HIV in London: Progress, Gaps, and What Comes Next

It’s the time of year for pumpkin spice lattes and the release of new HIV data, providing us with an opportunity to reflect on our progress, to celebrate what’s worked and to acknowledge the areas in which we need to do better. This year’s figures for London are striking we have cause for optimism but as the nature of the challenge evolves so must our approach.

WHAT’S WORTH CELEBRATING?

Testing is rebounding, including among heterosexual men.

In 2023, HIV testing in London rose by about 8 %, taking us past the levels we saw in 2019. A marker of resilience after the disruptions London’s sexual and reproductive health system endured during COVID. It is particularly heartening seeing more heterosexual men come forward for testing.

HIV testing also increased for Gay, Bisexual and other Men who have sex with Men (GBMSM), from 89,719 tests in 2022 to 96,929 in 2023, and test positivity continued to fall. That signals that London’s HIV prevention strategy is working thanks to the promotion of regular testing and PrEP.

Strong PrEP uptake among GBMSM

In London, around 75% of GBMSM who have been identified as needing PrEP, are using it. PrEP remains one of our most potent tools to prevent HIV transmission so this achievement is something that NHS providers in the capital can be proud of.

Improvements in late diagnosis, but still room to go.

Late diagnosis means individuals have missed years of potential treatment, people diagnosed late are ten times more likely to die within a year than those diagnosed early. Strides in earlier detection of HIV in London are being made through opt-out testing in A&Es and greater community reach are helping. More people are being diagnosed before it’s too late.

DIFFICULT TRUTHS WE CAN’T IGNORE

Late diagnoses among heterosexuals from ethnic minorities is increasing

Across England, the number of Black African Men diagnosed late in 2023 rose by 20% and by 11% among “Other ethnic minority” heterosexual adults. Numbers of heterosexual women and GBMSM diagnosed late have continued to fall across England. The data is undoubtedly impacted by opt out testing being deployed across A&E departments across England but this disparity hits hard, tells us that for some groups, testing is still done too late, is too hard to access, and is too fraught with stigma.

PrEP uptake by heterosexuals is not equitable

Yes, many GBMSM have good access to PrEP, but for heterosexual men and women, especially in Black African communities, uptake remains only around 40% of those with identified need. That’s a significant gap. It confirms that our messaging, our pathways, our access points- are not inclusive enough yet.

GBMSM being diagnosed with HIV in London are increasingly likely to be Black

Progress in the prevention of HIV isn’t uniform, the proportion of London’s GBMSM receiving new HIV diagnoses and identify as Black, continues to increase. In 2023, 40% of new diagnoses among GBMSM were among men from ethnic minority backgrounds. Prevention strategies and providers of PrEP must focus on overcoming the barriers to PrEP and testing for this increasingly important group.

PRIORITIES FOR LONDON

Here’s what we need to sharpen, intensify, and scale if we are to reduce the pervasive inequalities that are a feature of HIV for Londoners:

Deepen cultural competence in clinical and outreach services

We must get better at co-producing services with affected communities, using inclusive language and materials, training staff in unconscious bias and hiring diverse staff who reflect the populations served. Solutions built from the ground up will stand a better chance of being trusted and taken up.

Close the PrEP equity gaps for ethnicities

Make PrEP more visible and easier to access beyond our traditional clinics by embedding new pathways to PrEP across primary care, maternity services, and outreach providers. PrEP is already available online to residents of 9 authorities in the capital and this will expand far more widely next summer.  We will need to tailor the messaging, so it is relevant and trustworthy to underserved groups.

Continue to normalise HIV testing in other settings

High uptake of routine HIV testing and primary/urgent/emergency care centres, particularly in boroughs where late diagnoses are common, is essential to reducing inequalities in late diagnosis. Specialist sexual health services cannot do this on their own, we need the support of the NHS in London to succeed.

Together Toward an HIV-Free London

Ending HIV transmission in London won’t come from doing more of the same - it will come from listening harder, reaching further, and building services that reflect the strength and diversity of the communities we serve. By embedding equity into our strategies and amplifying community voices we can ensure no one is left behind.

Adrian Kelly

Lead Commissioner, SHL.UK