikely that the 2025 target of 80% reduction in new diagnoses will be met for any population
• inequalities are widening in access to HIV prevention interventions, treatment and ongoing care, quality of life and stigma across most demographic characteristics, in particular, age, ethnicity, gender identity and exposure
• HIV diagnoses fell by 12% from 2,801 in 2019 to 2,451 in 2022, but rose by 15% to 2,810 in 2023
• an estimated 104,000 (95% credible interval (CrI) 102,700 to 105,800) adults are living with HIV in England in 2023
• the ED opt-out testing programme, which identified 201 new HIV diagnoses in 2023, partly contributed to this rise in diagnoses between 2022 and 2023 particularly people living in London
• most of the increase in HIV diagnoses between 2022 and 2023 was among adults exposed through sex between men and women living outside London (increase of 51% among men and 44% among women)
• among men exposed through sex with men, HIV diagnoses fell by 35% from 1,242 in 2019 to 811 in 2023 – the decline was most apparent among white men whilst diagnoses among men of ethnic minorities made an increasing proportion of diagnoses acquired through sex between men, from 26% in 2019 to 33% in 2023
• using a CD4 back-calculation model linked to diagnosis data, HIV transmission among men exposed through sex with men in England was estimated to have plateaued in the last 4 years, with a small increase in transmission among men 25 to 34 years in 2023
• the number of diagnoses for an AIDS-defining condition within 3 months of HIV diagnosis decreased between 2019 and 2023 from 208 to 179 – with the current trend it is unlikely that the HIV Action Plan target of a 50% reduction in this figure will be achieved by 2025
• we applied the pan-European definitions for HIV-related and preventable deaths for the first time to the 2019 to 2023 data
• the estimated number of HIV-related deaths increased from 162 in 2019 to 193 in 2023, and if this trend continues, the 2025 target of a 50% decrease in HIV-related mortality is unlikely to be reached
• the UNAIDS 95-95-95 targets were met in England in 2023, with 95% of all those with HIV being diagnosed, 98% of those diagnosed receiving treatment, and 98% of those treated being virally suppressed and thus unable to pass on the virus – also expressed as 95%-98%-98%
• when missing data and information for those not in care are taken into account, the UNAIDS 95-95-95 estimates for 2023 range from 96%-94%-96% to 96%-94%-92%

A summary of indicators for Progress towards the HIV Action Plan can be found in Table 1.

Theme 1: maintain people’s negative HIV status

The main findings are:

• 936 people were reported as attending a specialist sexual health service (SHS) as a result of partner notification in 2023; 84% were tested, with 4.6% testing positive – this represented an increase since 2022 in both attendance and testing but still lower than 2019
• the number of people prescribed HIV PrEP in sexual health services (SHSs) continues to increase annually, from 86,616 in 2022 to 96,562 in 2023
• inequalities in PrEP initiation or continuation continue to exist by gender identity, sexual orientation and ethnicity
• the proportion of new HIV diagnoses among individuals who initiated or continued on PrEP in the past 12 months, is low at 0.05% each year

A summary of indicators for Theme 1 can be found in Table 2.

Theme 2: reduce the number of people living with HIV who are undiagnosed

The main findings are:

• an estimated 104,000 (95% CrI 102,700 to 105,800) adults are living with HIV in England in 2023
• an estimated 4,700 (95% CrI 3,700 to 6,300) of adults living with HIV were undiagnosed in 2023, compared with 4,000 (95% CrI 3,200 to 5,700) in 2022 and 6,000 (95% CrI 4,500 to 8,400) in 2019
• almost a quarter (1,200; 95% CrI 900 to 1,800) of the estimated number of people living with undiagnosed HIV lived in London, with 3,400 (95% CrI 2,600 to 4,800) living elsewhere in England in 2023
• the number of people tested for HIV in all SHSs rose by 8% between 2022 and 2023, representing a recovery to 96% of the testing levels seen in 2019
• the recovery in the number of people tested in SHSs is not uniform amongst different groups – for instance between 2019 and 2023, there has been a 10% and 22% decrease in the number of people tested in heterosexual and bisexual women and heterosexual men respectively but a 34% increase in gay, bisexual and other men who have sex with men (GBMSM)
• the number of heterosexual people of black African ethnicity tested increased from 2019 to 2023, while positivity remained stable between 0.3% and 0.4% – when this is considered together with trends in testing and late diagnosis in this population, it suggests transmission may be continuing with no evidence of a decrease
• 1 in 5 tests undertaken in community settings (and reported through the UKHSA community testing survey) were among people who had never tested for HIV in 2023

A summary of indicators for Theme 2 can be found in Table 3.

Theme 3: reduce the number of people with transmissible levels of virus

The main findings are:

• the number of adults living with transmissible levels of virus in England in 2023 was estimated to lie between 15,800 (lower bound) and 18,900 (upper bound), equivalent to 15% to 18% of the 104,000 adults estimated to be living with HIV in England
• of those estimated to have transmissible levels of virus (lower bound), 29% were undiagnosed, 2% not linked to care, 31% not retained in care, 10% not treated and 28% with no evidence of viral suppression
• of all adults diagnosed with HIV in England in 2023 (includes people first diagnosed with HIV in England and people continuing HIV care in England following a diagnosis abroad), 82% were linked to specialist HIV care within 2 weeks, compared to 71% in 2019
• between 5,000 and 12,000 people were not retained in care in 2023 if we consider people who attended in the previous year or the previous 5 years respectively
• the number and the proportion of adults who were not retained in HIV care in 2023 (5.3%; 4,960 of 93,388) was lower than the previous 3 years and similar to 2019 (5.5%; 4,732 of 86,741)

A summary of indicators for Theme 3 can be found in Table 4.

Theme 4: manage and prevent co-morbidities and HIV-related conditions

The main findings from Positive Voices 2022 are:

• the sharing of a person’s HIV status with their GP was less common among younger people and people who identified as trans, non-binary, or in another way and varied by ethnic group, with people of other white backgrounds and other ethnic backgrounds reporting the lowest levels
• the prevalence of mental health conditions has remained high and unchanged since 2017, with 39.4% having been diagnosed with at least one of these conditions in 2019 – this is substantially higher than in the English general population, with 26.4% having had such a diagnosis in 2014
• a high proportion of people living with HIV expressed the need for services, including support to manage long-term conditions, access to a psychologist or counsellor, and peer group support, that were often not met

A summary of indicators for Theme 4 can be found in Table 5a and Table 5b.

Theme 5: improve quality of life and reduce HIV stigma

The main findings from Positive Voices 2022 are:

• life satisfaction, measured using a scale of 0 to 10, where 0 was ‘not satisfied at all’ and 10 was ‘completely satisfied’ was 7.3 among people living with HIV, compared to 7.5 in the general population in England in 2022
• health-related quality of life (expressed as utility scores where 0 is as bad as being dead and 1 is full health) was 0.77 among people with HIV in 2022 and 2017; lower than the score of 0.82 among the general population in 2018
• among people who were aware of the undetectable = untransmissible (U=U) statement, only 62.7% strongly believed this statement to be true while 58.1% reported that this statement made them feel much better about their HV status
• 10.4% of people living with HIV had not shared their HIV status with anyone outside a healthcare setting

A summary of indicators for Theme 5 can be found in Table 6.

Background

On 1 December 2021, England’s government published an HIV Action Plan, an initiative that sets out the activities that need to be undertaken to meet England’s long-term commitment to end HIV transmission by 2030. Since 2020, England has met the UNAIDS 2025 targets of 95% of all people with HIV being diagnosed, 95% of those diagnosed on treatment and 95% of those on treatment being virally suppressed and so unable to pass on the virus.

The ambitions of the HIV Action Plan for England 2022 to 2025 aimed to reduce the following between 2019 (baseline data for the HIV Action Plan) and 2025:

• number of people first diagnosed with HIV in England by 80%
• number of people diagnosed with an AIDS-defining condition within 3 months of an HIV diagnosis by 50%
• HIV-related deaths in England by 50%
• HIV-related stigma

This 2024 report of the HIV Action Plan monitoring and evaluation framework measures progress towards achieving these ambitions up to December 2023 and collates the main HIV indicators at the national level (definitions of current and provisional indicators are available in Appendix 1).

Tracking and tackling inequalities is essential to end HIV transmission since the accessibility of healthcare services differs by population, and progress overall may mask widening inequalities for specific groups. This report also describes inequalities by ethnicity and region of residence for specific population groups.

Most of the data presented in this report was included in the official statistics published in October 2024. However, this report additionally interprets this information in relation to the HIV Action Plan 2022 to 2025 progress against 2019 baseline. It sets out indicators that can be used to identify and address inequalities and estimates the impact of ED opt-out testing on new HIV diagnoses increase. The report also includes additional information such as estimates for the number of people living with HIV (diagnosed and undiagnosed) and new HIV infections.

The baseline data year for the HIV Action Plan was 2019. However, during 2020 and 2021, the COVID-19 pandemic impacted the HIV epidemic in several ways with altered patterns of sexual behaviour, HIV testing and access to sexual health and HIV services in 2020 and 2021. The mpox clade IIb outbreak further affected these patterns in 2022. Among people living with diagnosed HIV, the proportion of consultations that were virtual rose during the pandemic response and fewer people had CD4 and viral load measurements reported. Although we have observed a recovery in HIV testing in 2023, these changes, combined with challenges in data collection and completeness mean that trends between 2019 and 2022 remain difficult to interpret.

Data presented within tables in this report only includes 2019, 2022 and 2023. Data from 2019 to 2023 is provided within Appendix 2. Estimates of the population living with HIV (including undiagnosed) are rounded within this report and adults are defined as all people aged 15 years and over.

Department of Health and Social Care (DHSC) is working with UKHSA, NHS England and a wide range of stakeholders to develop the new HIV Action Plan to be published in 2025. The findings of this report will feed into the development of this new HIV Action Plan.

Progress towards the HIV Action Plan ambitions

The HIV Action Plan uses 2019 as the baseline year against which the ambitions were set. In this report, the figures presented as the baseline year, 2019, differ from those published in the HIV Action Plan and in previously published monitoring and evaluation frameworks (2022 and 2023 reports). This is because additional data is received annually and integrated into the HIV database retrospectively so that the most up to date information gets published each year.

Table 1. Indicators for progress towards the HIV Action Plan ambitions and UNAIDS targets, England (data from 2019 to 2023 is provided in Appendix 2)

HIV Action Plan indicators	2019 baseline	2022	2023	Percentage change (2019 to 2023)	2025 ambition [note 1]	Annual decrease needed to achieve 2025 ambition [note 1]
HIV diagnoses [note 2]	2,801	2,451	2,810	+0.3%	560	1,125
Number of people diagnosed with an AIDS-defining condition within 3 months of HIV diagnosis	208	158	179	-14%	104	38
Estimated number of HIV-related deaths	162	160	193	+19%	81	56
UNAIDS 95-95-95 targets	94%-98%-97%	96%-98%-98%	95%-98%-98%	1%-0%-1% increase	95%-95%-95%	Target reached in 2020

Sources: Multi-parameter evidence synthesis (MPES) model, data from routine returns to the HIV and AIDS New Diagnoses and Deaths Database (HANDD), data from routine returns to the HIV and AIDS Reporting System (HARS) and data from The National HIV Mortality Review (NHMR).

Note 1: The 2025 HIV Action Plan ambitions are an 80% reduction in HIV diagnoses, a 50% reduction in people diagnosed with an AIDS-defining condition within 3 months of diagnosis and a 50% reduction in the number of HIV-related deaths as compared to the 2019 baseline year. Targets differ within previous monitoring and evaluation framework reports due to updated baseline figures. The annual decrease needed to achieve the 2025 ambition was calculated based on taking the difference between the 2019 and 2023 figure and then dividing by 2.

Note 2: HIV diagnoses are defined as HIV diagnoses first made in England.

Towards zero new HIV transmissions

New HIV diagnoses

HIV diagnoses first made in England (hereafter ‘HIV diagnoses’) do not accurately reflect HIV incidence or new transmission since they are impacted by multiple factors such as underlying testing patterns, increased presentation by specific population groups or past acquisition. HIV incidence at present is estimated for men exposed through sex with men through a CD4 back-calculation method; such estimation is not available for people exposed through sex between men and women. Trends in HIV diagnoses are therefore monitored for all groups as a proxy measure of new transmission, but may be difficult to interpret, even more so in 2023 due to the impact of the ED opt-out testing programme and data quality issues.

