http://sti.bmjjournals.com/cgi/content/full/80/3/159
Sex Transm Infect 2004;80:159-166
© 2004 BMJ Publishing Group Ltd
EPIDEMIOLOGICAL REVIEW
Recent trends in HIV and other STIs in the United Kingdom: data to the
end of 2002
A E Brown1, K E Sadler1, S E Tomkins1, C A McGarrigle1, D S
LaMontagne1, D Goldberg2, P A Tookey3, B Smyth4, D Thomas5, G Murphy6,
J V Parry6, B G Evans1, O N Gill1, F Ncube1 and K A Fenton1,7

1 HIV and STI Department, Health Protection Agency, Communicable
Disease Surveillance Centre, UK
2 The Scottish Centre for Infection and Environmental Health, UK
3 Institute of Child Health (ICH), University College London, UK
4 Health Protection Agency, Communicable Disease Surveillance Centre
(Northern Ireland), UK
5 National Public Health Service for Wales, Communicable Disease
Surveillance Centre, UK
6 The Sexually Transmitted and Blood Borne Viruses Laboratory,
Specialist and Reference Microbiology Division, Health Protection
Agency, UK
7 The Centre for Sexual Health and HIV Research, Department of Primary
Care and Population Sciences, Royal Free and University College
Medical School, London, UK

Correspondence to:
Alison Brown
HIV and STI Department, Communicable Disease Surveillance Centre, 61
Colindale Avenue, London NW9 5EQ, UK; alison.brown@hpa.org.uk

Accepted for publication 2 April 2004

ABSTRACT
Sexual health in the United Kingdom has deteriorated in recent years
with further increases in HIV and other sexually transmitted
infections (STIs) reported in 2002. This paper describes results from
the available surveillance data in the United Kingdom from the Health
Protection Agency and its national collaborators. The data sources
range from voluntary reports of HIV/AIDS from clinicians, CD4 cell
count monitoring, a national census of individuals living with HIV,
and the Unlinked Anonymous Programme, to statutory reports of STIs
from genitourinary medicine (GUM) clinics and enhanced STI
surveillance systems. In 2002, an estimated 49 500 adults aged over 15
years were living with HIV in the United Kingdom, of whom 31% were
unaware of their infection. Diagnoses of new HIV infections have
doubled from 1997 to 2002, mainly driven by heterosexuals who acquired
their infection abroad. HIV transmission also continues within the
United Kingdom, particularly among homo/bisexual men who, in 2002,
accounted for 80% of all newly diagnosed HIV infections acquired in
the United Kingdom. New diagnoses of syphilis have increased
eightfold, and diagnoses of chlamydia and gonorrhoea have doubled from
1997 to 2002 overall; STI rates disproportionately affect
homo/bisexual men and young people. Effective surveillance is
essential in the provision of timely information on the changing
epidemiology of HIV and other STIs; this information is necessary for
the targeting of prevention efforts and through providing baseline
information against which progress towards targets can be monitored.

Keywords: HIV; sexually transmitted infections; United Kingdom

Sexual health in the United Kingdom has deteriorated in recent
years.1,2 Increases in HIV and other sexually transmitted infections
(STIs) have placed enormous pressure on existing sexual health
services.3 Consequent delays in accessing diagnosis and care may in
turn be facilitating infection transmission. Since 2001, a range of
new initiatives aimed at improving sexual health have been established
in the United Kingdom. In England, the implementation of the 10 year
National Strategy for Sexual Health and HIV 4 has seen the appointment
of local sexual health leads in primary care trusts (PCTs) and the
Independent Advisory Group on Sexual Health5; greater investment in
genitourinary medicine (GUM) clinics, and phased implementation of
prevention interventions, such as the National Chlamydia Screening
Programme, aimed at specific population risk groups. There have been
similar strategies in other UK countries (Wales,6 Scotland,7 and
Northern Ireland).8 The Health Select Committee report on Sexual
Health,9 the All Party Parliamentary Group on AIDS report on Migration
and HIV,10 and most recently the government’s response to the Health
Select Committee’s report on sexual health11 have all drawn attention
to the need for greater political will and investment in tackling HIV
and STIs in the United Kingdom and globally.

Surveillance data have a key role in such strategies. The collection
and analysis of data, in conjunction with the monitoring of trends
with timely feedback provides information for the implementation and
evaluation of these initiatives. Specifically, by highlighting where
prevention efforts should be targeted and through providing baseline
information against which progress towards targets can be monitored.

