Valerie Delpech, MBBS, MPH, on the Trends of HIV Infection in the United Kingdom

In this podcast, Valerie Delpech, MBBS, MPH, speaks about her session at CROI 2020, which was focused on UK HIV epidemic and the programs that were implemented that helped reduce the number of HIV infections in the region. 

Additional Resources:

• Delpech V. Reflections on the UK epidemic. Presented at: Conference on Retroviruses and Opportunistic Infections 2020; March 8-11, 2020; Boston, MA. https://www.croiconference.org/sessions/reflections-uk-epidemic.
• 56 Dean Street. https://dean.st/. Accessed March 19, 2020.
• O’Halloran C, Owen G, Croxford S, Sims LB, Gill ON, Nutland W, Delpech V. Current experiences of accessing and using HIV pre-exposure prophylaxis (PrEP) in the United Kingdom: a cross-sectional online survey, May to July 2019. Euro Surveill. 2019;24(48):1900693. https://dx.doi.org/10.2807%2F1560-7917.ES.2019.24.48.1900693. 

Valerie Delpech, MBBS, MPH, FPHM, DiplEpi, is the head of HIV surveillance at Public Health England in the United Kingdom.

TRANSCRIPT:

Amanda Balbi: Hello, everyone. Welcome to another installment of Podcast360—your go‑to resource for medical news and clinical updates. I'm your moderator Amanda Balbi with Consultant360 Specialty Network.

The Conference on Retroviruses and Opportunistic Infections 2020 was a virtual meeting of the minds in infectious disease and public health. One of the sessions presented at CROI 2020 examined what makes epidemics recede. Part of that session focused on the UK HIV epidemic, and the programs that were implemented that helped reduce the number of HIV infections in the region.

The session was presented by Dr Valerie Delpech, who is the head of HIV Surveillance at Public Health England in the United Kingdom. She joins us today to give us more insight into her session.

Thank you for joining me today, Dr Delpech.

Valerie Delpech: Thank you.

Amanda Balbi: Can you give us an overview of your session, and the lessons learned from the HIV epidemic in the United Kingdom?

Valerie Delpech: Yes, of course. The United Kingdom has had a concentrated epidemic over the last few decades since HIV began. It's been focused mostly in gay and bisexual men, as well as black African communities, most of them who've been born abroad and living in the UK.

With that backdrop, we also have a universal health system, which provides free and confidential HIV and STI testing and treatment throughout the country. That's an important context to add. Overall, we've had about 100,000 people living with HIV in the UK, as of the end of 2018. It's the latest data. That's about a prevalence of around 1.4 per 1000 population, as I said, concentrated in those 2 populations. Very exciting, over the last 3 years, we've seen a decline in new diagnoses in gay/bisexual men in particular, which are the group who are more likely to acquire HIV in the UK.

That decline is confirmed using some modeling of a decline in also HIV transmission. We think that HIV transmission has declined now since 2012. We use a CD4 back‑calculation of new diagnoses to estimate incidence in the UK.

There are other methods, and a number of methods, all state that it is very exciting to finally see a decline across the country. It's largely concentrated in London, and there are particularly lessons to be learned there. The decline is largest in white British‑born men, but this is where we've seen the largest numbers in the past. They've contributed to about 85% of all cases from that group. We have seen smaller declines in other groups as well from other ethnicities and born in Europe and across the world. Essentially this is extremely exciting news, just to say we've seen also decline in diagnoses from men and women who acquire HIV heterosexually.

That's a much more complex picture because the majority of the decline are among those who are born in high-prevalence countries. Some of that is probably linked to changes in migration patterns with fewer people migrating to the UK from high-prevalence countries.

The exciting news of a declining transmission is what my talk was about, and it was to really give context as to why that could have happened. We've reached the UNA 90/90 target which means that we've diagnosed more than 90% ... In fact, 93% of all people living with HIV in the UK were diagnosed in 2018, so there's only a very small number now.

Probably only around 7000, perhaps up to 10,000, people who remain undiagnosed across the country with the population in the country around 66 million people. You can see that's a very small number of undiagnosed infections. Then when people are diagnosed, they very quickly get treated and put onto effective antiretroviral therapy.

The second UNA target is 97% people diagnosed are on treatment. Consequently, the retention and the care received through the National Health Service is very effective so that over 97% of people who are on treatment are virally suppressed. That means they are unable to pass on the virus to their partners. They're uninfectious. Undetectable equals untransmissable.