The number of HIV diagnoses decreased from 2,801 in 2019 to 2,222 in 2020, plateauing to 2,296 in 2021 before rising to 2,451 in 2022 and 2,810 in 2023 (Figure 1). To achieve the 2025 HIV Action Plan target of 560 new HIV diagnoses by 2025, a decrease of approximately 1,125 diagnoses, annually, from 2023 onwards, would need to be achieved. The overall trends in HIV diagnoses mask variation between populations which is explored in further detail in the following sub-sections.

Figure 1. New HIV diagnoses and 2025 HIV Action Plan ambition, England, 2015 to 2023

Source: Data from routine returns to HANDD.

New HIV diagnoses among men exposed through sex with men

Among men exposed through sex with men, HIV diagnoses decreased from 1,242 in 2019 to 811 in 2023, a reduction of 35% (Figure 2). This decrease (which first started in 2015) was most apparent between 2019 to 2020 and has since fluctuated slightly. Among men exposed through sex with men living in London, diagnoses decreased from 543 in 2019 to 321 in 2023. This compares to a decrease from 699 in 2019 to 490 in 2023 in men exposed through sex with men living outside London.

The overall fall in new diagnoses among men exposed through sex with men was most apparent in white men with a 44% decrease in diagnoses from 827 in 2019 to 461 in 2023. In 2023, men of an ethnic minority group (excluding white ethnic minorities) accounted for 33% (266 of 811) of diagnoses among men exposed through sex between men compared to 26% (321 of 1,242) in 2019. Between 2022 and 2023, among men living in London, the greatest increase, was among those of black ethnicity (28% increase from 25 to 32) followed by those of Asian ethnicity (25% increase from 32 to 40) in comparison to those of white ethnicity (5% increase from 137 to 144).

The recent rise in HIV diagnoses among men exposed through sex between men (7% rise from 761 in 2022 to 811 in 2023) is largely among those living in London, with a 16% rise from 276 in 2022 to 321 in 2023 compared to 1% from 485 in 2022 to 490 in 2023 among those living outside London.

New HIV diagnoses among people exposed through sex between men and women

In 2023, 28% (780 of 2,810) of HIV diagnoses were among women exposed through sex with men and 22% (605 of 2,810) were among men exposed through sex with women (Figure 2). However, data relating to 2022 and 2023 need to be interpreted with caution, particularly in relation to diagnoses among black African people exposed though sex between men and women living outside of London. This is due to data quality issues mentioned in the HIV diagnosis by country of first diagnosis section.

Between 2019 and 2023, HIV diagnoses in England rose by 11% (547 to 605) among men exposed through sex with women and by 32% (591 to 780) among women exposed through sex with men (Figure 2). This rise masks an initial fall in diagnoses in men (from 547 to 392) and women (from 591 to 403) between 2019 and 2020. Between 2022 and 2023, HIV diagnoses rose by 36% (445 to 605 among men; the equivalent increase among women was 30% (602 in 2022 to 780 in 2023).

The recent increase in HIV diagnoses among people exposed through sex between men and women is focused among people living outside of London. Between 2022 and 2023, there was a 51% increase in new diagnoses outside of London among men exposed through sex with women (286 to 432) and a 44% increase among women exposed through sex with men (413 to 595). Whilst diagnoses among men and women living in London increased amongst men (9% increase from 159 in 2022 to 173 in 2023), they decreased by 2% (189 in 2022 to 185 in 2023) among women.

HIV diagnoses decreased among white men exposed through sex with women by 30% (from 264 in 2019 to 184 in 2023) but increased by 56% from 149 to 232 in black African men and by 69% (from 32 to 54) in Asian men. In women exposed through sex with men, diagnoses decreased by 38% among women of white ethnicity (from 202 in 2019 to 126 in 2023), compared to women of black Caribbean ethnicity (41% decrease from 29 to 17) and Asian ethnicity (25% decrease from 28 to 21). However, among women of black African ethnicity, HIV diagnoses rose by 88% from 242 to 455.

HIV diagnoses among women exposed through sex with men, outside of London, increased from 2022 to 2023 in several ethnic groups. Diagnoses rose among women of white ethnicity (from 92 to 98), black African ethnicity (from 207 to 358), black other ethnicity (from 11 to 18), and mixed or other ethnicities (from 33 to 37). However, diagnoses decreased among women of Asian ethnicity, from 20 to 13. Among men exposed through sex with women living outside of London, diagnoses increased across all ethnic groups between 2022 and 2023, with the highest increase among men of black African ethnicity (from 84 to 171).

In 2023, overall, 2% (47 of 2,810) were among people exposed by injecting drug use, 1% (41 of 2,810) were among people exposed by vertical transmission, and 1% (15 of 2,810) were among people exposed through blood products. Probable route of exposure was not reported for 18% (506 of 2,810) of those diagnosed in 2023.

While no formal incidence estimates for people exposed through sex between men and women exist, the rise in HIV diagnoses in this group together with sustained test positivity and lower levels of HIV testing in sexual health services suggest HIV transmission is not declining.

Figure 2. New HIV diagnoses by gender identity and probable route of exposure, England, 2015 to 2023

Source: Data from routine returns to HANDD.

HIV diagnoses: data quality adjustment

Due to the increase in HIV diagnoses in England in 2023, UKHSA contacted individual reporting sites with the greatest increase in numbers to verify the data. Some data quality issues were identified, therefore, reporting sites were requested to correct submitted data, however, it is likely that the number of people first diagnosed in England is still overestimated. To assess the extent of overestimation of individuals reported as first diagnosed in England that were likely to be previously diagnosed abroad, data was explored with a provisional adjustment.

To be included in the adjustment, individuals had to meet all the criteria:

• were born abroad
• arrived in the UK within 2 years of diagnosis
• were virally suppressed within one month of England diagnosis – being virally suppressed within a month of diagnosis suggests prior initiation of antiretroviral treatment (ART)

With this adjustment, 253 HIV diagnoses in England in 2023 were likely previously diagnosed abroad (Figure 3). Further work is ongoing to try to accurately determine the number of people first diagnosed in England.

Figure 3. HIV diagnoses with adjustment [note 3] for potential misallocation of location of first diagnosis, England, 2015 to 2023

Source: Data from routine returns to HANDD.

Note 3: The dotted lines represent the number of new diagnoses by country of first diagnosis after adjusting for the 253 people who were reported as first diagnosed in England but were likely previously diagnosed abroad based on the 3 criteria above.

HIV diagnoses due to ED opt-out testing

In April 2022, implementation of an NHS England funded programme of ED opt-out testing in areas of very high diagnosed HIV prevalence, began. The increase in HIV diagnoses in 2023 prompted a review to evaluate the extent to which this programme has contributed to the overall rise in new diagnoses.

When adjusting for the potential misallocation of location of first diagnosis and excluding diagnoses occurring due to ED opt-out testing, there were 2,349 HIV diagnoses in 2023 (Figure 4). This is an increase of 9% as compared to 2022 (2,161 new diagnoses). Without excluding ED opt-out diagnoses, there was a 13% increase in new diagnoses between 2022 and 2023 (2,259 to 2,561). This shows that the increase in HIV diagnoses seen in 2023 is partially due to the increase in testing effort due to ED opt-out testing but does not account for the whole increase.

Figure 4. HIV diagnoses [note 4] adjusted for potential misallocation of location of first diagnosis and diagnoses occurring due to ED opt-out testing [note 5], England, 2019 to 2023

Sources: Data from routine returns to HANDD matched to ED opt-out data for Sentinel Surveillance of Bloodborne Virus (SSBBV) sites.

Note 4: Excludes people previously diagnosed abroad and non-England residents.

Note 5: Data only includes matched records between SSBBV and HANDD, therefore, HIV diagnoses due to ED opt-out testing are likely underestimated. Further information can be found in the 24-month ED evaluation report.

When looking at the regional contribution of ED opt-out testing to new diagnoses, in London, new diagnoses reduced from 854 to 771 between 2022 and 2023 (Figure 5). Therefore, ED opt-out testing is responsible for increasing the number of new diagnoses in London. However, a different pattern is seen outside London, where the increase in new diagnoses in 2023 are not due to ED opt-out testing. Outside London, there was an increase in new diagnoses first made in England from 1,302 in 2022 to 1,574 in 2023, after adjusting for the potential misallocation of location of first diagnosis and excluding diagnoses occurring due to ED opt-out testing. Between 2022 and 2023, outside of London, there was a 21% increase in new diagnoses after adjustment.

Outside of London, most of the increase in new HIV diagnoses is among people exposed through sex between men and women. From 2019 to 2023, after adjustment, new diagnoses for people exposed through sex between men and women rose by 41% from 603 to 853. The number of new diagnoses in men exposed through sex with women outside of London increased by 49% between 2022 and 2023 (257 to 383). In women exposed through sex with men there was an increase of 36% between 2022 and 2023 (345 to 469).

Figure 5. HIV diagnoses [note 6] adjusted for potential misallocation of location of first diagnosis and excluding diagnoses occurring due to ED opt-out testing [note 7] for people living in London and outside London, England, 2019 to 2023

Note 6: Excludes people previously diagnosed abroad and non-England residents.

Note 7: Data only includes matched records between SSBBV and HANDD, therefore, HIV diagnoses due to ED opt-out testing are likely underestimated. Further information can be found in the 24-month ED evaluation report.

As compared to 2019, after the adjustment and excluding diagnosed due to ED opt-out testing, new diagnoses have decreased by 40% in men exposed through sex with men and increased by 4% in men exposed through sex with women and 7% in women exposed through sex with men (1,212 to 729, 532 to 513 and 555 to 594 respectively between 2019 and 2023) (Figure 6).

Figure 6. New HIV diagnoses [note 8] adjusted for potential misallocation of location of first diagnosis and excluding diagnoses occurring due to ED opt-out testing [note 9] by probable route of exposure, England, 2019 to 2023

Source: Data from routine returns to HANDD matched to ED opt-out data for SSBBV sites.

Note 8: Excludes people previously diagnosed abroad and non-England residents.

Note 9: Data only includes matched records between SSBBV and HANDD, therefore, new HIV diagnoses due to ED opt-out testing are likely underestimated. Further information can be found in the 24-month ED evaluation report.

The adjustment mentioned above has not been applied to other analyses in the report since additional work is needed to audit and verify information relating to country of diagnosis. The data presented throughout this report is as reported to UKHSA.

New HIV diagnoses rates

New HIV diagnosis rates were estimated using population denominators derived from an MPES model, a complex Bayesian statistical model that combines and triangulates multiple sources of data including census, surveillance and survey-type prevalence data to estimate HIV prevalence (diagnosed and undiagnosed).

New HIV diagnosis rates remain disproportionately higher among men exposed through sex with men and black African heterosexual individuals in comparison to heterosexual individuals of non-black African ethnicities. Between 2019 and 2023, whilst overall new HIV diagnosis rates decreased amongst men exposed through sex with men (from 2.06 to 1.24), they remained the same in non-black African heterosexual men (0.02 in 2019 and 2023) and non-black African heterosexual women (0.02 in 2019 and 2023). Between 2019 and 2023, there was an increase in new HIV diagnosis rates among black African heterosexual men (from 0.30 to 0.47) and black African heterosexual women (from 0.44 to 0.78) (Figure 7).

Figure 7. New HIV diagnoses rate (per 1,000) among adults aged 15 to 74 years, by specific population groups, England, 2019 to 2023

Sources: MPES model combining numerous data sources and data from routine returns HANDD and HARS.

Estimating HIV incidence in gay, bisexual and other men who have sex with men

Estimates of HIV incidence (point estimates and 95% credible intervals (CrIs)) among GBMSM were obtained from a CD4 back-calculation model, where observed numbers of HIV diagnoses over time, the distribution of CD4 counts at or soon after diagnosis, and information on disease progression are used to reconstruct the unobserved HIV incidence and probabilities of HIV diagnosis underlying these data.

The incidence of HIV in GBMSM in England is estimated to have declined in the years preceding 2020, from 1,970 (95% CrI 1,870 to 2,070) in 2015 to 980 (95% CrI 900 to 1,070) in 2019 (Figure 8). This decline was followed by a plateau and slight rise in incidence during the past 4 years. In 2023 an estimated 1,050 (95% CrI 720 to 1470) new infections were acquired among GBMSM in England.

Figure 8. Estimated number of new infections using a CD4 back-calculation method, and new observed diagnoses in GBMSM, England, 2015 to 2023

Source: CD4 back-calculation model, using data from routine returns to HANDD.

An age-specific model is used to obtain estimates of HIV incidence by age group. The estimates from this model suggest an increase in incidence focussed among those aged 25 to 34 years, from 360 (95% CrI 300 to 430) in 2021, to 440 (95% CrI 290 to 660) in 2023 (Figure 9). Prior to 2021, the incidence of HIV in this age group had been declining, from 710 (95% CrI 660 to 760) in 2015 to 340 (95% CrI 300 to 390) in 2020. 