The immediate public health challenges facing sexual health in the
United Kingdom include increasing incidence and prevalence of HIV and
STIs; rising costs of HIV related care; variation in disease
determinants and distribution; and the associated long term morbidity
and mortality of these conditions. This paper summarises recent trends
in the UK surveillance data for HIV and other STIs up until the end of
2002.12

DATA SOURCES
In the United Kingdom, the majority of STIs, including HIV, are
diagnosed and treated in GUM clinics which form part of the National
Health Service. Although diagnoses of many STIs (particularly
chlamydia) occur in primary care and other community settings,13 only
GUM clinics have statutory reporting of STIs to the Health Protection
Agency and its collaborators by clinicians. The detailed methods of
the HIV and STI surveillance systems in the United Kingdom have been
described elsewhere12 and are briefly summarised here.

HIV/AIDS reporting
New diagnoses of HIV infections, AIDS cases, and deaths14 (HIV/AIDS
reporting) are reported by laboratories and clinicians through
voluntary reporting systems. The annual Survey of Prevalent HIV
Infections Diagnosed (SOPHID)15 provides a census of the number of
individuals living with diagnosed HIV infection and receiving care in
England, Wales, and Northern Ireland. Longitudinal data on CD4 T
lymphocytes16 (CD4 surveillance) are reported from laboratories in
England, Wales and Scotland and are used to monitor trends in
immunosuppression associated with HIV infection. In Scotland, these
data are used to gauge the number of people in specialist HIV care.

Unlinked anonymous HIV surveys
The unlinked anonymous (UA) HIV surveys17 measure the prevalence of
HIV, including undiagnosed HIV infections, in selected subgroups of
the population. The unlinked anonymous survey of GUM clinic attendees
(UA GUM survey) measures HIV prevalence in a high risk population
(attendees of sentinel GUM clinics in the United Kingdom).18 In
England, Wales, and Northern Ireland the incidence of HIV infection in
homo/bisexual men included in the UA GUM survey has been determined by
application of the Serological Testing Algorithm for Recent HIV
Seroconversion (STARHS).19

Prevalence in the general population is measured by surveys of
pregnant women (UA pregnant women surveys—pregnant women attending
antenatal care and women giving birth in England and Scotland). Live
births to diagnosed HIV infected women in the United Kingdom are
reported to the National Study of HIV in Pregnancy and Childhood.20
These reports are aligned with the overall prevalence estimates for
HIV in pregnant women by geographical area, to produce estimates of
the proportion of women giving birth who were diagnosed before
antenatal attendances, diagnosed through antenatal testing, and who
remained undiagnosed at delivery.21

STI surveillance
Statutory KC60 returns from all GUM clinics12 in England, Wales, and
Northern Ireland provide aggregate data on the total episodes of
diagnosed STIs by sex and age group (and sexual orientation for
selected conditions). The ISD(D)5 returns system provides disaggregate
data on all STI diagnoses in GUM clinics in Scotland.12 NHS
laboratories throughout the United Kingdom provide voluntary
electronic disaggregate reporting on laboratory diagnoses of selected
STIs with age and sex information. Enhanced Syphilis Surveillance
(ESS) collects further demographic and risk factor data in the United
Kingdom, and is designed to improve interpretation of the incidence
and distribution of infectious syphilis.22 The Gonococcal Resistance
to Antimicrobials Surveillance Programme (GRASP) is a sentinel
surveillance system for monitoring gonococcal antimicrobial resistance
and collects detailed behavioural information on diagnoses of
gonorrhoea in England.23

Related surveillance techniques
Estimates of the total number of HIV infected people in the United
Kingdom24 were calculated by combining data from SOPHID (for diagnosed
HIV infections) and the unlinked anonymous surveys (for undiagnosed
HIV infections), with estimates of the size of the population in
various exposure categories derived from the National Survey of Sexual
Attitudes and Lifestyles (Natsal 2000),25 and census 2001 population
estimates (Office for National Statistics).

Annual rates (cases/population) of diagnoses of STIs were calculated
per 100 000 people. The 2002 rates for all regions and countries in
the United Kingdom were calculated by dividing the number of cases
reported from GUM clinics in each area in 2002 by the mid-2002
population estimates from the Office for National Statistics (for
homo/bisexual men population estimates were derived from Natsal
200025). Descriptive epidemiology is the focus of the paper, but
hypothesis tests have been used to supplement the data where
appropriate using Stata 7 (StataCorp, 2001).

