Main findings

The main findings are that:

• community testing provides opportunities to diagnose HIV in populations who may not access testing via sexual health services
• in 2023, there was an increase in testing in community settings, with a 25% decrease in test reactivity, compared to 2022 – community testing in 2023 remains 20% lower than in 2019
• in 2023, nearly a quarter of all tests were reported among individuals being tested for HIV for the first time – this proportion remained consistent with that observed in 2022 but was lower than that observed in 2019
• in 2023, testing was highest among heterosexuals and test reactivity in heterosexuals was comparable to gay, bisexual, and other men who have sex with men (GBMSM)
• community testing finds high test reactivity in people of Black African, and Black Caribbean and any other Black ethnicities, people born in high diagnosed HIV prevalence countries and people residing in areas of high diagnosed HIV prevalence
• this testing initiative is successfully targeting people who may not access sexual health services or other care settings and those at greater risk of HIV acquisition

Introduction

Community-based testing has an integral role in facilitating the English government’s ambition of ending new HIV transmission in England by 2030. Since 2022, there has been an increase in new HIV diagnoses and in late-diagnosed HIV cases, particularly among individuals of Black African ethnicity, highlighting the importance of targeted testing within specific demographic groups who are less likely to access sexual health services.

The National Institute for Health and Care Excellence (NICE) 2016 HIV testing guidelines recommend that community testing services should be set up in areas of high or extremely high diagnosed HIV prevalence and in venues where there may be a high risk of HIV exposure. The UK Health Security Agency (UKHSA) annual survey of HIV testing in community settings monitors HIV testing activity in community-based testing services in England and evaluates the implementation of current guidelines.

It is important that we continue to monitor HIV testing in the community as this data is used to determine if targets are being achieved, how resources should be allocated and identify areas for improvement. UKHSA continues to increase awareness of the importance of monitoring HIV testing in the community by reporting the findings of this annual survey in the HIV Action Plan monitoring and evaluation framework.

Methods

Eligible community HIV testing services were identified through relevant external and internal stakeholders including third sector voluntary organisations and UKHSA sexual health facilitators.

A survey was used to collect aggregate data on the number of tests and reactive tests stratified by demographic group and geographical service location (upper tier local authority of testing service). Where data was available, the home postal address was used as geographic location. Results of confirmatory testing were not consistently reported.

Descriptive analyses were undertaken on number of tests, number of reactive tests and reactivity rate by demographic group. Unknown and not reported categories were removed from the denominator when calculating proportions.

Survey results

Overall

A total of 19,669 tests were reported from 19 community HIV testing services resulting in 55 reactive tests (Figures 1a and 1b). This represents a 7% increase (from 18,422) in testing and a 25% (0.4% to 0.3%) decrease in test reactivity compared to 2022. Testing remains 30% below levels seen in 2019 (28,082 from 25 testing services).

Among the tests reported in this survey, 902 were carried out during HIV testing week (6 February to 12 February 2023) resulting in 1 reactive test. There was a 22% increase in the number of tests carried out in this time compared to 2022 (737 tests and 2 reactive tests). Other testing initiatives that take place during HIV testing week such as the HIV and syphilis self-sampling programme are excluded from these results.

The most common type of test used in community services were point-of-care tests (54.4%, 10,702 of 19,669), followed by self-testing kits (31.3%, 6,154 of 19,669) (Figure 1).

Figure 1a. Number of tests by test type, England, 2023

Test type	Tests	Proportion of total tests
Blood tests	224	1.1%
Dried blood spot	1,632	8.3%
Point of care tests	10,702	54.4%
Self-sampling kits	957	4.9%
Self-testing kits	6,154	31.3%

Figure 1b. Number of reactive test results by test type, England, 2023

Test type	Reactive tests	Reactivity (%)
Blood tests	0	0%
Dried blood spot	0	0%
Point of care tests	28	0.3%
Self-sampling kits	1	0.1%
Self-testing kits	26	0.4%

Demographic breakdown

Geographical service location

Testing was reported from services in all 9 UKHSA regions (Figures 2a and 2b) and all 152 upper tier local authorities (upper tier local authority) with the largest number of tests by region carried out in London (32.6%, 5,866 of 17,979) followed by Yorkshire and the Humber (22.3%, 4,014 of 17,979). The largest number of tests by upper tier local authority were reported from services based in Leeds (7%, 1,335 of 17,979), Brighton and Hove (6%, 1,149 of 17,979), followed by Croydon (6%, 1,139 of 17,979).