Figure 9. Estimated number of new infections using a CD4 back-calculation method, and new observed diagnoses in GBMSM, by age group, England, 2015 to 2023

Source: Age-specific CD4 back-calculation model, using data from routine returns to HANDD.

Towards zero new HIV transmissions: summary

It is unlikely that the target to reduce HIV transmission by 80% by 2025 from 2019 will be achieved. However, there has been an overall fall in estimated HIV transmission in GBMSM between 2019 and 2022, with a slight rise in 2023. Among people who acquired HIV through sex between men and women, after a slight fall between 2019 and 2020, the number of HIV diagnoses increased year on year in the last 3 years.

The estimated rise in incidence in 2023 has occurred in tandem with a rise in diagnoses, which was partly driven by the ED opt-out testing programme. Furthermore, contribution of the ED opt-out testing programme was more apparent in an increase of all HIV diagnoses in London compared to outside London. The rise in HIV diagnoses from 2022 to 2023 outside of London (after accounting for ED opt-out testing contribution and data quality issues), combined with lower rates of testing, might indicate a rise in transmission.

Towards zero AIDS-defining conditions diagnosed at HIV diagnosis

The number of AIDS-defining condition diagnoses within 3 months of HIV diagnosis showed a decrease between 2019 and 2023 from 208 to 179 (Figure 10). If we are to meet the HIV Action Plan ambition of fewer than 104 in 2025, we would need to reduce the number of AIDS-defining condition diagnoses within 3 months of an HIV diagnosis by 38 people each year from 2024 onwards.

Towards zero HIV-related deaths

In 2023, 659 deaths occurred in people with HIV in England, a 4% increase from the 634 deaths in 2022, a decrease from the 757 deaths in 2021 and 743 deaths in 2020 but an 18% increase from 560 in 2019. The NHMR has been used to supplement reports of deaths from 2019, contributing to some of the increase between 2019 and 2022.

The higher number of deaths for 2020 and 2021 is also partly due to COVID-19 related deaths, directly due to the infection, as well as its indirect impact through disruption to healthcare services.

For the first time, we implemented the pan-European definition of HIV-related mortality to the NHMR reports and the definition of preventable HIV-related mortality to the NHMR records that could be linked to the HIV surveillance databases.

Of the 460 deaths reported for 2023 through NHMR (out of a total of 659 deaths through NHMR and other reporting schemes), 16% (75 of 460) of deaths were HIV-related and 8% (37 of 460) were possibly HIV-related. Estimated proportions for all HIV-related and possibly HIV-related deaths for 2019, 2020, 2021 and 2022 were 25% (87 of 347), 24% (128 of 540), 21% (109 of 531) and 20% (94 of 463), respectively (Figure 10).

If we estimate that 24% (112 HIV-related or possibly HIV-related of 460 reported through NHMR) of all deaths among people with HIV were HIV-related in 2023, this equates to 193 deaths (29% of 659) when considering deaths from all data sources. Similar estimates were 162 (29% of 560) deaths in 2019 and 160 (25% of 634) deaths in 2022. This estimation will be used in future years to monitor progress for HIV-related deaths.

With a corresponding target of fewer than 81 HIV-related deaths in 2025 to meet, the number of deaths would need to reduce by 56 each year from 2024 onwards. It is not likely this target will be met by 2025.

Of the 112 HIV-related or possibly HIV-related deaths, 17% (19) were considered preventable (either AIDS diagnosis or late HIV diagnosis within 12 months of death) and 32% potentially preventable (36 excluding people where we suspected palliative care), including: 3 deaths among people who started ART more than 3 months after diagnosis and within 12 months of death; 16 people with at least 3 records of viraemia more than 1,000 copies per millilitre (mL) in the 3 years before death; 17 people with a no evidence of being on ART or of attending HIV care in the 3 years before death.

Figure 10. AIDS-defining condition at HIV diagnosis and HIV-related deaths, and corresponding 2025 HIV Action Plan ambitions, England, 2019 to 2023

Sources: Data from routine returns to HANDD supplemented with data from NHMR.

Towards zero stigma and discrimination

The UNAIDS 2025 targets set an ambition for stigma to be experienced by under 10% of people living with HIV by 2025. Data from the Positive Voices 2022 survey (to be published soon) indicates slight improvements across a range of stigma indicators compared to Positive Voices 2017 and the People Living with HIV StigmaSurvey UK 2015. However, levels remain unacceptably high with 10% of people not sharing their HIV status with anyone outside of healthcare settings and 16% reporting ever feeling that they were not treated well in a healthcare setting because of their HIV status.

Perceived stigma is also important as it can lead to delays in seeking healthcare behaviour. Overall, 31% of people living with HIV reported ever worrying that they would be treated differently to other patients by healthcare staff due to their HIV status and 15% reported ever avoiding going to healthcare services when they needed to go. Across most stigma indicators, younger people and trans, non-binary and people who define their gender identity in another way were more likely to report higher levels of stigma.

UNAIDS 95-95-95 progress

In 2023, England again achieved the UNAIDS 95-95-95 target nationally, with an estimated 95% (99,300, 95% CrI 98,500 to 100,100, of 104,000, 95% CrI 102,700 to 105,800), of adults living with HIV being diagnosed, 98% (97,800 of 99,300) of those diagnosed being on treatment and 98% (95,500 of 97,800) of those on treatment having an undetectable viral load (Figure 11). These estimates exclude deaths and children aged under 15 years to align with the methodology for estimating numbers of people living with transmissible levels of virus.

Among adults living in London, an estimated 97% (38,500 out of 39,700) of adults living with HIV were being diagnosed, 98% (37,700 out of 38,500) and 98% (36,800 out of 37,700) of those on treatment having an undetectable viral load. 

Among adults living outside London, an estimated 95% (60,900, 95% CrI 60,200 to 61,500, of 64,300, 95% CrI 63,200 to 65,80) of people living with HIV were being diagnosed, 99% (60,100 out of 60,900) of those diagnosed were on treatment and 98% (58,700 out of 60,100) of those on treatment were virally suppressed.

In order to better take into account people not attending HIV care and missing data, we explored different assumptions for the estimated number of people living with transmissible HIV. These translate into a lower- and an upper-bound 95-95-95 estimate ranging from 96%-94%-96% to 96%-94%-92% (see the transmissible virus section for more information).

Figure 11. Progress towards the UNAIDS 95-95-95 targets, England, 2019 to 2023

Sources: MPES model combining numerous data sources and data from routine returns to HANDD and HARS.

Theme 1: maintain people’s negative HIV status

Increased access to HIV health prevention and promotion interventions, HIV partner notification, frequent HIV testing, PrEP and post-exposure prophylaxis (PEP) will help maintain the HIV status of those who are HIV negative (see flowcharts in the HIV Action Plan monitoring and evaluation framework 2022 report).

HIV partner notification is a highly effective strategy for identifying people living with undiagnosed HIV and provides contact with services to maintain the HIV status of those partners who test negative. Offering PrEP to HIV negative individuals helps maintain their status, preventing onwards transmission.

Table 2. Indicators for Theme 1: maintain people’s negative HIV status (data from 2019 to 2023 is provided in Appendix 2)

Code	Description	2019	2022	2023
PT1A	Number of people attending specialist SHSs due to HIV partner notification	1,564	842	936
PT1B	Ratio of number of people attending specialist SHSs due to HIV partner not ification to the number of new HIV diagnosis in all SHSs	1.01	0.84	0.79
PT1C	Number of people attending though HIV partner notification who tested for HIV	1,393	655	784
PT1D	Ratio of number of people testing for HIV due to HIV partner notification to number of new HIV di agnoses at all SHSs – a ratio of 1 suggests each HIV diagnosis results in at least one partner having a test	0.89	0.65	0.66
PT1E	Number of people attending through HIV partner notification who tested positive	59	36	36
PT1F	Proportion of all HIV negative individuals accessing specialist SHSs categorised as having a PrEP need [note 10]	Not available	9.7%	10.1%
PT1G	Proportion of all HIV negative individuals with estimated PrEP need who had this need identified [note 10]	Not available	83.3%	83.9%
PT1H	Proportion of all HIV negative individuals with estimated PrEP need who started or continued PrEP [note 10]	Not available	71.2%	73.0%
PT1I	Number of individuals accessing specialist SHSs who are receiving PrEP [note 10]	Not available	86,616	96,562
PT1J	Number (and proportion) of new HIV diagnoses in individuals who received PrEP in the last 12 months [note 10]	Not available	40 of 86,616 (0.05%)	45 of 96,562 (0.05%)

Source: Data from routine returns to the GUMCAD STI Surveillance System.

Note 10: PrEP indicators for 2019 are unavailable due to the introduction of routinely commissioned PrEP in the autumn of 2020.

Partner notification (codes PT1A, PT1C, PT1D, PT1E)

In 2023, a total of 936 people were reported by specialist SHSs as a contact following partner notification, an 11% increase from 842 in 2022. However, there has been a 40% decrease between 2019 and 2023 (1564 to 936).

The ratio of the number of new HIV diagnoses in all SHS settings to the number of attendees in specialist SHS due to HIV partner notification was 1.01 in 2019, 0.84 in 2022 and 0.79 in 2023. This means for every 100 HIV diagnoses in SHSs in 2023, 79 people subsequently attended SHS because of HIV partner notification.

Overall, 4% (59 of 1,564) of those attending due to HIV partner notification tested positive for HIV in 2019 compared to 4% (36 of 936) in 2023. This is much higher than the proportion positive overall in all SHSs (0.1% in 2023). This indicates that when implemented, HIV partner notification is an extremely effective strategy to find people with undiagnosed HIV.

While most HIV partner notification attendees were GBMSM (32%; 297 of 936), the highest ratios of new HIV diagnoses to HIV partner notification attendees were observed in heterosexual adults across all 4 years since 2020 (Figure 12).

In non-specialist SHSs (including online services), 265 people were reported as a contact following partner notification in 2023, an increase from 21 in 2019. Of these, 89% (236 of 265) were tested and people testing positive are referred to specialist services for confirmatory testing.

Figure 12. Number of people who attended specialist SHSs due to HIV partner notification, their HIV testing outcome and the ratio of new HIV diagnoses to attendees, England, 2019 to 2023

Source: Data from routine returns to the GUMCAD STI Surveillance System.

Pre-exposure prophylaxis (codes PT1F, PT1G, PT1H, PT1J)

Overall PrEP performance

HIV PrEP is an important component of prevention strategies, involving the administration of antiretroviral medications to HIV-negative individuals to significantly reduce the risk of HIV acquisition. 2023 PrEP data was published in HIV Official Statistics.

The PrEP monitoring and evaluation framework, published in March 2022 outlined a series of indicators to inform service improvement in PrEP commissioning and delivery. Four of these indicators are presented here. The data presented below pertains exclusively to HIV-negative individuals attending specialist SHSs.

In line with previous years, PrEP need (definition in Appendix 1) was highest in GBMSM at 70.3% (110,338 of 156,997) in 2023, compared to 1.8% (4,826 of 267,689) in heterosexual men and 0.8% (4,969 of 647,165) in heterosexual and bisexual women. Similarly, 85.2% (94,026 of 110,338) of GBMSM were more likely to have their PrEP need identified in 2023 compared to 60.8% (2,935 of 4,826) in heterosexual men and 62.2% (3,090 of 4,969) in heterosexual and bisexual women. Among GBMSM with PrEP need, 75.4% (83,210 of 110,338) initiated or continued PrEP in 2023, compared to 39.0% (1,884 of 4,826) in heterosexual men and 40.9% (2,034 of 4,969) in heterosexual and bisexual women.

PrEP need, need identified and use by regions (codes PT1F, PT1G, PT1H)

London had the highest proportions of PrEP need (17.7%; 59,256 of 334,378) and PrEP initiated or continued (78.2%; 46,345 of 59,256) while Yorkshire and Humber had the highest proportions of PrEP need identified (89.1%; 6,982 of 7,839) (Figure 13).

Figure 13. Proportion of people with need identified (by initiation status) or not identified among people with PrEP need, by gender identity, sexual orientation and region, England, 2023

Source: Data from routine returns to the GUMCAD STI Surveillance System.

PrEP use by gender identity, sexual orientation, and ethnicity (code PT1H)

There were inequalities between population groups defined by gender identity and sexual orientation and among different ethnic groups for PrEP need, initiation, or continuation (Figure 14). Initiation or continuation of PrEP was lowest in GBMSM of black Caribbean or black other ethnicity (65.9%; 1,711 of 2,595) and GBMSM of black African ethnicity (66.3%; 1,449 of 2,187).