Previously undiagnosed HIV infection

This includes both HIV infected individuals who were diagnosed with
HIV at the episode of clinical care, and individuals who left clinical
care remaining unaware of their infection, but excludes individuals
whose HIV infection was diagnosed before the episode of clinical care



OVERALL HIV/STI SURVEILLANCE TRENDS
Estimates of the total prevalent infections indicate that at the end
of 2002, 49 500 adults aged over 15 were living with HIV in the United
Kingdom, of whom 15 200 (31%) were unaware of their infection. There
were 5542 new HIV diagnoses reported for 2002: double the 2735
diagnoses in 1997.

At the end of 2002, overall HIV prevalence among homo/bisexual men in
the United Kingdom was estimated at 7%, with estimates of total
prevalent infections indicating that 22 600 homo/bisexual men were
infected with HIV, of whom 5500 (24%) were unaware of their infection.
Of the newly diagnosed HIV infections that were acquired in the United
Kingdom, 80% (1500/1850) were among homo/bisexual men. The UA GUM
survey found 4% (27/672) of homo/bisexual men aged under 25 in London
had a previously undiagnosed HIV infection in 2002, indicating
continuing transmission in this population (fig 1A). Annual incidence
in GUM attendees, measured using STARHS, rose to approximately 3.5% in
2002.26

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     Figure 1 Prevalence of previously undiagnosed HIV infection in
England, Wales, and Northern Ireland, 1993–2002. (A) Previously
undiagnosed* HIV infection in homo/bisexual men{dagger} by clinical
presentation and age group. (B) Previously undiagnosed* HIV infection
in heterosexuals{dagger} and overall HIV prevalence in women giving
birth. (*Excludes HIV infected attendees who were previously
diagnosed.{dagger}Attendees at 15 GUM clinics in England, Wales, and
Northern Ireland (seven in London, eight elsewhere). {ddagger}Acute
STI is defined as presenting with one of the following diagnoses:
infectious syphilis, gonorrhoea, chancroid/donovanosis/LGV, chlamydia,
NSU, trichomoniasis, scabies/pediculosis, HSV/HPV first attack or
molluscum contagiosum. §Through unlinked anonymous testing of neonatal
dried blood spots.) Data source: Unlinked Anonymous Programme.


However, the recent increases in reports of new HIV diagnoses have
largely been driven by heterosexually acquired infections, which
accounted for 57% (3152/5542) of all those reported in 2002. Of these
infections, three quarters (2338/3152) were probably acquired in
Africa (table 1). Estimates of the total prevalent infections indicate
that by the end of 2002, 15 400 African heterosexuals aged over 15
were living with HIV in the United Kingdom, of whom 4800 (31%) were
undiagnosed.

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     Table 1 Subcategory of HIV infections diagnosed in the United
Kingdom that were probably acquired heterosexually, 1992–2002

In 2002, one third (1850/5542) of new HIV diagnoses were probably
acquired in the United Kingdom. Although 80% (1500) of these
infections were diagnosed in homo/bisexual men, since 1997 there has
been a steady increase in the number of diagnoses of heterosexually
acquired HIV infection in the United Kingdom. In 2002, 275 such HIV
infections were diagnosed compared to 141 in 1997 (table 1); 56%
(153/275) of these diagnoses were acquired through partners who were
probably infected outside Europe. In England, Wales, and Northern
Ireland, although remaining low, the prevalence of previously
undiagnosed HIV infection rose significantly among UK born
heterosexual males from 0.12% (30/24 465) to 0.3% (72/24 040) between
1997 and 2002 (p<0.0001); prevalence in UK born women was unchanged.

Major acute STI diagnoses reported through KC60 returns have continued
their rising trend since the mid-1990s. From 1997 to 2002, there was a
103% increase to 82 206 chlamydia diagnoses (rates were 138/100 000 in
males and 167/100 000 in females); a 97% increase to 24 958 gonorrhoea
diagnoses (males: 66/100 000, females: 167/100 000); a 716% increase
to 1232 syphilis diagnoses (males: 4/100 000, females: 0.5/100 000); a
9% increase to 69 449 genital warts diagnoses (males: 141/100 000,
females: 118/100 000); and a 17% increase to 18 379 genital herpes
diagnoses (males: 26/100 000, females: 42/100 000) in England, Wales,
and Northern Ireland. Laboratory reports of STIs have also increased
recently in Scotland; 12 392 chlamydia positive isolates were reported
in 2002, a 16% increase on 2001 (10 636).