Figure 2a. Number of tests by region, England, 2023

Region	Tests	Proportion of total tests
North East	202	1.1%
North West	1,309	7.3%
Yorkshire and the Humber	4,014	22.3%
East Midlands	1,459	8.1%
West Midlands	540	3%
East of England	1,118	6.2%
London	5,866	32.6%
South East	2,142	11.9%
South West	1,329	7.4%
Unknown region	1,690	0%

Note: Unknown region values are excluded from the calculation of proportion of total tests.

Figure 2b. Number of by reactive test results by region, England, 2023

Region	Reactive tests	Reactivity (%)
North East	1	0.5%
North West	4	0.3%
Yorkshire and the Humber	9	0.2%
East Midlands	2	0.1%
West Midlands	0	0%
East of England	7	0.6%
London	26	0.4%
South East	3	0%
South West	3	0.2%
Unknown region	0	0%

Age and self-reported testing history

The largest number of tests by age group were carried out among people aged 25 to 34 (33.7%, 5,802 of 17,227) and reactivity was highest in people aged 35 to 49 (0.5%, 29 of 5,536) (Figures 3a to 3d). Testing history was reported for 68% (13,354 of 19,669) of tests. Of these, 23% (3,033 of 13,354) were first-time testers for HIV. This is in comparison to 37% (8,055 of 21,624) of first-time testers in 2019 and an equivalent proportion in 2022, at 22% (3,060 of 13,705). Test reactivity was highest among people previously tested for HIV compared to first-time testers (0.4% versus 0.3%).

Figure 3a. Number of tests by age group, England, 2023

Characteristic	Tests	Proportion of total tests
Aged 15 to 24	3,610	21%
Aged 25 to 34	5,802	33.7%
Aged 35 to 49	5,536	32.1%
Aged 50 to 64	1,915	11.1%
Aged 65 and over	364	2.1%
Unknown age	2,442	0%

Note: Unknown age group values are excluded from the calculation of proportion of total tests.

Figure 3b. Number of reactive test results by age group, England, 2023

Characteristic	Reactive tests	Reactivity (%)
Aged 15 to 24	6	0.2%
Aged 25 to 34	15	0.3%
Aged 35 to 49	29	0.5%
Aged 50 to 64	5	0.3%
Aged 65 and over	0	0%
Unknown age	0	0%

Figure 3c. Number of tests by self-reported testing history, England, 2023

Characteristic	Tests	Proportion of total tests
Never tested for HIV	3,033	22.7%
Previously tested for HIV	10,321	77.3%
Unknown tested for HIV	6,315	0%

Note: Unknown age group values are excluded from the calculation of proportion of total tests.

Figure 3d. Number of reactive test results by self-reported testing history, England, 2023

Characteristic	Reactive tests	Reactivity (%)
Never tested for HIV	8	0.3%
Previously tested for HIV	40	0.4%
Unknown tested for HIV	7	0.1%

Gender and sexual orientation

The largest number of tests reported through the community survey were carried out among men (including transgender men) (70.1%, 12,518 of 17,860), compared with 28% (4,993 of 17,860) of tests carried out on women (including transgender women) (Figures 4a to 4d). This compares with 46% (583,635 of 1,269,944) of tests carried out among men and 50% (636,655 of 1,269,944) of tests carried out among women in sexual health services in 2023. Test reactivity was higher in women than in men (0.4% versus 0.3%); equivalent figures for 2022 were 0.5% for women and 0.4% for men. The largest number of tests by sexual orientation were carried out among heterosexuals (52%, 8,600 of 16,541) with a test reactivity of 0.3%; comparable figures for GBMSM were 45.1% (7,468 of 16,541) and 0.3%. In 2022, most tests were carried out among GBMSM (54.3%, 9,057 of 16,692) with a test reactivity of 0.4%, while heterosexuals accounted for 44% (7,352 of 16,692) with a reactivity of 0.5%.

A total of 252 (1.4%) tests were carried out among people identifying as transgender and 1 reactive test was reported in this group. Of these, 90 (36%) tests were carried out on transgender men and 162 (64%) tests were carried out on transgender women. This compares with 142 (0.8%) tests carried out among those identifying as transgender in 2022, of which 68 (48%) tests were carried out on transgender men and 74 (52%) tests were carried out on transgender women.

Figure 4a. Number of tests by gender, England, 2023

Characteristic	Tests	Proportion of total tests
Men (including transgender men)	12,518	70%
Women (including transgender women)	4,993	28%
Other gender	349	2%
Unknown gender	1,809	0%

Notes: Unknown gender values are excluded from the calculation of proportion of total tests.