Among heterosexual men with a PrEP need, the lowest proportion of PrEP initiated or continued was lowest in people of black Caribbean or black other ethnicity (29.6%; 64 of 216) (Figure 14).

Among heterosexual and bisexual women with a PrEP need, the lowest proportions of PrEP initiated or continued were, in those of black African ethnicity (30.2%; 124 of 411), Indian or Bangladeshi or Pakistani (30.1%; 37 of 123) and those of black Caribbean or black other ethnicity (29.5%; 64 of 217) (Figure 14).

The highest proportions of PrEP initiation/continuation were observed among people of white, and any other Asian (not Indian, Bangladeshi or Pakistani) ethnicities (Figure 14).

Figure 14. Proportion of people with need identified (by initiation status) or not identified among people with PrEP need, by gender identity, sexual orientation and ethnicity [note 11], England, 2023

Source: Data from routine returns to the GUMCAD STI Surveillance System.

Note 11: The ‘All other ethnic groups combined’ category includes individuals of mixed and other ethnic backgrounds.

PrEP use by gender identity, sexual orientation, and age group (code PT1H)

Amongst GBMSM with PrEP need, those aged 15 to 24 years (64.6%; 10,491 of 16,239) had the lowest proportions of PrEP initiated and continued compared to other GBMSM age groups (Figure 15).

Among heterosexual men and heterosexual and bisexual women with PrEP need, there were differences in PrEP initiation by age groups (Figure 15).

Figure 15. Proportion of people with need identified (by initiation status) or not identified among people with PrEP need, by gender identity, sexual orientation and age group, England, 2023

Source: Data from routine returns to the GUMCAD STI Surveillance System.

New HIV diagnoses among people receiving PrEP (code PT1J)

The proportion of new HIV diagnoses, among individuals who initiated or continued PrEP in the past 12 months, is low at 0.05% each year. We have no information on PrEP adherence for these individuals and cannot rule out that they acquired HIV after stopping PrEP.

Post-exposure prophylaxis

In 2023, 8,222 people received PEP for HIV, a 6% decrease from 2022 (8,706) and representing 68% (8,222 of 12,078) of PEP provision reported in 2019. GBMSM constituted 60% (4,945 of 8,222) of all those receiving PEP, with heterosexual and bisexual women and heterosexual men representing 12% (981 of 8,222) and 13% (1,035 of 8,222), respectively. Among the 604 people receiving more than one course of PEP in 2023, 80% (471 of 604) were GBMSM.

Theme 2: reduce the number of people living with HIV who are undiagnosed

HIV testing reduces the number of people living with undiagnosed HIV and reduces late diagnoses, lowering morbidity, mortality, and onward transmission. Most people access HIV tests through SHSs, including online, but testing also occurs in primary care, secondary care, and community settings. This section provides an overview of testing activity, where data was available.

Table 3. Indicators for Theme 2: reduce the number of people living with HIV who are undiagnosed (data from 2019 to 2023 is provided in Appendix 2)

Code	Description	2019	2022	2023
PT2A	Estimated number of people living with undiagnosed HIV	6,000 (95% CrI 4,500 to 8,400)	4,000 (95% CrI 3,200 to 5,700)	4,700 (95% CrI 3,700 to 6,300)
PT2A(i)	Estimated number of adults living with HIV (diagnosed and undiagnosed)	96,300 (95% CrI 94,600 to 98,800)	98,500 (95% CrI 97,300 to 100,300)	104,000 (95% CrI 102,700 to 105,800)
PT2B	Number of people HIV tested in all SHSs	1,325,994	1,171,837	1,269,944
PT2B(i)	Number of people HIV tested in specialist SHSs	1,005,252	573,581	691,519
PT2C	Number of people declining a test in specialist SHSs	296,955	191,698	216,634
PT2D	HIV test uptake in specialist SHSs	77%	75%	76%
PT2E	Number of GBMSM who had tested for HIV at least once in the calendar year prior to their most recent HIV test in specialist SHS	54,344	49,258	61,268
PT2F	HIV testing coverage for universal antenatal screening – financial year	2018 to 2019 99.7%	2021 to 2022 99.8%	2022 to 2023 98.6%
PT2G	Number of tests in EDs in higher prevalence areas [note 12]	116,456	185,736	210,166
PT2H	Number (and rate) of reactive tests in EDs in higher prevalence areas [note 12][note 13]	642 (0.6%)	924 (0.5%)	1,190 (0.6%)
PT2I	Number of tests in EDs participating in opt-out BBV testing [note 14]	Not available	856,861 (April 2022 to March 2023)	1,124,729 (April 2023 to March 2024)
PT2J	Number of new HIV positive tests that were confirmed new diagnoses in EDs participating in opt-out BBV testing [note 15]	Not available	190	201
PT2K	Number of positive tests in people previously diagnosed and not in care in EDs participating in opt-out BBV testing [note 15]	Not available	161	153
PT2L	Number of late diagnoses in those first diagnosed in England	889	896	923
PT2M	Number of late HIV presentations among all people previously diagnosed abroad	167	233	422

Sources: MPES model, data from routine returns to HANDD and HARS, ED opt-out data from SSBBV and data from routine returns to the GUMCAD STI Surveillance System.

Note 12: Data from SSBBV is provisional and may underestimate testing assigned these ED settings. This data contains all Emergency Departments reporting to SSBBV that are within high and very high diagnosed HIV prevalence areas (more than 2 per 1,000 population).

Note 13: Number of reactive tests does not equate to number of new diagnoses. A person may be tested more than once, a reactive test requires a confirmatory test, and this data does not take into account people previously diagnosed.

Note 14: Data from 34 Emergency Departments who are participating in SSBBV and joined the ED opt-out testing programme in or after April 2022. Data from NHSE opt-out testing dashboard.

Note 15: Data from 21 Emergency Departments who are participating in SSBBV and joined the ED opt-out testing programme in or after April 2022.

Estimated number of people living with undiagnosed HIV (code PT2A)

The number of people living with HIV in England, including those undiagnosed, are estimated from a MPES model, which is fitted to census, surveillance, and survey-type prevalence data.

In 2023, there were an estimated 4,700 (95% CrI 3,700 to 6,300) adults unaware of their HIV status, equivalent to 5% (95% CrI 4% to 6%) of all adults estimated to be living with HIV in England (104,000, 95% CrI 102,700 to 105,800). An estimated 1,600 (95% CrI 1,000 to 2,800) GBMSM were living with undiagnosed HIV compared with 600 (95% CrI 400 to 900) black African heterosexual men and 1,000 (95% CrI 800 to 1,300) among black African heterosexual women. Around a quarter of adults with undiagnosed HIV infection lived In London; there were 1,200 (95% CrI 900 to 1,800) adults estimated to be living with undiagnosed HIV in London compared with 3,400 (95% CrI 2,600 to 4,800) outside London.

Trends in the estimated number of people living with undiagnosed HIV from 2019 to 2023 for different exposure groups and different regions vary considerably (Figure 16).

Figure 16. Estimated number of people living with undiagnosed HIV in London and outside London by exposure group, gender identity and ethnicity, England, 2019 to 2023

Sources: MPES model combining numerous data sources.

HIV testing in sexual health services

Number of people tested at all SHSs (code PT2B) and in specialist SHSs (code PT2B(i))

The number of people having an HIV test at all SHSs increased by 8% between 2022 and 2023 (1,171,837 to 1,269,944), a substantial recovery to 96% of the testing levels in 2019.

In 2019, 19% of people (255,492 out of 1,325,994 total tests) tested for HIV based on ordering a self-sampling kit online. In 2023, this increased to 44% (555,585 of 1,269,944), showing a major shift in testing methods over this period. Between 2022 and 2023, there has been a reduction in the proportion of HIV tests undertaken through people ordering self-sampling kits online (44% in 2023 as compared to 49%; 577,995 of 1,171,837 in 2022).

The continued recovery in testing between 2020 and 2023 was not seen equally across demographic groups. The number of GBMSM having an HIV test in all SHSs increased by 4% from 194,552 in 2022 to 201,732 in 2023, 34% higher than the 150,413 people tested in 2019. In heterosexual and bisexual women, an 8% increase was seen between 2022 and 2023 (514,448 to 555,507), comprising 90% of 2019 testing levels (615,653). Testing in heterosexual men increased by 13% between 2022 and 2023 from 287,081 to 324,835, comprising 78% of 2019 tests (414,550). In each group, online testing increased between 2019 and 2023; by 135% in GBMSM, by 144% in heterosexual and bisexual women and by 141% in heterosexual men.

Number declining a test (code PT2C) and test uptake (code PT2D) in specialist SHSs

Overall, in 2023, of people who were offered an HIV test at specialist SHSs, 24% (216,634 of 908,153) declined a test (Figure 17). This varied considerably between different groups. Testing uptake was highest in GBMSM, with only 4% declining testing (4% 5,111 of 128,201).

Substantially lower levels of test uptake were seen in heterosexual and bisexual women overall, with 36% (137,059 of 384,664) of non-black African women and 22% (4,942 of 22,080) of black African women declining a test in 2023 (Figure 17).

Figure 17. HIV testing offer and uptake among people tested at specialist SHS, by ethnicity, sexual orientation and gender identity, England, 2023

Source: Data from routine returns to the GUMCAD STI Surveillance System.

Frequency of HIV testing among GBMSM (code PT2E)

The 2016 HIV testing recommendations from the National Institute for Health and Care Excellence suggest that GBMSM should be tested for HIV at least once a year and every 3 months if they are having sex without condoms with new or casual partners.

The number of GBMSM attending specialist SHSs and who had at least one HIV test in the year before their most recent test has increased, with 35,410 in 2021, 49,258 in 2022 and 61,268 in 2023. The figure for 2023 is the highest across all the years, with a 13% increase when comparing 2019 to 2023 (54,344 compared to 61,268).

HIV testing in settings other than sexual health services

Universal antenatal screening (code PT2F)

Universal antenatal screening is available through the NHS infectious diseases in pregnancy screening (IDPS) programme, with all pregnant women offered and recommended screening. HIV testing coverage for pregnant women in antenatal care remained high at 99.8%, with 631,449 women tested (632,915 eligible women) in England during the 2022 to 2023 financial year. This has met the UNAIDS 2025 target of 95% coverage of antenatal services testing to end vertical HIV transmission. Data for positivity and new diagnoses was not available for 2023.

HIV testing in other settings (code PT2G)

1. Home and community

In 2023, the HIV and syphilis self-sampling program distributed 11,212 self-sampling kits during National HIV Testing Week (activities covering the period January 30 to February 26). Of these, 6,333 kits (56%) were returned. A total of 5,971 HIV tests were conducted, with a reactivity rate of 0.6% (37 of 5,971).

Most tests taken were among GBMSM, accounting for 43% (2,574 of 5,971). Reactivity was slightly higher among heterosexual men (0.6%; 7 of 1,225) compared to GBMSM (0.5%; 12 of 2,574). Most tests were carried out among people of white ethnicity (70%; 4,170 of 5,971) and test reactivity was highest among people of mixed ethnicity (1.3%; fewer than 5 of 307), people of black African ethnicity (1.2%; 7 of 586) and people of other ethnicities (1.2%; fewer than 5 of 83).

Additionally, 10,414 self-testing kits were dispatched, with a reactivity rate of 0.4% (42 of 10,414). Most kits were dispatched to GBMSM (45%; 4,723 of 10,414) and people of white ethnicity (72%; 7,483 of 10,414). Between 2022 and 2023 we saw an increase in the number of testing kits dispatched to those in the black African ethnic group. In 2022, 1,594 self-sampling kits were dispatched to those within this group, versus 1,149 self-sampling and 983 self-testing kits in 2023, for a combined total of 2,132 kits. This represents an increase of nearly 34%.

Another 18,938 tests were reported through the UKHSA survey of HIV testing in community settings in 2023, compared with 18,422 tests reported in 2022 and 13,127 tests reported in 2021. This is a decrease as compared to the 28,082 tests reported in 2019. The overall test reactivity rate was 0.3% in 2023, a decrease from 0.4% in 2022. Where information was known, more than half of all tests were carried out among heterosexuals (51%; 8,074 of 15,892), although test reactivity was higher among GBMSM (0.4% compared to 0.3%). Test reactivity was highest among those of black Caribbean (1.4%) and black African (0.7%) ethnicities, those born in countries with high diagnosed HIV prevalence (0.8%) and those born in countries other than the UK with non-high diagnosed HIV prevalence (0.7%). Additionally, 1 in 5 tests done in community settings (and reported through the UKHSA community testing survey) were among people who had never tested for HIV.

