Epidemiology of HIV infection and associated behaviours among people who inject drugs in England, Wales, and Northern Ireland: Nearly 40 years on

Introduction

People who inject drugs are at high risk of blood‐borne infections. We describe the epidemiology of HIV among people who inject drugs in England, Wales, and Northern Ireland (EW&NI) since 1981.

Methods

National HIV surveillance data were used to describe trends in diagnoses (1981–2019), prevalence (1990–2019), and behaviours (1990–2019) among people who inject drugs aged ≥15 years in EW&NI. HIV care and treatment uptake were assessed among those attending in 2019.

Results

Over the past four decades, the prevalence of HIV among people who inject drugs in EW&NI remained low (range: 0.64%–1.81%). Overall, 4978 people who inject drugs were diagnosed with HIV (3.2% of cases). Diagnoses peaked at 234 in 1987, decreasing to 78 in 2019; the majority were among white men born in the UK/Europe (90%), though the epidemic diversified over time. Late diagnosis (CD4 <350 cells/µl) was common (2010–2019: 52% [429/832]). Of those who last attended for HIV care in 2019, 97% (1503/1550) were receiving HIV treatment and 90% (1375/1520) had a suppressed viral load (<200 copies/ml).

HIV testing uptake has steadily increased among people who inject drugs (32% since 1990). However, in 2019, 18% (246/1404) of those currently injecting reported never testing. The proportion of people currently injecting reporting sharing needles/syringes decreased from 1999 to 2012, before increasing to 20% (288/1426) in 2019, with sharing of any injecting equipment at 37% (523/1429).

Conclusion

The HIV epidemic among people who inject drugs in EW&NI has remained relatively contained compared with in other countries, most likely because of the prompt implementation of an effective national harm reduction programme. However, risk behaviours and varied access to preventive interventions among people who inject drugs indicate the potential for HIV outbreaks.

Trends and predictors of linkage to HIV outpatient care following diagnosis in the era of expanded testing in England, Wales and Northern Ireland: Results of a national cohort study

OBJECTIVES

We explore trends in linkage to HIV care following diagnosis and investigate the impact of diagnosis setting on linkage in the era of expanded testing.

METHODS

All adults (aged ≥ 15 years) diagnosed with HIV between 2005 and 2014 in England, Wales and Northern Ireland (EW&NI) were followed up until the end of 2017. People who died within 1 month of diagnosis were excluded (n = 1009). Trends in linkage to outpatient care (time to first CD4 count) were examined by sub-population and diagnosis setting. Logistic regression identified predictors of delayed linkage of > 1 month, > 3 months and > 1 year post-diagnosis (2012-2014).

RESULTS

Overall, 97% (60 250/62 079) of people linked to care; linkage ≤ 1 month was 75% (44 291/59 312), ≤ 3 months was 88% (52 460) and ≤ 1 year was 95% (56 319). Median time to link declined from 15 days [interquartile range (IQR): 4-43] in 2005 to 6 (IQR: 0-20) days in 2014 (similar across sub-populations/diagnosis settings). In multivariable analysis, delayed linkage to care was associated with acquiring HIV through injecting drug use, heterosexual contact or other routes compared with sex between men (> 1 month/3 months/1 year), being diagnosed in earlier years (> 1 month/3 months/1 year) and having a first CD4 ≥ 200 cells/μL (> 3 months/1 year). Diagnosis outside of sexual health clinics, antenatal services and infectious disease units predicted delays of > 1 month. By 3 months, only diagnosis in 'other' settings (prisons, drug services, community and other medical settings) was significant.

CONCLUSIONS

Linkage to care following HIV diagnosis is relatively timely in EW&NI. However, non-traditional testing venues should have well-defined referral pathways established to facilitate access to care and treatment.

Where do we diagnose HIV infection? Monitoring new diagnoses made in nontraditional settings in England, Wales and Northern Ireland

OBJECTIVES

The objectives of the study were to describe 10-year trends in HIV diagnosis setting and to explore predictors of being diagnosed outside a sexual health clinic (SHC).

METHODS

Analyses of national HIV surveillance data were restricted to adults (aged ≥ 15 years) diagnosed in 2005-2014 in England, Wales and Northern Ireland. Logistic regression identified factors associated with diagnosis outside an SHC (2011-2014).

RESULTS

Between 2005 and 2014, 63 599 adults were newly diagnosed with HIV infection; 83% had a diagnosis setting reported. Most people were diagnosed in SHCs (69%) followed by: medical admissions/accident and emergency (A&E; 8.6%), general practice (6.4%), antenatal services (5.5%), out-patient services (3.6%), infectious disease units (2.7%) and other settings (4.0%). The proportion of people diagnosed outside SHCs increased from 2005 to 2014, overall (from 27% to 32%, respectively) and among men who have sex with men (MSM) (from 14% to 21%) and black African men (from 25% to 37%) and women (from 39% to 52%) (all trend P < 0.001). Median CD4 increased across all settings, but was highest in SHCs (384 cells/μL) and lowest in medical admissions/A&E (94 cells/μL). Predictors of being diagnosed outside SHCs included: acquiring HIV through heterosexual contact [adjusted odds ratio (aOR) 1.99; 95% confidence interval (CI) 1.81-2.18] or injecting drug use (aOR: 3.28; 95% CI: 2.56-4.19; reference: MSM), being diagnosed late (< 350 cells/μL) (aOR: 2.55; 95% CI: 2.36-2.74; reference: diagnosed promptly) and being of older age at diagnosis (35-49 years: aOR: 1.60; 95% CI: 1.39-1.83; ≥ 50 years: aOR: 2.48; 95% CI: 2.13-2.88; reference: 15-24 years).

CONCLUSIONS

The proportion of HIV diagnoses made outside SHCs has increased over the past decade in line with evolving HIV testing guidelines. However, the rate of late diagnosis remains high, indicating that further expansion of testing is necessary, as many people may have had missed opportunities for earlier diagnosis.