Figure 4b. Number of reactive results by gender, England, 2023

Characteristic	Reactive tests	Reactivity (%)
Men (including transgender men)	37	0.3%
Women (including transgender women)	18	0.4%
Other gender	0	0%
Unknown gender	0	0%

Figure 4c. Number of tests by sexual orientation, England, 2023

Characteristic	Tests	Proportion of total tests
GBMSM	7,468	45.1%
Heterosexual	8,600	52%
Women who have sex with women	473	2.9%
Unknown sexual orientation	3,128	0%

Note: Unknown sexual orientation values are excluded from the calculation of proportion of total tests.

Figure 4d. Number of reactive results by sexual orientation, England, 2023

Characteristic	Reactive tests	Reactivity (%)
GBMSM	26	0.4%
Heterosexual	28	0.3%
Women who have sex with women	1	0.2%
Unknown sexual orientation	0	0%

Ethnicity and country of birth

When comparing ethnic groups, 62% (10,865 of 17,527) of tests were carried out among people of White ethnicity, 14.1% (2,473 of 17,527) among people of Black African ethnicity, 11.2% (1,967 of 17,527) among people of Asian ethnicity, 8.6% (1,515 of 17,527), among people of Mixed or any other ethnicities, and 4% (707 of 17,527) among Black Caribbean and Black ethnicities (Figures 5a to 5d). Test reactivity was highest among people of Black Caribbean and any other Black ethnicities (1.0%, 7 of 707) followed by people of Black African ethnicity (0.6%, 16 of 2,473), people of Asian ethnicity (0.3%, 6 of 1,967), and people of Mixed or any other ethnicities (0.3%, 4 of 1,515). Test reactivity among people of White ethnicity was 0.2% (19 of 10,865).

Country of birth was reported for 44% (8,595 of 19,669) of tests, with over half of those tests carried out among people born in the UK (54.3%, 4,671 of 8,595) and 11.6 (996 of 8,595) among people born in a high prevalence country (where diagnosed HIV prevalence is 1% or greater). Reactivity in this latter group was higher than in UK-born testers (0.7% versus 0.1%).

Figure 5a. Number of tests by ethnic group, England, 2023

Characteristic	Tests	Proportion of total tests
Asian ethnicity	1,967	11.2%
Black African ethnicity	2,473	14.1%
Black Caribbean or any other Black ethnicity	707	4%
White ethnicity	10,865	62%
Mixed or any other ethnicity	1,515	8.6%
Unknown ethnicity	2,142	0%

Notes: Unknown country of birth values are excluded from the calculation of proportion of total tests. Proportion of total tests does not add to 100% due to rounding.

Figure 5b. Number of reactive results by ethnic group, England, 2023

Characteristic	Reactive tests	Reactivity (%)
Asian ethnicity	6	0.3%
Black African ethnicity	16	0.6%
Black Caribbean or any other Black ethnicity	7	1%
White ethnicity	19	0.2%
Mixed or any other ethnicity	4	0.3%
Unknown ethnicity	3	0.1%

Figure 5c. Number of tests by country of birth, England, 2023

Characteristic	Tests	Proportion of total tests
High HIV prevalence country of birth	996	11.6%
Non-UK country of birth	2,928	34.1%
UK country of birth	4,671	54.3%
Unknown country of birth	11,074	0%

Note: Unknown country of birth values are excluded from the calculation of proportion of total tests.

Figure 5d. Number of reactive results by country of birth, England, 2023

Characteristic	Reactive tests	Reactivity (%)
High HIV prevalence country of birth	7	0.7%
Non-UK country of birth	18	0.6%
UK country of birth	4	0.1%
Unknown country of birth	26	0.3%

Testing rate by diagnosed HIV prevalence areas

The rate of community-based testing in extremely high prevalence areas was more than double that of testing in low prevalence areas (61 versus 24 tests per 100,000 population, respectively) (Figures 6a and 6b). These testing rates reflect the location of the reporting testing service, which may differ from the residence of the people tested. Of the 17,979 tests reported in 2023 with known upper tier local authority of testing, 36% (6,516 of 17,979) were carried out in low prevalence areas; 30% (5,424 of 17,979) in high prevalence areas and 34% (6,039 of 17,979) in extremely high prevalence areas. Reactivity was higher at 0.4% in high prevalence areas compared with 0.3% in both extremely high prevalence areas and low prevalence areas.