2. Blood donation services

In 2023, almost 1.8 million blood donations were screened across the UK, with 7 donors confirmed positive for HIV (0.4 per 100,000 donations), a slight decrease on 2022 data. Five were new donors and 2 were repeat donors having donated in the previous 2 years. 6 of the 7 HIV positive donations were given by men. The HIV positive donors were aged 30 to 65 years, with a median age of 42 years. Of the 5 new donors, 2 reported sex between men, 2 reported sex between men and women and 1 did not respond. Six donors were likely to have acquired HIV in the UK, 2 since their last donation. All were referred to sexual health services for further care.

Since June 2021, UK blood donor policies have allowed GBMSM in stable relationships and individuals with partners from HIV endemic areas to donate, provided no other donor exclusion criteria applies. Data to the end of 2023 showed observed cases of recently acquired HIV remained low, with no impact on blood supply safety. The residual risk of undetected HIV is below 1 in 1 million donations, with ongoing close monitoring.

3. Tuberculosis testing

In 2023, testing information was available for 96% (4,317 of 4,498) of people notified with tuberculosis (TB) who had a previously unknown HIV status and excluding those who were diagnosed with TB post-mortem. Of these people, 96% (4,157 of 4,317) were tested for HIV (testing coverage). The proportion of people notified with TB who were tested for HIV was highest in people born in countries with high HIV prevalence at 97.5% compared with people born in the UK (93.8%).

4. People who inject drugs

The unlinked anonymous monitoring (UAM) survey of people who inject drugs (PWID) is an annual cross-sectional bio-behavioural survey that recruits people who have ever injected psychoactive drugs who attend specialist drug and alcohol services across England, Wales, and Northern Ireland.

In England, the proportion of PWID who reported ever being tested for HIV was 82% (95% confidence interval (CI) 81% to 84%) in 2023, with 49% (95% CI 47% to 51%) of these people reporting having a test in current or previous survey year. Among PWID who started injecting for the first time within the past 3 years, 78% (95% CI 69% to 85%) reported ever having had a diagnostic HIV test in 2023, with 56% (95% CI 45% to 67%) of these people reporting a test in the current or previous survey year.

5. Prisons

In March 2018, opt-out testing of BBVs, including HIV, was implemented in all adult prisons in England. New arrivals and people transferring between prisons should now be offered HIV tests, unless they have been tested within the last year and are not at risk, or they have a known HIV positive status.

In 2023, 92% of new receptions and transfers not already confirmed as HIV positive were offered HIV testing within 7 days of reception (149,786 of 162,383). Where a test was not declined and was considered appropriate, 73% were tested within 2 weeks of reception date (88,687 of 120,957). Among those tested, 0.7% had a positive test (651 of 88,687).

6. General practice and out-patient secondary care

In 2023, 26 laboratories reported HIV testing data from GP and hospitals to the SSBBV. A total of 139,333 people tested at a GP in 2023 (119,580 in 2022) and 264,948 in secondary care (242,927 in 2022) as reported through SSBBV, with 0.4% and 0.7% testing positive, respectively. The number of individuals tested are comparable to pre-COVID-19 pandemic levels. An individual can test in more than one service type.

7. Emergency departments (codes PT2G to PT2K)

The UK has committed to ending new HIV transmissions in the country and therefore multi-faceted testing strategies are needed to achieve this target. ED opt-out testing in England can address inequalities in testing for those who may not self-identify as at risk or face barriers to other health services. It also offers an opportunity to re-engage people previously diagnosed who are not currently in care.

Between April 2022 to March 2024, 1,981,590 HIV tests were taken across 34 sites. In the first year of the ED opt-out programme, 856,861 tests were taken and in the second year this rose to 1,124,729, a 31% increase.

An analysis of 21 sites found that there were 391 new HIV diagnoses between April 2022 and December 2023. This is likely an underestimate of the true number of new diagnoses, see the 24-month evaluation for more information.

Compared to people diagnosed with HIV in other settings (not including the programme) between April 2022 and December 2023, people diagnosed through the ED opt-out programme were:

• older
• more likely to be women
• less likely to be Asian, and more likely to be of black ethnicity
• less likely to be from deprived areas

A final report evaluating the impact of ED opt-out testing will be published in 2025.

Late HIV diagnosis and late presentation

Late diagnosis among those first diagnosed in England (code PT2L)

A late HIV diagnosis is defined as having as an adult with a CD4 count below 350 cells per cubic millimeter (mm³) of blood within 91 days of diagnosis and no evidence of a recent infection (full definition of late HIV diagnosis in Appendix 1).

In England, the proportion of diagnoses made at a late stage of infection remained relatively stable at 41% (889 of 2,184) in 2019 to 40% (923 of 2,286) in 2023. From 2022 to 2023, the proportion late diagnosed decreased (45% in 2022 compared to 40% in 2023), while the number diagnosed late rose slightly (3%; 896 in 2022 compared to 923 in 2023).

Overall, there was a rise in the number late diagnosed between 2020 and 2022 (700 to 896) which likely reflects delays in diagnoses from 2020 due to the impact of the COVID-19 pandemic on sexual health and HIV services as well as the mpox outbreak and a rise in diagnoses among people likely to have acquired HIV abroad in the same period.

Across all years (2019 to 2023), men exposed through sex with women consistently have higher proportion of those late diagnosed, as compared to women exposed through sex with men and men exposed through sex with men (Figure 18).

In men exposed through sex with men, the proportion diagnosed late increased from 29% (296 of 1,031) in 2019 to 31% (220 of 715) in 2023. This masks a dip in number diagnosed late between 2019 (296) and 2020 (185) with proportions and numbers remaining relatively stable between 2021 (37%; 235 of 642) and 2022 (36%; 233 of 651) (Figure 18).

The numbers of late HIV diagnoses slightly increased for men who were exposed through sex with women and women exposed through sex with men since 2019 however the proportions decreased, that is 55% (254 of 463) in 2019 to 51% (259 of 512) in 2023 and 48% (228 of 475) in 2019 to 42% (263 of 632) in 2023 respectively.

Figure 18. Late HIV diagnoses in adults by probable route of exposure, England, 2019 to 2023

Source: Data from routine returns to HANDD.

In all ethnic groups, the proportion of men exposed through sex with men diagnosed late increased between 2019 and 2023, other than in men of white ethnicity, where it remained relatively stable (31%; 216 of 697 in 2019 compared to 30%; 124 out 419 in 2023) (Figure 19). Late HIV diagnoses proportions, among men exposed through sex with men of black African ethnicity rose from 21% (6 of 28) in 2019 to 31% (11 of 35) in 2023. Late HIV diagnoses proportions, among men exposed through sex with men of Asian, mixed or other ethnicities rose from 25% (50 of 204) in 2019 to 32% (52 of 163) in 2023. GBMSM of black Caribbean or black other ethnicity has a slight increase of late HIV diagnoses proportions by 17% (5 of 29) to 22% (6 of 27).

In men exposed through sex with women, the proportion diagnosed late decreased from 55% (254 of 463) in 2019 to 51% (259 of 512) in 2023. The proportion diagnosed late decreased between 2022 and 2023, however, the number late diagnosed increased (60%; 223 of 374 in 2022 compared to 51%; 259 of 512) (Figure 19). In 2023, the proportion and number diagnosed late in men of white ethnicity was 53% (85 of 160), 50% (101 of 202) among men of black African ethnicity, 51% (18 of 35) among men of black Caribbean or black other ethnicity, 53% (42 of 80) in men of Asian, mixed or other ethnicities.

Among women exposed through sex with men, the proportion diagnosed late remained relatively stable between 2019 and 2022, with the proportion decreasing from 49% (251 of 508) in 2022 to 42% (263 of 632) in 2023 (Figure 19). In 2023, the proportion was 40% (42 of 105) in white women, 44% (164 of 373) in black African women, 43% (17 of 40) in women of black Caribbean or black other ethnicity, 30% (18 of 60) in Asian, mixed or other ethnicities.

Figure 19. Late HIV diagnoses in adults by ethnicity and probable route of exposure, England, 2019 to 2023

Source: Data from routine returns to HANDD.

In London residents, the proportion of late HIV diagnoses among women exposed through sex with men increased from 45% (66 of 146) in 2019 to 59% (61 of 104) in 2020. However, a decrease in 2023 was seen to the same proportion as seen in 2019 (45%; 73 of 162) (Figure 20). Late HIV diagnoses numbers and proportions for men exposed through sex with men, residing in London, increased from 20% (91 of 453) in 2019 to 28% (81 of 292) in 2023.

Figure 20. Late HIV diagnoses by probable route of exposure and region of residence, England, 2019 to 2023

Source: Data from routine returns to HANDD.

In London, the proportion and number of late HIV diagnoses increased among people of white ethnicity from 24% (80 of 340) in 2019 to 34% (88 of 261) in 2023. Late HIV diagnoses proportions and numbers increased among people of Asian, mixed or other ethnicities residing in London from 29% (57 of 200) in 2019 to 41% (74 of 182) in 2023.

Late HIV presentation among those previously diagnosed abroad (code PT2M )

Late HIV presentation relates to individuals who were previously diagnosed outside of England, and who present at a late stage of infection. Among all HIV diagnoses in 2023, 53% (3,198 of 6,008) were among people previously diagnosed abroad, higher than previous years (38% in 2022 and 27% in 2019). Late presentation represented 31% (422 of 1,345) of all diagnoses made at a late stage of infection among adults in 2023, which is an increase to the 21% (233 of 1,129) in 2022.

The proportion of adults diagnosed who presented at a late stage of infection decreased from 20% (167 of 836) in 2019 to 15% (422 of 2,739) in 2023, however, the number with a late infection at presentation rose by 153%.

Theme 3: reduce the number of people with transmissible levels of virus

For those who test positive, reducing the time from diagnosis to treatment initiation reduces the time people are living with a detectable viral load. Keeping individuals on treatment with an undetectable viral load eliminates onwards transmission of HIV. This includes ensuring those diagnosed are linked to, engaged in, or re-engaged in care to access treatment and achieve viral suppression.

Table 4. Indicators for Theme 3: reduce the number of people living with transmissible levels of virus (data from 2019 to 2023 is provided in Appendix 2)

Code	Description	2019	2022	2023
PT3A	Estimated number of adults living with transmissible levels of virus in England (lower- to upper-bound estimates)	18,100 to 22,500	13,000 to 17,900	15,800 to 18,900
PT3A(i)	Number of adults not linked to care within calendar year of diagnosis	564	546	317
PT3A(ii)	Number of adults seen for care with missing treatment status [note 16]	0	0	0
PT3A(iii)	Number of adults on treatment and no evidence of viral suppression	4,649	2,080	2,229
PT3B	Number (and proportion) of people linked to care within 2 weeks of HIV diagnosis	1,835 (69%)	1,708 (74%)	2,034 (75%)
PT3C	Number (and proportion) of people linked to care within 1 month of HIV diagnosis	2,203 (83%)	1,948 (85%)	2,367 (86%)
PT3D	Number of people who had not attended care for more than 15 months and have attended a new appointment following opt-out testing in ED [note 17]	Not available	71	109
PT3E	Number (and proportion) of adults starting treatment within 3 months of diagnosis	2,409 (87%)	2,000 (82%)	2,104 (75%)
PT3F	Number of adults seen for HIV care and not on treatment	1,603	1,689	1,533
PT3G	Number (and proportion) of adults treated who are not virally suppressed (viral load greater than 200 copies per mL )	2,095 (2.6%)	1,991 (2.3%)	2,139 (2.3%)
PT3H	Number (and proportion) of adults not attending care for at least 15 months (‘not retained in HIV care’)	4,732 (5.5%)	4,974 (5.5%)	4,960 (5.3%)
PT3I	Number of adults who had not attended care for at least 15 months and have attended a new appointment	2,692 (57%)	2,339 (47%)	Not available [note 18]
PT3J	Number of adults 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 months	1,254 (66% people of not virally suppressed at re-attendance)	970 (82% of people not virally suppressed at re-attendance)	Not available [note 18]

Sources: Data from routine returns to HANDD, HARS and ED opt-out data in SSBBV.

Note 16: Data quality issue relating to missing ART information affecting 2021.

Note 17: Provisional indicator. Data presented for only 21 SSBBV sites. Data provided based on the year they were tested within the ED and not the year they received HIV care post-test.

Note 18: Follow up appointments for people not seen for specialist HIV care in 2023 will be available with 2024 data.