STIs have risen markedly among homo/bisexual men (fig 2). In this
population, cases of gonorrhoea have almost doubled from 1842 in 1999
to 3363 in 2002, and cases of syphilis have increased from 52 to 607
over the same period; this latter rise is as a result of ongoing
outbreaks in urban centres in the United Kingdom.22

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     Figure 2 Trends in rates of major acute STIs in homo/bisexual
men*, United Kingdom{dagger}, 1995–2002. (*Rates are based on an
estimated population of 310 000 homo/bisexual men resident in England,
Wales, and Scotland.25 {dagger}2001 and 2002 data not available for
Scotland for KC60 and ISD(D)5 data.) Data sources: KC60 statutory
returns and ISD(D)5 data, and HIV/AIDS Reports, reports received by
the end of June 2003.


Among heterosexuals, young people and black minority communities
continue to be disproportionately represented in STI statistics. Rates
of diagnoses of chlamydia in GUM clinics have increased by 215% in
women aged 16–24, from 529/100 000 in 1997 to 1135/100 000 in 2002 in
England, Wales, and Northern Ireland (fig 3). In the 2002 GRASP data
collection, black ethnic groups, mainly black Caribbeans, accounted
for 55% (516/936) and 44% (249/563) of gonococcal isolates collected
from heterosexual males and females respectively (fig 4).

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     Figure 3 Trends in the rates of selected acute STIs in young
females and males aged 16–24 in the United Kingdom*, 1995–2002. (A)
Males. (B) Females. (*2001 and 2002 data not available for Scotland.)
Data source: KC60 Statutory returns and ISD(D)5 data.



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     Figure 4 Proportion of new diagnoses of uncomplicated
gonorrhoea by ethnicity, England and Wales, 2002. Data source:
Gonococcal Resistance to Antimicrobials Surveillance Programme
(GRASP).



POPULATION SUBGROUPS
Homo/bisexual men
Since HIV/AIDS reporting began in the United Kingdom in the early
1980s there have been 29 890 HIV diagnoses reported in homo/bisexual
men, 12 284 of whom have progressed to AIDS, and 8761 of whom have
died. HIV was the third most commonly diagnosed major STI in
homo/bisexual men in 2002 (fig 2).

In 2002, the UA GUM survey found that 6.5% (97/1495) of previously
undiagnosed HIV infected homo/bisexual men were co-infected with an
acute STI; the equivalent figure in Scotland was 2.9% (12/416) and
elsewhere in England, Wales, and Northern Ireland, 3.5% (25/719). Such
individuals are of particular concern since they may be at higher risk
of passing on their HIV infection to others. In London, 4% (27/672) of
homo/bisexual men under 25 years attending GUM clinics had a
previously undiagnosed HIV infection a clear indication of continuing
HIV transmission at relatively high levels. Application of STARHS
found that annual HIV incidence among homo/bisexual men rose to
approximately 3.5% in 2002,26 compared to 2–3% from 1995–2001,27
although this difference is not statistically significant. The highest
incidence was seen in those aged 35–44 (5.9%, 95% confidence intervals
3.7 to 8.8). This increasing trend occurred in a period when there
were intensive health promotion campaigns and when 60–70% of diagnosed
HIV infected homo/bisexual men were on antiretroviral therapy (ARV).

Since 1999, considerable increases in the rate of acute STI diagnoses
in homo/bisexual men attending GUM clinics have been observed (fig 2).
Rates of gonorrhoea diagnoses doubled between 1999 and 2001, from
612/100 000 to 1242/100 000. A slight decrease was observed overall in
2002, but there was no decrease in men aged 16–24 where rates
increased from 648/100 000 in 1999 to 1194/100 000 in 2002. In 2002,
rates of homosexually acquired infectious syphilis have shown a marked
rise since 1999 (616%). This has been associated with a series of
large localised outbreaks in Brighton, Manchester, Newcastle upon
Tyne, London,22 central Scotland,28 and Northern Ireland.29 Data
collected between April 2001 and September 2003 from the ESS programme
indicate that 46% of homo/bisexual men diagnosed with infectious
syphilis in London were co-infected with HIV. Increases in genital
chlamydia infections in homo/bisexual men were also observed in 2002,
up 144% since 1999.