This is extremely good news. We have fewer people undiagnosed and we have fewer people who are diagnosed who may be able to transmit the virus. A lot of that has been due to increases in testing and getting people on treatments.

In more recent years, it's certainly been also the case that PrEP has been on the scene and certainly had also another surge in creating fewer people being diagnosed with HIV.

Amanda Balbi: Yesterday, one of the plenary sessions was about the HIV epidemic in Vancouver, and even a little bit in the US and how the face of HIV is changing in North America. It seems like it's a little bit different in the UK. Can you go into the ways that the HIV epidemic is different in the UK vs other parts of the world?

Valerie Delpech: Yes. The UK epidemic has been focused in gay, bisexual, and other men who have sex with men, mostly UK born and of white ethnicity. That's one group. The other group has been heterosexual men and women born abroad of black African ethnicity who migrated into the UK.

Now we know that most of those had acquired their HIV prior to coming to the UK. That's a very different type of epidemic to gay and bisexual men, mostly acquired within the UK.

Within that group, we do see some men being born abroad who acquire their infection on arriving in the UK. But as I've said, it's been very, very much largely UK‑born men who caused the infection.

What's been important is some of the outcomes looking at testing uptake and treatment, diagnosis and treatment uptake across different groups show that we're not seeing the health inequalities that might be seen in parts of America—Northern America.

In the UK, for instance, when we look at the uptake of treatment across different modalities such as gender, age, ethnicity, or exposure or even region of geography, the uptake of treatment is very, very high, over 95% regardless of that subgrouping. We're not seeing inequalities in access to treatment and uptake of treatment or loss to follow-up of treatment.

I think that's a real legacy to the National Health Service and universal and free access to testing and treatment. That's quite different, I know, to parts of the United States in particular.

Amanda Balbi: Absolutely. Before you mentioned something about there's a decline in the HIV incidence and even a few people in the UK are undiagnosed with HIV. Based on those challenges—and even that great goal that you've set the bar high for the rest of us—what types of public health interventions are being implemented or have been implemented based on those challenges?

Valerie Delpech: The challenge has been to try and reach all people who need to be tested for HIV to be tested for HIV. Certainly, there's been very focused and targeted campaigns throughout the last decades—similar to that you see in Northern America, trying to particularly increase awareness of HIV and the need for testing and the benefits of testing for personal as well as public health. That's been targeted in our key populations in gay/bisexual men, as well as black African communities living in the UK in particular.

Then there's been a range of modalities to ensure that people are aware that they can get tested in sexual health clinics. They can also get tested online now and order a field testing or field sampling test or even get one from the chemist, or they can be tested at attending health services where there are higher rates of HIV in a geographical locality that the testing guidelines now advocate the testing in general practice, on admission in hospitals, for instance.

There are many ways that people can be offered the test, but also can initiate a test. A lot of the campaigns over the last 15 years has been to target, in particular, those 2 communities to take up testing, and it's worked. That's been really crucial.

The awareness has worked. A culture of testing in gay men, in particular, has shifted tremendously when I arrived to work in the UK. Coming from Australia where the culture of testing was already very established among gay men, I was really quite astonished to see that very few gay men in England were testing regularly. It was less than 30% were testing regularly.

Now, it's over 90% of gay men are testing regularly over the last 10 years. That's a key strategy. Not only that, it's also for those who are at high risk with multiple sexual partners and condomless sex to be testing more frequently than once a year.

We're seeing that number increase. We went, over the last few years, from 20,000 to 40,000 are now testing more frequently than once a year. That's being key. Getting people to test frequently. More recently, to also take up PrEP, should that be suitable to their needs. These are being some of the really key strategies in getting people tested.

The other key to that is getting people very quickly on treatment. In my talk, I talk about a clinic in Soho, London, which is the heart of the gay quarters in London. A clinic called 56 Dean Street, which is being key and instrumental in getting gay men to test frequently, and to get on PrEP or other strategies if they're negative.

If they're positive, to get on to antiretroviral therapy very quickly. In the last few years, they've dropped the number of people, the time for treatment from several weeks to now 48 to 72 hours. All men are on treatment when they're diagnosed.

If you can imagine where you have a situation which either you're negative and you go on to PrEP or other behavioral strategy to reduce your risk or if you're positive, you get on to treatment immediately and you test very frequently—you've got a situation where there are very few people who may be able to transmit virus.

Amanda Balbi: Great. A 2019 user survey that you and your colleagues had administered found that access to PrEP medication was a challenge for patients with HIV. How is this challenge being addressed? Who or what organizations are involved?