Estimated number of adults with transmissible levels of virus in England (code PT3A)

Using the UNAIDS 95-95-95 methodology, the estimated number of adults living with transmissible levels of virus was 8,400 in 2023 in England, equivalent to 8% of the estimated 104,000 (95% CrI 102,700 to 105,800) adults living with HIV in England (Figure 21). The equivalent numbers for 2019, 2020, 2021 and 2022 were 9,900 (10%), 8,900 (9%), 8,200 (8%) and 7,800 (8%) respectively. These estimates exclude deaths and children aged under 15 years.

To take better account of people not attending care and missing data, we provide a lower and upper level estimate with different assumptions. This analysis is feasible as the HIV surveillance system allows tracking people over time. A person is considered virally suppressed if their viral load is equal to or less than 200 copies per mL.

The lower-bound estimate (scenario A) excludes people who were on treatment and had no record of a viral load in the year of interest but had suppressed viral loads in the year prior; and people who were on treatment and had no record of a viral load or treatment in the year of interest but had suppressed viral loads at their first attendance the following year. This suggests they were seen for care elsewhere or their previous attendance was not recorded).

For the upper-bound estimate (scenario B), we assume that all people with missing care, treatment or viral load records for a given year have transmissible levels of virus for that year.

For the lower-bound estimate (scenario A in Figure 21), 15,800 people were estimated to be living with transmissible levels of virus, equivalent to 15% of the estimated 104,000 adults estimated to be living with HIV in England, corresponding to:

• an estimated 4,700 (95% CrI 3,700 to 6,300) (29%) were undiagnosed in 2023
• 317 (2%) were first diagnosed in 2023 and not linked to HIV care by the end of the year
• 4,960 (31%) were not retained in HIV care (not seen in care for at least 15 months since their last HIV care appointment between October 2021 and September 2022)
• 1,533 (10%) attended HIV care in 2023 but were not receiving treatment
• 4,366 (28%) were on treatment in 2023 but were not virally suppressed or had no viral load reported that year but were not virally suppressed the year before (Figure 21)

Of the 15,800 adults with transmissible levels of virus in 2023 as per scenario A, 5,000 were men exposed through sex between men, 2,600 were black African women exposed through sex with men, 1,800 were women from other ethnicities exposed through sex with men, 1,400 were black African men exposed through sex with women and 1,500 were men of other ethnicities exposed through sex with women. In 2023, 37% of the 15,800 adults estimated to be living with transmissible levels of virus resided in London. The 95-95-95 corresponding to scenario A would be 96%-94%-96% for 2023 (Figure 22).

For the upper-bound estimate (scenario B Figure 21), the estimated number of adults (aged 15 years and over) living with transmissible levels of virus was 18,900 in 2023 in England, equivalent to 18% of the estimated 104,000 adults living with HIV in England. Demographic breakdowns were almost identical between scenario A and B, so are only presented for scenario A. The corresponding unadjusted 95-95-95 would be 96%-94%-92% for 2023 (Figure 22).

Further work is planned to refine estimates of number of people living with transmissible levels of virus include improving definitions and developing a model to take into account missing data and uncertainty in the distinct categories included in the calculations above.

Figure 21. Estimates for the number of adults living with transmissible levels of virus, England, 2023

Sources: Data from routine returns to HANDD and HARS.

Figure 22. Progress towards the UNAIDS 95-95-95 targets by scenario, England, 2023

Sources: MPES model combining numerous data sources and data from routine returns to HANDD and HARS.

Linkage to HIV care (codes PT3B and PT3C)

Linkage to HIV care is crucial for everyone diagnosed with HIV and hence why this section looks at linkage overall, in those previously diagnosed abroad and HIV diagnoses first made in England.

Of all adults (aged 15 years and over) diagnosed with HIV in England in 2023 (includes those first diagnosed with HIV in England and those first diagnosed abroad with a subsequent England diagnosis), 82% (4,827 of 5,857) were linked to HIV care within 2 weeks compared to 71% (2,629 of 3,713) in 2019.

Of adults first diagnosed abroad with a subsequent England diagnosis, 89% (2,793 of 3,151) were linked to care within 2 weeks of their England diagnosis in 2023 compared to 76% (794 of 1,041) in 2019.

Current BHIVA (British HIV Association) standards of care indicate that people should be linked to care within 2 weeks of diagnosis. In 2023, 75% (2,034 of 2,706) of adults with an HIV diagnosis were linked to HIV care within 2 weeks, 88% (2,367 of 2,703) within one month and 96% within 3 months (2,578 of 2,695). This compared to 69% (1,835 of 2,672) within 2 weeks, 83% (2,203 of 2,668) within one month and 90% (2,397 of 2,660) within 3 months in 2019 (Figure 23).

Figure 23. Linkage to HIV care within 2 weeks, 1 month and 3 months among adults first diagnosed with HIV in England, England, 2019 to 2023

Sources: Data from routine returns to HANDD and HARS.

In 2023, 79% (629 of 797) of men exposed through sex with men, 72% (426 of 588) of men exposed through sex with women and 72% (549 of 762) of women exposed through sex with men were linked to care within 2 weeks of HIV diagnosis. This compared to 72% (876 of 1,218) men exposed through sex with men, 71% (381 of 538) men exposed through sex with women and 65% (379 of 582) women exposed through sex with men were linked to care within 2 weeks of HIV diagnosis in 2019.

Among men exposed through sex with men, the overall proportion of adults linked to care within 2 weeks increased across all ethnic groups when comparing 2019 to 2023 (with year-on-year fluctuations) except for men of mixed or other ethnicity where the proportion remained the same in 2019 and 2023.

Among men exposed through sex with women, the overall proportion of adults linked to care within 2 weeks increased across all ethnic groups when comparing 2019 to 2023 except for men of mixed or other ethnicity where the proportion decreased from 73% (29 of 40) in 2019 to 70% (28 of 40) in 2023.

Among women exposed through sex with men, the proportion of adults linked to care within 2 weeks of diagnosis increased across all ethnic groups when comparing 2019 to 2023 except for women with unknown ethnicity where the proportion decreased from 73% (19 of 28) in 2019 to 59% (46 of 78) in 2023.

Linkage to care by setting of diagnosis

In 2023, by setting of diagnosis, as reported by the sexual health or HIV clinic in HANDD, linkage to care within 2 weeks was highest in SHSs or HIV clinics (84%; 1,074 of 1,285) followed by diagnoses with a ‘not reported’ setting of diagnosis (81%; 146 of 181). Linkage was lowest in ‘other settings’ (55%; 41 of 75), inpatient care (58%; 140 of 243) and GP settings (60%; 145 of 242) (Figure 24).

Figure 24. Linkage to HIV care within 2 weeks among adults first diagnosed with HIV by first setting of diagnosis [note 19], England, 2019 to 2023

Sources: Data from routine returns to HANDD and HARS.

Note 19: Accident and emergency refers to the setting of diagnosis as reported by the sexual health or HIV clinic in HANDD, therefore, this does not correspond to data presented in this report on the ED opt-out testing programme. The ‘other outpatient’ category includes NHS outpatients, infectious disease outpatients and antenatal clinics. ‘Community and home testing’ includes community testing, self-sampling, home testing and pharmacy. ‘Other settings include drug and alcohol services, prisons, private medical care, blood transfusion services and services categorised as other.

Linkage to care following diagnosis in ED opt-out testing programme (code PT3D)

ED opt-out testing aims to diagnose people with HIV (and hepatitis B and hepatitis C) who are unaware of their status and re-engage those who are previously diagnosed but not in care. When looking at those previously diagnosed but not in care in the previous 15 months, 58% (180 of 314) of those who were positive had re-engaged in care subsequent to a test within an ED. For more information on linkage to care see the 24-month evaluation report for the ED opt-out testing programme.

Prompt HIV treatment (code PT3E)

Among those diagnosed first in England in 2023, 75% (2,104 of 2,795) started HIV treatment also known as ART within 3 months of diagnosis, compared with 87% (2,409 of 2,778) in 2019, 82% (1,808 of 2,213) in 2020, 83% (1,880 of 2,276) in 2021 and 82% (2,000 of 2,436) in 2022.

Among men exposed through sex between men first diagnosed in England in 2023, 83% (671 of 811) started ART within 3 months, compared with 76% (594 of 780) for women exposed through sex with men and 77% (468 of 605) for men exposed though sex with women (Figure 25).

In 2023, the proportion of adults diagnosed who started ART within 3 months was highest for people of mixed or other (81%; 198 of 245), white (79%; 751 of 951) ethnicities and Asian (77%; 175 of 227) ethnicities and lowest among people of black (75%; 745 of 988) ethnicities.

Among adults first diagnosed in England, the proportion of adults who started ART within 3 months was 83% (458 of 551) for people living in the North of England, 65% (635 of 978) for those living in London, 80% (604 of 752) for those living in the Midlands and East of England and 79% (407 of 514) for those living in the South of England.

Figure 25. Adults starting ART within 3 months of diagnosis by probable route of exposure, England, 2019 to 2023

Sources: Data from routine returns to HANDD and HARS.

Treatment coverage (codes PT3A(ii) and PT3F)

The proportion of people receiving ART amongst adults (aged 15 years and over) attending in HIV care remains extremely high, at 98% (98,061 of 99,594) in 2023, compared with 98% (88,271 out of 89,873) in 2019.

In 2023, 1,533 adults were attending HIV care and were not receiving ART compared to 1,603 for 2019, 1,006 for 2020, 1,166 for 2021 and 1,689 for 2022. In 2023, there were 0 adults seen for HIV care with unknown or missing treatment status.

Of the 1,533 adults attending HIV care and not receiving ART, 31% (473) were men exposed through sex with men, 18% (269) were black African women exposed through sex with men, 11% (167) were women exposed through sex with men of other ethnicities and 17% (267) were men exposed through sex with women. In 2023, 48% (734 of 1,533) of adults attending care and not receiving ART were living in London.

Among adults with an ART status recorded, the proportion of adults seen for HIV care and not on ART living in London was 1.9% (734 of 38,327) and 1.3% (799 of 61,275) among those living outside London (Figure 26). Men exposed through sex with men living in London and outside London (1.1% and 1.1%) had the lowest proportion seen for HIV care and not on ART.

Figure 26. Adults seen for HIV care and not on ART by probable route of exposure, gender identity and ethnicity, England, 2023

Sources: Data from routine returns to HANDD and HARS.

Viral suppression (codes PT3A(iii) and PT3G)

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 treatment as prevention (TasP) and is also promoted as U=U.

In England, 98% (90,628 of 92,765) of adults on treatment and with viral load results available were virally suppressed in 2023, similar to previous years.

In 2023, 2,229 adults on treatment had no evidence of viral suppression: they had either a reported detectable viral load or did not have any viral load recorded for that year (excluding people on ART and with undetectable viral load in 2022). This compared with 4,649 in 2019, 5,058 in 2020, 3,641 in 2021 and 2,080 in 2022.

In 2023, the proportion of adult men exposed through sex with men on treatment who had no evidence of viral suppression was 1.4% (584 of 40,714), whilst men exposed through sex with women and women exposed through sex with men of different ethnic groups ranged between 2.3% and 2.4%. The proportion of adults living in London was 2.7% (951 of 35,432) compared with 2.2% (1,278 of 57,333).

The number of adults on treatment who were not virally suppressed was 2,139 in 2023 which was a 2% increase from 2019 (2,095) (Figure 27). Of these 2,139 adults on treatment who were not virally suppressed, 860 were living in London and 1,279 were living outside London.

Among adults living in London on treatment who were not virally suppressed, by exposure, the proportion was lowest among men who were exposed through sex with men (1.7%) while black African men exposed through sex with women had the highest (3.2%) (Figure 27).

Among those living outside London, men exposed through sex with men on treatment who were not virally suppressed had the lowest proportion (1.6%) while non-black African men exposed through sex with women and non-black African women exposed through sex with men had the highest (2.5%).

Figure 27. Adults on ART who are not virally suppressed (viral load greater than 200 copies per mL) by probable route of exposure, gender identity and ethnicity, England, 2023

Sources: Data from routine returns to HANDD and HARS.

Retention in care (codes PT3H, PT3I and PT3J)

Current BHIVA standards of care recommend that people living with HIV should attend specialist HIV care annually. Though most people are seen within 12 months, attendance may fall slightly outside a precise 12-month period. Therefore, people not retained in care are defined as those not seen within 15 months of their last attendance for the below measures.

Among the 93,388 adults seen for HIV care between 1 October 2021 and 30 September 2022, 4,960 (5.3%) were not retained in care that is, they were not seen for care for at least 15 months after the last appointment in that period. This is a small decrease in number and proportion compared to previous years, similar to 2019 (4,732 of 86,741; 5.5%) and lower than in 2020 (6,670 of 89,155; 7.5%) when the public health measures to control COVID-19 pandemic on HIV care access and delivery. The figures for 2021 and 2022 were 6,608 (of 88,875, 7.4%) and 4,974 (of 90,844, 5.5%), respectively. People not retained in care are not receiving the treatment and need support to remain healthy and virally suppressed.