Factors influencing transmission
Behavioural surveillance data among homo/bisexual men in the United
Kingdom have demonstrated increases in rates of unprotected anal
intercourse (UAI), and specifically, UAI involving HIV discordant or
unknown status partners.30 Data from Natsal 200025 suggest that there
have been increases in the prevalence of male homosexual behaviour in
the general population, and increases in some high risk behaviours
among homosexually active men.31 The reasons for this rising risk are
unclear. However, continued liberalisation of attitudes towards
homosexuality,32 and "safer sex" fatigue in the era of ARV,33 coupled
with expansions in opportunities which facilitate partner acquisition
(for example, the internet, saunas)34 may be contributing factors.

Young people
People aged 16–24 accounted for just over 10% (588/5542) of all
reports of new HIV diagnoses in 2002; a proportion that has remained
constant over time. Their risk exposure distribution was similar to
that of people aged over 24. Heterosexual HIV acquisition accounted
for 63% (370/588) of new HIV diagnoses in 2002 in those aged 16–24,
with the majority of individuals (65%, 242/370) probably infected in
Africa.

Rates of STIs have risen markedly among young people (fig 3) and this
population subgroup bear a disproportionate burden of STI diagnoses.
In 2002, women aged 16–24 accounted for 72% (33 205/46 140) of all
female chlamydia diagnoses, 66% (5031/7569) of gonorrhoea, 62%
(50/137) of syphilis and 61% (19 792/32 544) of genital warts reported
from GUM clinics in England, Wales, and Northern Ireland.

Rates of diagnoses from GUM clinics for chlamydia, gonorrhoea, and
genital warts were highest among females aged 16–19 and males aged
20–24. The highest rates of chlamydial diagnoses were seen in women
aged 16–19 and men aged 20–24 at 1209 and 842/100 000 respectively.
These figures are likely to underestimate the total number of
infections because most infections in women are asymptomatic, and thus
care and treatment are not sought. Chlamydial infections diagnosed in
primary care and other community settings13 are not reported in the
KC60 returns and also contribute to this underestimation. Of women
diagnosed with gonorrhoea, 40% were under 20. In men, rates of
gonorrhoea were highest in those aged 20–24 in 2002 (296/100 000), an
increase of 231% since 1997. Similarly, rates of genital herpes
simplex infection remain highest among males and females aged 20–24
(93/100 000 and 296/100 000 respectively). Unlike other bacterial
STIs, rates of syphilis among young people remain low.

Factors influencing transmission
Young people are behaviourally more vulnerable to STI acquisition as
they generally have higher numbers of sexual partners, more concurrent
partnerships, and change partners more often than older age groups.35
Although consistent and proper use of condoms reduces the risk of STI
transmission and unintended pregnancy, many young people may not have
developed the skills and confidence to implement this successfully.36

STI re-infection is a particular concern in this population. In a
study of three GUM clinics,37 young age was a key determinant of STI
re-infection within a year of initial diagnosis. Studies in the United
States have also found that re-infection rates are high among
adolescents and young adults, particularly women,38 including those
aged under 15.39

Black and ethnic minority populations
The number of HIV infected black African adults born in the United
Kingdom is increasing but currently remains low. It is estimated that
in 2002, black African adults accounted for 63% (15 400) of the total
of prevalent HIV infections in heterosexuals, and 51% (4800) of
heterosexuals who are unaware of their HIV infection. In 2002, of the
12 203 HIV infected heterosexuals reported to SOPHID, 68% (8262) of
those for whom ethnicity was reported were black African (a 330%
increase since 1997), 4% (501) black Caribbean, and 21% (2580) white.
The UA pregnant women surveys found an HIV prevalence of 2.5% (239/47
075) in women born in sub-Saharan Africa who gave birth in 2002. This
compares with a prevalence of 0.03% (42/121 833) in their UK born
counterparts (fig 1B). These data reflect the focus of the HIV
pandemic in sub-Saharan African countries and the impact of population
movement on the UK statistics.

Undiagnosed HIV infection continues to be a feature of the treatment
histories of black heterosexuals. Among sub-Saharan born heterosexuals
included in the UA GUM survey, the prevalence of previously
undiagnosed HIV infection rose to 4.2% (159/3752) in London and 7.9%
(60/757) outside London (fig 1B). The latter figure may be due to the
recent dispersal to areas outside London of migrant populations
originating from high HIV prevalence countries. In Scotland, the
prevalence of previously undiagnosed HIV infection was 5.7% (9/157) in
heterosexuals of African nationality, compared to 0.1% (13/133 314) in
heterosexuals of British nationality.