Figure 6a. HIV testing rates per 100,000 population by diagnosed HIV prevalence band of the community testing service geographical location, England, 2023

Diagnosed HIV prevalence band	Number of tests	Tests per 100,000 resident population
Low	6,516	24
High	5,424	31
Extremely high	6,039	61

Figure 6b. HIV test reactivity by diagnosed HIV prevalence band of the community testing service geographical location, England, 2023

Diagnosed HIV prevalence band	Number of reactive tests	Reactivity (%)
Low	18	0.3
High	20	0.4
Extremely high	17	0.3

Note: Data presented where upper tier local authority information was known. Testing rates reflect the location where the reporting service conducted the test and may differ from the residence of the people tested. are based on the number of people diagnosed with HIV and accessing care at HIV outpatient clinics in a given year. Low: HIV prevalence less than 2 in 1,000 population aged 15 to 59 years; high: HIV prevalence between 2 and 5 in 1,000 population aged 15 to 59 years; extremely high: HIV prevalence of 5 or more in 1,000 population aged 15 to 59 years.

Reactive tests and confirmatory testing

In 2023, 42% (8 of 19) of services had a reactive result with an overall test reactivity of 0.3% (55 of 19,669) (Figure 7). Where upper tier local authority information was known, 31% (17 of 55) were reported from services in extremely high prevalence areas, 36% (20 of 55) from services in high prevalence areas and 33% (18 of 55) from services in low prevalence areas.

Results of confirmatory testing were known for 40% (22 of 55) of the reactive results. Of these 22 confirmatory tests, 15 (68%) were new diagnoses, 5 (23%) had previously been diagnosed elsewhere, 1 (4.5%) had unknown diagnosis status and 1 (4.5%) was a false positive.

Figure 7. Results of confirmatory testing reported by community HIV testing services, England, 2023

Of the 19 services surveyed, 13 reported testing for other sexually transmitted infections (STIs) in addition to HIV. Most commonly, services reported testing for syphilis, gonorrhoea and chlamydia (Figure 8). Number of tests undertaken for other STIs was not reported in this survey.

Figure 8. Number of services reporting testing for STIs other than HIV, England 2023

STI tested	Number of services
Chlamydia	12
Gonorrhoea	12
Hepatitis A	1
Hepatitis B	7
Hepatitis C	6
Syphilis	13

Conclusion

Following a decrease in testing between 2019 and 2020, results from recent surveys have shown an overall increase in testing, although this remains below pre-pandemic levels. Notably, the number of tests conducted during HIV Testing Week in 2023 increased by almost a quarter compared to 2022.

Test reactivity showed an overall decline between 2022 and 2023. In 2023, heterosexual men and women accounted for the largest number of tests, as well as the largest number of reactive tests. However, test reactivity was comparable between GBMSM and heterosexual populations. Based on self-reported testing, almost a quarter of tests were among individuals testing for HIV for the first time. These results suggest a need to test in community settings and that community HIV testing is succeeding in reaching people who may not test routinely via sexual health services or in other settings.

Community testing is carried out in all UKHSA regions and upper tier local authorities. However, surveys are completed on a voluntary basis and therefore should be treated as a snapshot of the testing that takes place in the community rather than its full representation.

The results of confirmatory testing were available for only 40% of the reactive tests reported, which underrepresents the true number of positive tests. The high specificity of diagnostic HIV tests offers assurance that the unconfirmed reactive tests are likely to be true positives. Almost three quarters of true positive tests had no previous diagnosis. There was only one negative confirmatory test.

We encourage the reporting of confirmatory results, if known, and completion of the confidential online questionnaire regarding reactive tests allowing for linkage to HIV routine surveillance data sets held at UKHSA. This would strengthen the evidence and further demonstrate the value of community testing.

Community testing is successfully reaching people at a higher risk of HIV acquisition shown by the high rate of test reactivity among people of Black ethnicity, people born in a country of high diagnosed HIV prevalence and people living in high HIV prevalence areas. Our analysis indicates that the number of tests needed to obtain a single reactive result was 271 in high HIV prevalence areas, compared with 355 in extremely high prevalence areas and 362 in low prevalence areas. This pattern may reflect the success of previous targeted interventions in extremely high prevalence areas, where a higher proportion of people living with HIV have already been diagnosed.

Community HIV testing is an important component of a broader set of interventions to increase testing rates. It offers an alternative approach that encourages test uptake and facilitates linkage to care, especially in groups who may not engage with traditional settings, such as sexual health services. This is particularly important among people at a higher risk of HIV acquisition. Improved data collection in future surveys will help identify the most effective methods for community-based HIV testing.

Community testing services interested in participating in future surveys are encouraged to contact the HIV Testing Team at hivtesting@ukhsa.gov.uk

Acknowledgements

Contributors: Debbie Mou, UKHSA Sexual Health Facilitators, Terrence Higgins Trust, The National AIDS Trust and all services who submitted surveys in the last 5 years.

Suggested citation

Neil Mackay, Victoria Schoemig, Veronique Martin, Sema Mandal and Tamara Djuretic. HIV testing in community settings in England: results from January to December 2023, February 2025, UK Health Security Agency, London