Among men exposed through sex with men, the proportion not retained in care was 4% (1,552 of 36,740). Among black Caribbean men exposed through sex with men, 3% were not retained in care (21 of 747) compared with 4% of white men (1,167 of 29,183), black other men (14 of 354), mixed or other men (103 of 2,504) and 5% in Asian men exposed through sex with men (Figure 28). Among men exposed through sex with men living in London, the proportion not retained was 4% (496 of 14,042) compared with 5% (1,056 of 22,698) for men living outside London.

In 2023, 5% (746 of 14,309) men exposed through sex with women were not retained in care, with lowest level (4%) among men of black African ethnicity (275 of 6,602), 5% for men of Asian (38 of 697), 6% for men of white (273 of 4,765), black other (24 of 435) and mixed or other ethnicities (43 of 719), and 7% for black Caribbean men (40 of 559) (Figure 28). The proportion not retained for men exposed through sex with women was 5% for people living in London (207 of 4,326) and for people living outside London (539 of 9,983).

Among women exposed through sex with men, 4% (950 of 23,649) were not retained in care in 2023, at 4% for women of all ethnic groups and 10% for women with no reported ethnic group (Figure 28). In 2023, the proportion not retained in care for women exposed through sex with men was 3% whether they lived in London (251 of 7,251) or outside London (699 of 16,398).

Of the 6,291 adults who were categorised as not receiving HIV care for at least 15 months by end of 2022, 2,339 subsequently attended HIV care after that care gap, 49% (1,154 of 2,339) of whom were already virally suppressed at that first appointment after the care gap. Among the remaining 1,185 adults who had a missing viral load or viral load greater than 200 copies per mL when they re-engaged with care, 970 (82%) had an undetectable viral load within 6 months of the returning appointment. This compares to 66% (1,254 of 1,907) in 2019, 78% (1,800 of 2,314) in 2020 and 80% (1,548 of 1,932) in 2021.

Of the estimated 115,536 people seen for HIV care in the 5-year period between October 2017 and September 2022, up to 12,065 adults (10%) were not receiving specialist HIV care, the lowest proportion and number in the last 5 years. Comparable figures for 2019 and 2022 were 12% (12,896 of 105,633) and 11% (12,657 of 110,502) respectively.

Figure 28. Adults not retained in care by ethnicity, England, 2023

Source: Data from routine returns to HARS.

Theme 4: manage and prevent co-morbidities and HIV-related conditions

Delivering high-quality care in line with BHIVA standards of care and BHIVA guidelines will improve the quality of life and reduce morbidity, AIDS-defining conditions and HIV-related mortality to achieve the interim ambitions for 2025 and to end transmission of HIV by 2030.

In Theme 4 we list 4 indicators under development (Table 5a) and present data for 8 potential indicators (Table 5b) for the management and prevention of co-morbidities and HIV-related conditions from 2 UK-based surveys Positive Voices 2017 and Positive Voices 2022.

Table 5a. Indicators under development for Theme 4: manage and prevent co-morbidities and HIV-related conditions in people living with HIV

Code	Description
PT4A	Successful linkage from paediatric to adult HIV care
PT4B	Drug resistance to different classes of ART agents
PT4C	Hepatitis B co-infection
PT4D	Hepatitis C co-infection (diagnoses, treatment and cure)

Drug resistance to different classes of ART agents (PT4B)

The English surveillance programme for antimicrobial utilisation and resistance (ESPAUR) provided data on drug resistance. Drug resistance prevalence in drug-naïve patients increased from 6.1% in 2015 to 8.5% in 2021, mainly reflecting an increase in resistance to nucleos(t)ide reverse transcriptase inhibitors (NRTIs) from 4.1% to 6.8%. The prevalence of resistance to non-nucleoside reverse transcriptase inhibitor (NNRTI) remained stable, at 1.7% in 2015 and 1.4% in 2021; integrase strand transfer inhibitor (InSTI) resistance usually remained at less than 1% each year.

Data relating to this indicator is only complete up to the end of 2019 as the database is under development.

Table 5b. Indicators for Theme 4: manage and prevent co-morbidities and HIV-related conditions in people living with HIV (data from 2019 to 2023 is provided in Appendix 2)

Code	Description	Positive Voices survey (2017) [note 20]	Positive Voices survey (2022) [note 20]
PT4E	Percentage of people living with HIV whose GP was aware of their HIV status	93.8%	89.3%
PT4F	GP service rating – ranging from 0 (worst) to 10 (best)	6.9	6.5
PT4G	HIV clinical service rating – ranging from 0 (worst) to 10 (best)	9.5	9.6
PT4H	Percentage of people living with HIV reporting a long-term health condition, excluding any mental health condition	60.9%	66.8%
PT4I	Percentage of people living with HIV reporting a diagnosed mental health condition	37.4%	39.4%
PT4J	Percentage of people with HIV needing support to manage a long-term condition (and percentage met and unmet)	43.3% (29.2% and 14.0%)	36.3% (19.2% and 17.0%)
PT4K	Percentage of people with HIV needing support from a psychologist or counsellor (and percentage met and unmet)	30.6% (18.8% and 11.8%)	27.8% (13.0% and 14.8%)
PT4L	Percentage of people living with HIV needing peer support or social contact with other people with HIV (and percentage met and unmet)	33.3% (19.1% and 14.3%)	30.2% (14.0% and 16.2%)

Sources: Data from the 2017 and 2022 Positive Voices survey

Note 20: Positive Voices data was presented as weighted percentages to represent the population living with diagnosed HIV, rather than frequencies from the survey. See the Positive Voices report for sampling and weighting methodology.

GP was aware of HIV status (code PT4E)

The proportion of people who were registered with a GP increased from 97.5% in Positive Voices 2017 to 98.4% in Positive Voices 2022. However, the proportion of those registered who had shared their HIV status with their GP decreased from 93.8% in 2017 to 89.3% in 2022.

In Positive Voices 2022, the sharing of a person’s HIV status with their GP was less common among younger people (74.8% among those aged 18 to 34 years) and people who identified as trans, non-binary, or in another way (80.4%) and varied by ethnic group, with people of other white backgrounds and other ethnic backgrounds reporting the lowest levels (84.6% and 84.9%, respectively), compared to people of black African (90.0%) and white British (91.9%) ethnicity.

HIV clinical service rating (code PT4F)

Overall, people highly rated the care they received from their HIV clinic with an average score of 9.4 out of 10, like in 2017 (9.3). The highest average score (9.5) was among people aged 65 years and over, heterosexual men, and those based in the south of England. The lowest average score (8.8) was among people who identified as trans, non-binary, or in another way.

GP service rating (code PT4G)

Overall, people rated the care they received from their GP as moderate at 6.5 out of 10, signifying a decrease in the rating compared to 2017 (6.9). The average GP rating was much lower than the average HIV clinic rating (9.4).

The lowest GP ratings were reported by younger people (5.5 among people aged 18 to 34 years), people who identified as trans, non-binary, or in another way (5.4), and people of other white ethnic backgrounds (6.0). People aged 65 years and over and people of black African ethnicity reported the highest GP ratings (7.1 and 6.9, respectively).

Despite the relatively low average rating, GP satisfaction was not as low as reported by the general population, and the decrease since 2017 was also comparatively small. The 2022 British Attitudes survey reported the lowest level of satisfaction with GP services since the survey began, with only 35% of the general population satisfied with their GP, much lower than in 2017 when it was 65%.

Long-term health conditions (code PT4H)

People living with HIV were asked whether they had ever been diagnosed with an additional long-term or chronic health condition. Conditions listed included diabetes, high cholesterol, hypertension (high blood pressure), osteopenia or osteoporosis, arthritis, asthma, chronic obstructive pulmonary disease, erectile dysfunction, kidney disease, neuropathy, dementia, epilepsy, and sleep disorder. Stroke was excluded as it was considered an acute condition (although long-term sequelae may persist).

As may be expected from an ageing population, the prevalence of additional long-term conditions increased in 2022, with 66.8% reporting one or more conditions compared to 60.9% in 2017. The prevalence of long-term conditions increased with age, and an increase was observed in all age groups. Most people aged 65 years and over (88.7%) had an additional long-term condition.

Diagnosed mental health conditions (code PT4I)

Participants were asked if they had ever been diagnosed with any of the following mental health conditions: anxiety, depression, personality disorder, bipolar disorder, eating disorder, post-traumatic stress disorder, psychosis/schizophrenia, or other.

The prevalence of mental health conditions has remained high and unchanged since 2017, with approximately 2 in 5 people (39.4%) having been diagnosed with at least one of these conditions (37.4% in 2017). This is substantially higher than in the English general population, with just over a quarter (26.4%) having had such a diagnosis in 2014 (most up to date data available).

Mental health condition diagnoses across the demographic groups followed the same pattern as in 2017, with conditions disproportionality affecting younger people (44.4% in those aged 18 to 34 years), people of white British ethnicity (49.4%) and gay and bisexual men (47.7%). More than half (56.0%) of people who identified as trans, non-binary or in another way reported ever having had a diagnosis.

Met and unmet needs (codes PT4J, PT4K, and PT4L)

People with HIV were asked about their need for support to manage a long-term condition, access to a psychologist or counsellor, and peer group support, and whether these needs had been met. For each type of support, they were asked to indicate one of the following: ‘I received this service’ or ‘I needed the service but could not get it’ or ‘I needed the service but did not try to get it’ or ‘I needed the service but did not know about it’, or ‘I did not need the service’.

The needs of people living with HIV are diverse. The extent to which people’s needs are met may impact their overall health and well-being. A high proportion of people living with HIV expressed the need for services, including support to manage a long-term condition, access to a psychologist or counsellor, and peer group support that often remained unmet (17.0%, 14.8%, and 16.2%, respectively), an increase in the proportion of people living with HIV expressing unmet needs for these services in 2017 (14,0%, 11.8, and 14.3%, respectively).

Theme 5: improve quality of life and reduce HIV stigma

Reducing HIV stigma and improving quality of life are key to achieving the HIV Action Plan’s ambition of ending HIV transmission by 2030 and the UNAIDS 2025 wellbeing targets. This is because HIV-associated stigma remains a significant factor in people’s experience of living with HIV and negatively impacts access to testing and effective prevention interventions. Furthermore, for some people with diagnosed HIV, it can be challenging to prioritise their HIV care and adherence to treatment if they are experiencing personal, financial, housing, immigration, or mental health difficulties, and stigma. Increasing retention in care, adherence to treatment and support in achieving good health outcomes should result in a reduction of HIV transmission. Improving the quality of life for people with long-term conditions is a well-established goal for the NHS and the wider health and care system.

Table 6. Indicators for Theme 5: improve quality of life and reduce stigma in people living with HIV (data from 2019 to 2023 is provided in Appendix 2)

Code	Description	Stigma Survey UK (2015)	Positive Voices (2017) [note 21]	Positive Voices (2022) [note 21]
PT5A	Life satisfaction (ranged between 0 [not satisfied at all] and 10 [completely satisfied])	Not available	7.4	7.3
PT5B	Percentage of people reporting problems with pain and discomfort	Not available	46.1%	48.8%
PT5C	Average health-related quality of life score (range: 0 to 1, 0 = as bad as being dead; 1 = full health) [note 22]	Not available	0.77	0.77
PT5D	Enacted stigma – percentage of people who felt that they were not treated well in a healthcare setting within the last year because of their HIV status	26% [note 23]	7.6% [note 23]	5.8%
PT5E	Perceived stigma – percentage of people who felt they had been refused healthcare or delayed a treatment or medical procedure within the last year because of their HIV status	15%	5.0%	4.1%
PT5F	Anticipated stigma – percentage of people who felt worried that they would be treated differently from other patients within the last year because of their HIV status	46%	15.9%	13.7% [note 24]
PT5G	Anticipated stigma – percentage of people who had avoided going to a healthcare service when they needed to within the last year because of their HIV status	24% [note 25]	9.8% [note 25]	7.2%
PT5H	Self-stigma – percentage of people who felt ashamed of their HIV status	Not available	Not available	45.1%
PT5I	Percentage of people who did not share their HIV status with anyone outside of a healthcare setting	15%	13.0%	10.4%

Sources: Data from 3 UK-based surveys: the People Living with HIV Stigma Survey UK 2015, Positive Voices 2017 and Positive Voices 2022.