STI diagnoses disproportionately fall on the United Kingdom’s black
minority populations.40,41 In the 2002 GRASP23 data collection (fig
4), black ethnic groups, mainly black Caribbean, accounted for 55%
(516/936) and 44% (249/563) of gonococcal isolates in heterosexual
males and females respectively. The ESS programme in London revealed
that 48% (187/393) of heterosexual syphilis diagnoses were among black
or black British ethnic groups.

Factors influencing transmission
Black and ethnic minority populations in the United Kingdom continue
to have poor sexual health. However, few behavioural surveys give
insight into sexual health among ethnic minority groups. Variations in
the burden of STIs among these populations are known to be influenced
by a number of behavioural and social factors.42 Qualitative community
based studies highlight variations in sexual socialisation, attitudes
and community norms related to sexual behaviour; sex, religious
beliefs, and degree of acculturation are all influential factors.43
Although qualitative studies suggest that variations in high risk
behaviour do exist across ethnic groups,44,45 these alone cannot
explain the observed disparities. Factors such as patterns of sexual
mixing, differential access to curative services, and background
disease prevalence in the communities concerned may also be
contributing.42,46 Data from population based surveys and mathematical
modelling will be needed to further elucidate these associations.

HIV SCREENING AND TREATMENT
There has been some success in interventions aimed at reducing HIV
transmission in the United Kingdom. Diagnosis at an earlier stage of
HIV infection presents the opportunity for treatment to postpone
further illness and to reduce viral load which, along with changes in
sexual behaviour, may reduce the risk of onward HIV transmission.

The number of GUM clinic attendees accepting a voluntary confidential
HIV test (VCT) can be measured through the UA GUM survey, which
collects KC60 data in addition to limited demographic information.
Voluntary confidential HIV testing (VCT) has increased in
homo/bisexual men and heterosexuals respectively, from 45% (2724/6019)
and 25% (16 886/66 880) in 1997, to 62% (4604/7372) and 54% (40 746/74
935) in 2002 in England, Wales, and Northern Ireland. From 2003,
modified KC60 data will allow better monitoring of VCT uptake. In
Scotland, data indicate that uptake of VCT has increased in
homo/bisexual men and heterosexuals respectively, from 47% (454/959)
and 23% (2624/11 223) in 1997, to 59% (761/1290) and 36% (5142/14 281)
in 2002.

Similarly, over recent years, CD4 surveillance data show a recent
trend towards earlier diagnosis for homo/bisexual men. Only 24% of
homo/bisexual men had a CD4 cell count less than 200 cells x106/l at
HIV diagnosis (an indicator of a "late diagnosis") in 2002 compared to
28% in 1997. In contrast, 43% of newly diagnosed heterosexuals had a
"late diagnosis" in 2002. This may be because a high proportion of
heterosexuals were infected, and previously lived abroad.
Additionally, heterosexuals may perceive themselves to be at lower
risk from HIV and may present for testing only when they become
symptomatic.47,48

In England, the proportion of HIV infected pregnant women remaining
undiagnosed by the time of delivery has declined since the
introduction of the universal offer and recommendation of an HIV test
as a routine part of antenatal care in 199949,50; this policy has now
been introduced elsewhere in the United Kingdom.

In 2002 there were an estimated 686 births to HIV positive women in
England, Wales and Scotland, of whom at least 79% (539/686) were
reported as diagnosed before delivery. Overall, HIV detection rates in
2002 are currently estimated at 75% (318/422) for London, 85%
(199/234) elsewhere in England and Wales and 73% (22/30) in Scotland
(fig 5). These minimum estimates are subject to reporting delay and
are likely to rise as more diagnosed infections in pregnancies are
reported.

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     Figure 5 Estimated proportion of HIV infected women diagnosed
before delivery* and of exposed children becoming infected with
HIV{dagger}{ddagger}, 1997–2002. (A) London. (B) Outside
London—England, Wales, and Scotland. (*Includes those previously
diagnosed and those diagnosed through antenatal testing.
{dagger}Assumes a vertical transmission rate of 26.5% in undiagnosed
women and 2.2% in diagnosed women.53 {ddagger}These data contain
reports received by the end of September 2003. §Data for 2002 should
be considered preliminary minimum estimates, and as the number of
reports rise, estimates of infants becoming HIV infected will fall.)
Data source: Unlinked Anonymous Programme and the National Study of
HIV in Pregnancy and Childhood (NSHPC).