Valerie Delpech: Yes, that's a great question. A little bit of history about PrEP—in this country PrEP has been available informally since about 2015 on the internet. We had a trial called PROUD trial, which showed very efficient and effective uptake of treatment among gay men in the real world. But that was a small trial of less than 1000 people.

Since then, in October 2017, in England we began a PrEP impact trial, which enrolled over 10,000 men to start taking up PrEP but in an observed way to better understand the type of regimen that works best for them. In other words, event‑based or daily based, to better understand the impact of regular monitoring on the health care system. Also, to understand the impact of taking PrEP on other sexually transmitted infections as well as, obviously, the HIV incidence.

This trial has provided already some really important answers around the logistics of delivering a large PrEP program across the National Health Service, which has been very insightful. The places have increased to over 26,000 in March last year. However, as the survey shows, when we conducted it in the summer of last year, in 2019, this still wasn't enough for England. A lot of men were demanding it and wanting PrEP.

Subsequently, a lot of lobbying went on from clinicians and community groups to really make PrEP a much more commissioned service—in other words, delivered free through the NHS. This is about to happen. It will happen at any moment now. Coronavirus hasn't helped and probably delayed some of that. That will mean it'll be a lot more places available. In addition to having free access to PrEP on the NHS, there's also the continued access of PrEP privately through shops. Dean Street provides generic PrEP, for instance, at their clinic. There are also some websites where people can purchase PrEP at semireasonable prices.

That is improving but it just shows how important, how much a game changer PrEP has been for many gay men. Certainly, we're trying to expand its access and the awareness of PrEP in other groups, including transgender and women at high risk as well.

Amanda Balbi: Perfect. Overall, what would you say the key take‑home message is from your presentation?

Valerie Delpech: There's a couple of reflections for me. The science was all about combination‑prevention. In other words, health promotion, early testing, diagnosis, and putting people on treatment as well as the option of PrEP, another behavioral and preventive.

Equally as important is our health care system, the universal access and free access to these where possible. Also, it's about the players. It's about the fact that in the UK, we've had a very strong political will and system leadership. We've also had some strong clinical leadership through the British HIV Association, a lot of engaged community members, and civil society, all galvanizing together on common goals to achieve what needed to be achieved. PrEP is a great example, but many other examples, for instance, ensuring universal access to health for migrants regardless of migration status are ensuring that we do not dis-invest in HIV prevention.

All of that has been galvanized through a community with a common goal even if there were a ton of differences. Egos were dropped to ensure that they together could form partnerships and take the government to account. That's being a key. It's not just about the science, it is about the people, the politics, and the partnerships.

In the talk, this is obviously some biases from my perspective being a public health physician is the importance of public health monitoring. That has been key to the response.

We're very fortunate. I have an excellent team of HIV managers, data managers, and scientists who work with me to collate really important information from all sorts of clinics and clinicians throughout the country, with extremely good and high rates of reporting. This means that we have a comprehensive national cohort of people accessing HIV care across the whole of the NHS, which is why I can provide you with very accurate information around treatment uptake and viral load uptake.

The numbers that get into care, the numbers that get tested through sexual health clinics, this is all because we have tremendous data.

That is the goodwill of reporters, of people living with HIV allowing the data to be used for public health purposes, but also a very strong public health infrastructure and surveillance and monitoring.

An example of that is that we provide data down to local levels that each clinic in the UK has a clinical dashboard.

At least once if not twice a year, they'll have their dashboard, and they'll know exactly the number of people who were late to diagnose through their center the number that was seen in care within a month of all newly diagnosed, the number that we suppressed biologically following treatment.

The proportion of the cohort at their clinic who are suppressed and on treatment, and of course, time to treatment is something we've added more recently. An example of that, over the country, now 83% of people diagnosed will be initiating treatment within 3 months. We can do that across each clinic, and then get each clinic to really engage with that data, order the data, and better understand what their policies are in retaining people in care, offering treatment.

So it's very powerful, and I think public health data really can drive a response, also initiate new policies and monitor recommendations.

Amanda Balbi: Great. Thank you so much for speaking with me today about your session.

Valerie Delpech: It's been a real pleasure. In summary, I think we are on a really good trajectory in the UK to eliminate HIV. There are stiff challenges, however, and we need to sustain our efforts and certainly that does mean addressing a range of issues. I hope we get there, and I hope some of the lessons learned can also have impact in other countries.

Thank you for the opportunity to talk with you today.