Note 21: See the Positive Voices report for sampling and weighting methodology.

Note 22: People were asked to identify problems and symptoms experienced on the day of answering questions about their daily life and activities, relating to the 5 domains of physical and mental health in the standardised 5 dimensions, 5 level, health outcome tool by EuroQoL (EQ-5D-5L) instrument for measuring HRQoL. These 5 domains were combined to give an overall utility score. Higher scores are better.

Note 23: Respondents were asked if they had been treated differently to other patients which is different to Positive Voices 2022, where respondents were asked if they felt they were not treated well in a healthcare setting.

Note 24: In Positive Voices 2022, the question specified ‘by healthcare staff.’

Note 25: Respondents were asked if they avoided seeking healthcare when they needed it, which is slightly different from Positive Voices 2022, where respondents were asked if they avoided going to healthcare services when they needed to.

Life satisfaction (code PT5A)

In the 2022 Positive Voices study, average life satisfaction among people living with HIV was 7.3 on a 0 (‘not satisfied at all’) to 10 (‘completely satisfied’) scale. This compared to 7.5 in the general English population (according to ONS annual personal wellbeing estimates).

Satisfaction was similar across gender identity, age and ethnic groups, however, lowest among people who identified as trans, non-binary or in another way (5.7). The highest level of satisfaction was among people of black African ethnicity (7.8). Life satisfaction rose with age, from 7.0 in ages 18 to 34 years to 7.5 for those aged 65 years and over.

Health-related quality of life (codes PT5B and PT5C)

Health-related quality of life (HRQoL) may be influenced by personal, psychosocial, and health conditions. Since 2017, there has been little change in the proportion who reported problems other than an increase in the proportion of people living with HIV who were experiencing pain and discomfort from 46.1% to 48.8% in 2022. Compared to the general population, the proportion of people living with HIV was higher across all 5 domains. The largest difference was observed in those experiencing anxiety and depression (48.1% among people with HIV compared to 33.0% in the general English population).

The individual HRQoL responses were converted into combined ‘utility scores’(the higher the score the better, details are available in the Positive Voices 2022 survey report appendices). The overall score in Positive Voices 2017 and 2022 was 0.77 among people living with HIV in 2022 and 2017 compared to 0.82 among the general population (data from 2018). Consistently between 2017 and 2022, the highest scores were observed in people of black African ethnicity (0.81 in 2022). Low utility scores were seen in people living with HIV who were unsatisfied with their medication (0.64); unable to have their peer support needs met (0.64); behind with bills (0.66); experiencing poor self-esteem (0.67); and living alone (0.71).

Enacted, perceived, and anticipated stigma in healthcare settings (codes PT5D to PT5G)

Experienced or enacted stigma is the lived experience of negative reactions, perceived stigma is an individual’s perception about how they will be treated because they are living with HIV, and anticipated stigma and discrimination describe the stigma expected by an individual.

Since 2015, there has been a decrease in the proportion of people living with HIV who felt that they were not treated well in a healthcare setting in the last year due to their HIV status (5.8% in 2022 compared to 7.6% in 2017 and 26% in 2015). In 2022, 1 in 25 people living with HIV felt that they were refused healthcare in the last year because of their HIV status. More than 1 in 10 had worried in the last year about being treated differently to other patients by healthcare staff and 7.2% had avoided accessing healthcare services in the last year because of their HIV status.

Self-stigma (code PT5H)

Self-stigma (or internalised stigma) is when one applies negative ideas about living with HIV to oneself. Data from 2022 showed that almost half of people (45.1%) felt ashamed of their HIV status. Self-stigma was more common in younger people (54.4% in those aged 18 to 34 years versus 36.7% among people aged 65 years and over), heterosexual adults (47.7% in women and 48.1% in heterosexual men versus 42.5% in gay and bisexual men) and people who identified as trans, non-binary or in another way (47.6%).

The U=U (undetectable = untransmittable) campaign aims to reduce stigma by spreading awareness of the following message: ‘A person on HIV treatment with undetectable viral load cannot pass on HIV through sex’. Overall, in 2022, awareness of U=U was very high with 9 in 10 (92.3%) people aware of the statement. However, only 62.7% strongly believed this statement to be true and only 58.1% reported that this statement made them feel much better about their HV status.

Sharing HIV status with anyone outside of a healthcare setting (code PT5I)

The Positive Voices 2022 survey data showed that 10.4% of people living with HIV had not shared their HIV status with anyone outside of healthcare settings, compared with 13.0% in Positive Voices 2017 and 15% in the People Living with HIV Stigma Survey UK 2015.

Among respondents to the Positive Voices 2022 survey, older people (15.9% for people aged 65 years and over compared to 8.7% for people aged 18 to 34 years), black African respondents (14.8% compared to 6.6% for white British respondents), women and heterosexual men (14.1% and 13.9, retrospectively, compared to 6.5% for gay and bisexual men) were more likely not to share their HIV status with anyone.

Conclusions

This 2024 report of the HIV Action Plan monitoring and evaluation framework provides an overview of progress towards meeting the ambitions of the HIV Action Plan for England of reducing HIV transmission by 80%, and HIV-related deaths and AIDS diagnoses by 50% from 2019 to 2025. This report also sets out key indicators, and highlights differences by demographic characteristics where possible, to identify areas for further work to meet these ambitions.

There is much to commend such as 95% of people diagnosed, with 98% treated and 98% having an undetectable viral load (when missing data and information for those not in care are taken into account, the estimates for 2023 range from 96%-94%-96% to 96%-94%-92%), and increased HIV testing and access to PrEP, and detection of new diagnoses from the ED opt-out testing programme. However, significant challenges remain with increasing diagnoses and widening inequalities in age, gender identity, ethnicity and exposure across the whole HIV pathway.

New HIV diagnoses have increased in 2023 and were higher than in 2019. Additionally, HIV incidence among GBMSM is estimated to have increased in the past 2 years, mostly attributed to a rise in the 25 to 34 years age group.

The report shows a rise in new HIV diagnoses in England in 2023, with ethnic minorities among both men exposed through sex between men and people exposed through sex between men and women disproportionately affected. One in 3 diagnoses among men exposed through sex with men are in an ethnic minority group (excluding white ethnic minorities) and this rises to 2 in 3 among people who acquired HIV through heterosexual contact in 2023.

Inequalities persisted also in access to, and utilisation of, HIV prevention interventions. Overall, in all SHSs, the number of people tested for HIV has recovered to 96% of levels seen in 2019 but not for all groups. While 2023 saw the highest number of GBMSM ever tested, testing levels among heterosexual men and women have not recovered to 2019 levels. Furthermore, women were less likely to accept an HIV test compared to men. One-fifth of heterosexual and bisexual women of black African ethnicity declined the offer of an HIV test and this, coupled with high positivity in this group, means that these missed diagnostic opportunities might have a larger impact on transmission. It is possible that the lower levels of HIV testing among heterosexual men and women have led to the observed rise in the number of late HIV diagnoses among people exposed through sex between men and women.

The ED opt-out testing programme has made a significant contribution to HIV testing provision in areas of very high diagnosed HIV prevalence since April 2022. This has provided the opportunity to find people living with undiagnosed HIV who may not have attended SHSs or re-engage people with diagnosed HIV who may not be currently attending specialist HIV care.

Despite a 10% increase between 2022 and 2023, the number of people reported as attending an SHS following partner notification has decreased by 41% since 2019. Partner notification remains an extremely effective prevention intervention with a high positivity among those tested (5% in 2023). It can also provide access to HIV testing among people who would not otherwise attend SHS. Although trends are moving in a positive direction, it is concerning that levels of partner notification have not recovered to those seen pre-pandemic.

The overall number of people taking PrEP has increased annually since it became available in 2020. GBMSM had the highest proportion and number of people with PrEP need identified and starting PrEP, compared to heterosexual men and women. In contrast, GBMSM and heterosexual men of black African and black Caribbean ethnic origin had the lowest needs identified and lowest initiation for PrEP alongside heterosexual and bisexual women of black Caribbean and black African origin as well as Indian, Bangladeshi and Pakistan origin.

The estimated number of adults aged 15 years and over living with transmissible levels of virus in 2023 in England was between 15% to 18% of those estimated to be living with HIV in England. These include people not detected, diagnosed but not linked to, or not seen for, specialist HIV care, not on treatment or with no evidence of viral suppression. Over 25% of people with transmissible levels of virus were from a black African background. There is a significant challenge across the whole HIV pathway to ensure that these cohorts of people are promptly identified and linked back to care as well as supported to be retained in care if we were to achieve zero HIV transmission by 2030. There is a need for improved access to HIV prevention, testing and care interventions for GBMSM and heterosexual population from ethnic minority background.

The number and the proportion of adults who were not retained in specialist HIV care in 2023 were similar to 2019, after 3 years with higher levels due to changes in access to care and in health-seeking behaviour following the COVID-19 pandemic. This shows good progress but still about 5,000 people and up to 12,065 if we go back 5 years.

HIV-related stigma and discrimination affects people across the continuum of HIV pathway. A recent European survey showed that HIV-related stigma and discrimination in healthcare settings still exists in the UK but is less prominent among healthcare workers with good knowledge of HIV. Educating all frontline staff in healthcare settings about HIV might have an impact on stigma reduction and outcomes for people living with HIV and HIV transmission in the longer term.

It is unlikely that the HIV Action Plan 2025 ambitions will be met, despite significant improvements across a number of indicators, including better detection rates. Although the number of new diagnoses is expected to increase over the next few years with increased testing such as the ED opt-out testing programme, decreases in HIV transmission will only be achieved by concerted efforts on reducing inequalities across the whole HIV pathway, improving earlier diagnoses and reducing the number of people not retained in care.

This report should prompt consideration across the wide range of interested stakeholders for potential improvements to be incorporated into the new HIV Action Plan due to be published in summer 2025. These include potential changes in service provision across 3 main areas presented below.

1. For HIV prevention interventions, that include HIV testing and PrEP:

• full implementation and monitoring of BHIVA, British Association for Sexual Health and HIV (BASHH) and British Infection Association (BIA) Adult HIV testing guidelines 2020, including opt-out in sexual health services, subject to agreed support mechanisms for implementation
• continuation of ED opt-out testing in very high and high prevalence HIV areas (subject to results of the final evaluation of the programme due in October 2025)
• scaling up community testing focusing on those groups that are more likely to benefit from HIV testing in these settings such as ethnic minority populations
• understanding reasons behind the decline of HIV testing in women
• scaling up of partner notification activities
• understanding the drivers of late diagnosis in order to better focus interventions
• reducing inequalities in access and uptake to PrEP through implementation of the PrEP roadmap

2. To reduce the number of people with transmissible levels of virus:

• maintaining rapid access to care for those diagnosed in any setting and not just those diagnosed in sexual health services to reduce the number of people with transmissible levels of virus
• ensuring smooth pathways into care among people diagnosed abroad and continuing care in England
• having peer support in HIV services to improve retention in care and treatment adherence

3. To improve quality of life and reduce stigma:

• focusing on designing services that would support people living well with HIV into older age such as focus on co-morbidities, training and equitable access to social care
• scaling training for health and social care workers to tackle stigma
• continuing to monitor levels of stigma across various parts of the system

Acknowledgements

Adamma Aghaizu, Alison Brown, Amal Farah, Amina Addow, Ammi Shah, Anne Presanis, Anu Fasanya, Carole Kelly, Catriona Harrison, Clare Macdonald, Cuong Chau, Daniela De Angelis, Debbie Mou, Eloise Cross, Erna Buitendam, Georgina Wilkinson, Hamish Mohammed, Hannah Kitt, James Lester, Janice Morgan, Joan Ekajeh, Kathy Lowndes, Katy Sinka, Kedeen Okumu-Camerra, Mary Ramsay, Natasha Ratna, Neil Mackay, Nicholas Cooper, Olaide Adebayo-Clement, Paul Birrell, Peter Kirwan, Rachel Roche, Ross Harris, Ruth Simmons, Sema Mandal, Shahin Parmar, Shaun Bera, Sonia Rafeeq, Susan Hopkins, Tamara Đuretić, Temitope Omisore, Tobi Kolawole, Tom Clare, Veronique Martin, Victoria Schoemig

Suggested citation

Victoria Schoemig, Veronique Martin, Ammi Shah, Kedeen Okumu-Camerra, Neil Mackay, Shaun Bera, Hannah Kitt, Carole Kelly, Tobi Kolawole, Natasha Ratna, Cuong Chau, Tamara Đuretić, Alison Brown and contributors. HIV Action Plan monitoring and evaluation framework 2024 report: Report summarising progress from 2019 to 2023. December 2024, UK Health Security Agency, London