These improved maternal HIV detection rates have reduced the
proportion of exposed children who go on to acquire the infection
vertically. In London, in 2002 (based on the current estimated
detection rates), the estimated proportion of children exposed to HIV
vertically who were themselves infected was 8% (35/422) compared with
19% (37/200) in 1997. In the rest of the United Kingdom this
proportion decreased from 22% (25/113) in 1997 to 6% (16/264) in 2002.

A high proportion of HIV infected people who were eligible for ARV
were on medication in 2002 in the United Kingdom. Of the 1708
homo/bisexual men with CD4 counts of 200 cells x106/l or less, 78%
were on therapy; of the 2433 heterosexuals, 78% were on therapy; and
of the 211 IDUs, 73% were on therapy (measured through SOPHID).
Equivalent figures were higher for Scotland: 92% (72, p = 0.006), 94%
(84, p = 0.0004), and 92% (98, p = 0.0002). However, in Scotland ARV
therapy is measured through CD4 monitoring which is largely undertaken
to assess a patients eligibility for ARV. These data confirm that
exposure group does not affect the level of therapy uptake.

DISCUSSION
The surveillance data confirm that HIV and other STIs have increased
within the UK population. Population subgroups that have high rates of
sexual partner change continue to have higher infection rates, in
particular HIV and STIs among homo/bisexual men and STIs among young
people. Black and ethnic minority populations (including subgroups
born in high prevalence countries) are disproportionately affected by
poor sexual health. There is some evidence of onward HIV transmission
rising within the United Kingdom though as yet this is limited.

Health promotion campaigns, targeted HIV and chlamydia screening
initiatives, and increased sensitivity of diagnostic tests may all
have played a part in the rising number of HIV and STI diagnoses
reported in 2002. The well documented pressure mounting upon GUM
clinics3 through increased numbers of high risk patients attending has
undoubtedly contributed to the observed trends. Since KC60 returns
data are aggregate, it is not possible to determine what proportion of
attendees are re-attending for follow up and/or are becoming
re-infected. A disaggregate STI surveillance system is currently under
development and will help interpretation of future trends.

STI diagnoses are mainly reported through GUM clinics and voluntarily
from NHS laboratories. The former misses cases diagnosed in other
settings and the latter reports are incomplete. This combined with the
requirement for data accuracy over data quantity may have led to a
general underestimate of HIV and STI diagnoses in the United Kingdom.

Indications from Natsal 200025 of increasing high risk behaviour
(including concurrent partnerships and higher rates of partner
acquisition), the continuing immigration of heterosexuals from
countries of high HIV prevalence, and the suggested rising of HIV
incidence, undiagnosed HIV infection, and STI diagnoses in
homo/bisexual men all indicate that sexual health is deteriorating and
the documented increases are real.

Through national collaboration, high levels of data reporting,
analysis and feedback performed in conjunction within a complementary
set of UK surveillance systems, allow the data to be used as a
powerful tool in providing information for action. The role of
surveillance has been instrumental in the creation and monitoring of
successful initiatives such as the introduction of the universal offer
and recommendation of an HIV test in pregnant women.49,50

Our data confirm the need for national and local prioritisation of
sexual health and HIV prevention activities. Interventions such as
those outlined in the English Sexual Health and HIV Strategy4 need to
be implemented urgently. For homo/bisexual men this includes HIV/STI
education, promotion of safer sex and HIV testing, and increasing the
uptake of hepatitis B vaccination in GUM clinics. The strategy has
also specifically identified young people as a priority group for
action and the Department of Health is currently implementing a range
of interventions including the National Chlamydia Screening Programme.
The persistent ethnic disparities in sexual health outcomes deserve
even greater attention, particularly with emerging evidence of
increasing HIV transmission within the United Kingdom among black
communities. The disaggregate STI surveillance system currently under
development51 will allow ethnic disparities in sexual health to be
monitored in the future and will facilitate the determination of where
preventive efforts need to be targeted. In the meantime, key
interventions for prioritisation include improving access to treatment
and care services in hyperendemic areas; raising community HIV/STI
awareness; and enhancing secondary prevention actives including
partner notification.42

Key messages

   * Prevalence of HIV infection in the United Kingdom is increasing;
an estimated 49 500 adults aged over 15 were living with HIV in the
United Kingdom in 2002, of whom 31% were unaware of their infection
   * While many newly diagnosed heterosexual cases are thought to
have acquired their infection overseas, there is evidence of
continuing transmission of HIV in the United Kingdom, particularly
among homo/bisexual men
   * New diagnoses of major acute STIs have risen in the past 5
years, with rates highest in homo/bisexual men and young people
   * Effective surveillance is essential to provide timely
information on the changing epidemiology of HIV and other STIs in the
United Kingdom



Elsewhere in the United Kingdom, health promotion campaigns aimed at
high risk subgroups are being implemented and will undoubtedly require
scaling up in the near future. In Wales, for example, the "Come Clean"
multimedia campaign has been run by BBC Wales and the Welsh Assembly
and is targeted at young people.52 Effective secondary prevention
activities are also needed to tackle the growing problem of STI
re-infection and epidemiological synergy between STIs and HIV
infection. Such initiatives need to be fully supported and sustained
if further deterioration in the United Kingdom’s sexual health is to
be prevented. Finally, although the impact of these initiatives can
only be recognised over many years it is important that medium and
long term targets are set and progress monitored to ensure the most
appropriate, cost effective, and efficient use of scarce resources.

Further information on HIV/STI surveillance trends can be found in a
report published by the Health Protection Agency and others: Health
Protection Agency, SCIEH, ISD, National Public Health Service for
Wales, CDSC Northern Ireland and the UASSG. Renewing the focus. HIV
and other Sexually Transmitted Infections in the United Kingdom in
2002. London: Health Protection Agency November 200312
(www.hpa.org.uk/infections/topics_az/hiv_and_sti/publications/annual2003/annual20
03.pdf).

ACKNOWLEDGEMENTS
We extend our thanks to everybody who contributed to the writing of
the annual report: Renewing the Focus: Tim Chadborn, Glenn Codere,
Leah de Souza, Sarah Dougan, Gillian Elam, Josh Forde, John Harris,
Vivian Hope, Alisha Johnston, Louise Logan, Catherine Lowndes, Neil
MacDonald, Helen Munro, Bela Patel, Lara Payne, Brian Rice, Elizabeth
Rudd, Ian Simms, and Katy Sinka.

We gratefully acknowledge the continuing collaboration of the Sexually
Transmitted and Blood Borne Viruses Laboratory, Specialist and
Reference Microbiology Division, Health Protection Agency, and of
clinicians, microbiologists, immunologists, public health
practitioners, occupational health doctors and nurses, and other
colleagues who contribute to the surveillance of HIV and STIs in the
United Kingdom.

We would like to thank our collaborating centres for HIV and AIDS
surveillance in the UK: The Scottish Centre for Infection and
Environmental Health; The Institute of Child Health (London); The UK
Haemophilia Centres Doctors Organisation; members of the Scottish
ISD(D)5 Collaborative Group; Collaborators on the Unlinked Anonymous
Programme (a full list of collaborators available at
www.hpa.org.uk/infections/topics_az/hiv_and_sti/hiv/epidemiology/ua.htm).

Finally, we thank Philip Mortimer for commenting on this paper and we
are also grateful to colleagues at the UK Departments of Health both
for funding specific surveys and for helpful comments on this paper at
draft stage.

CONTRIBUTORS
AB, ST with KS, CM, SLM, and GM, analysed the data from the Unlinked
Anonymous Surveys, HIV/AIDS reports, prevalence estimates and
behavioural surveillance, STI surveillance, and STARHS respectively
with support from BG, NG, FN, and KF; DG, DT, and BS analysed and are
responsible for data from the Scottish Centre Infection and
Environmental Health, the National Public Health Service for Wales,
CDSC, and the Health Protection Agency, CDSC, Northern Ireland
respectively; PT coordinates the National Study of HIV in Pregnancy
and Childhood and collaborated with the analysis of the Unlinked
Anonymous Pregnant Women Surveys; NG is the programme manager and is
responsible for data from the Unlinked Anonymous Programme; BG is
responsible for data from HIV/AIDS reports; and FN is responsible for
data from the unlinked anonymous surveys of Pregnant Women. JP is
responsible for laboratory aspects for the Unlinked Anonymous Surveys
and assisted with the interpretation of data; all authors were
involved in interpretation of the results and drafting the paper; AB
undertook the main writing of the paper.

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