HPS Weekly Report
27 Nov 2018
Volume 52 No. 47
World AIDS Day - HIV in Scotland (2018)
World AIDS Day, held annually on 1 December, serves as a yearly reminder of the global HIV and AIDS epidemic. In June 1981, the first reports of Acquired Immune Deficiency Syndrome (or AIDS) were published. The case definition for AIDS (established by CDC in 1982), and the subsequent surveillance of the condition, led to the discovery and characterisation of the infectious agent, HIV, in 1983.
According to the latest worldwide report of the United Nations Joint Programme on HIV/AIDS (UNAIDS), almost 37 million people were thought to be living with HIV in 2017. The upward trajectory of the global HIV/AIDS epidemic has been halted and reversed in recent years. This is evident in a reduction in both new infections and AIDS-related deaths as a consequence of advances in HIV treatment and the huge scale-up in treatment access. In 2017, an estimated 1.8 million people were newly infected with HIV (approximately 180,000 of whom were children); this represents decreases of 16% and 35% in diagnoses among adults and children, respectively, since 2010. Worldwide, young women are disproportionately affected by HIV with around 7,000 women aged 15-24 years becoming infected with HIV every week.
In 2014, UNAIDS launched the ‘Fast-Track’ strategy which aims to end the world AIDS epidemic by 2030. As part of the strategy, 90-90-90 targets have been set which require that, by 2020, 90% of people living with HIV know their HIV status, 90% of people who know their HIV-positive status are on treatment, and 90% of people on treatment have a suppressed viral load. In 2017, globally, 75% of those individuals infected knew their HIV status, of whom 79% were accessing treatment. Of those receiving treatment, 81% had achieved viral suppression. While considerable progress has been made, UNAIDS has warned that the current rate of decline in the number of new infections, for example, will be too slow to reach the Fast-Track Target of 500,000 new infections per year by 2020. Therefore, further efforts are required to diagnose and treat those who are infected if these targets are to be met.
Advances in HIV treatment, and the scale-up of access to treatment in recent years, continue to save lives. In 2017, the number of AIDS-related deaths halved from the peak of 1.9 million in 2004 to 940,000. According to UNAIDS, 2.3 million more people had access to life-saving antiretroviral drugs in 2017 compared to 2016, resulting in a total of 21.7 million individuals on treatment worldwide. This is a remarkable expansion in access to HIV treatment, more than doubling from 8.0 million in 2010. If the increasing rate of access to treatment is sustained, then there is the potential to achieve the UNAIDS target of 30 million on treatment by 2020.
A ‘treat all’ strategy is now recommended by both UNAIDS and the World Health Organisation (WHO) (related guidelines available from WHO) which calls for treatment initiation at the time of diagnosis for all HIV infected individuals. While such a strategy undoubtedly saves more lives, it also presents strategic, logistical and financial challenges in many countries. Yet it is expected that this approach will be cost-effective in the long-term as new infections will be averted and infected individuals will be retained in care, enabling them to stay healthier for longer with fewer morbidities and deaths. The 2015 British HIV Association (BHIVA) guidelines for the treatment of HIV-1 positive adults with antiretroviral therapy similarly recommend starting treatment soon after diagnosis, where possible, regardless of CD4 count.
The latest quarterly data on confirmed HIV-positive diagnoses and an overall update on HIV infection in Scotland are published this week on our website.
From January to September 2018, there were 213 reports of HIV infection, which include 141 (66%) individuals newly diagnosed and 72 (34%) reports for individuals who had been previously diagnosed before moving to Scotland. In 2017, 361 HIV-positive reports were recorded by HPS; this represents an increase compared to 2016 (321) and a return to the annual average of 360 observed in the preceding five year period. It should be noted that, over the last ten years, the number of new diagnoses has been slowly decreasing, notably among men who have sex with men (MSM) and those who acquire the infection through heterosexual intercourse, with a total of 228 in 2017 compared to 291 in 2009.
Unprotected sexual intercourse among MSM remains the main route through which new HIV infections are acquired in Scotland, however, it should be noted that, since 2015, an outbreak of HIV among people who inject drugs (PWID) in NHS Greater Glasgow & Clyde has resulted in an increase in the number of new HIV diagnoses in this group although transmissions are still occurring. Public health interventions to limit further transmission include: i) a sustained focus on testing those at risk, ii) the provision of outreach treatment services, and iii) community prescribing of HIV medication. Notably, the innovative model of care implemented has been highly successful with very high levels of PWID currently engaged in HIV treatment and care.
To the end of September 2018, an estimated 5,265 individuals have been diagnosed and are living with HIV in Scotland; however, there are also individuals who have the virus but who are unaware of their infection. Using newly published UK data on undiagnosed HIV infection, an estimated 91% of the estimated population living with HIV have been diagnosed; this suggests that one in eleven (9%) of those infected (around 500 people in Scotland) remain undiagnosed. The good news is that this indicates that we have now reached the first of the UNAIDS 90-90-90 targets, that is 90% of those living with HIV being aware of their status. While we should celebrate the prevention effort, we must continue to encourage and promote testing opportunities particularly as the evidence suggests that most new infections are a result of transmission from individuals who are unaware of their status. Opportunities for testing are available at specialist services (including sexual and reproductive health clinics), in the primary care setting, in community venues, via home sampling kits and also by purchasing self-testing kits which are available on-line. At a European level, health care practitioners are encouraged to unite their efforts to offer HIV and hepatitis testing to at-risk individuals during European HIV-Hepatitis Testing Week which runs this week (from 23-30 November 2018). Initiated in 2013, this annual event aims to consolidate efforts to promote testing and to raise awareness of the benefits of early diagnosis. More information is available on the European Testing Week website
Twenty-two years on from the introduction of freely available, highly effective, life-saving, antiretroviral treatment in the UK, access to treatment and care in Scotland is good: in the past year (from 1 July 2017 to 30 June 2018), 4,734 individuals attended specialist services for HIV treatment and care; of those attending, 98% received antiretroviral drugs. Therapy continues to be successful: 97% of patients undergoing treatment had evidence of viral suppression at their last attendance. Thus, continuing high levels of care and treatment are being provided for the increasing number of people diagnosed and living with HIV in Scotland and, in so doing, the UNAIDS targets of 90% of those diagnosed receiving antiretroviral therapy (ART), and 90% of all those receiving ART gaining viral suppression, have been achieved. Yet, public health action is still needed to widen further the access to, and increase opportunities for, HIV testing. In 2017, 43% of those newly diagnosed were at a late stage of infection at which point treatment may be less effective on a weakened immune system.
Prevention of HIV transmission remains a public health challenge both worldwide and here in Scotland. Since July 2017, HIV pre-exposure prophylaxis (PrEP) has been available through the NHS in Scotland for individuals attending sexual health clinics who are at high risk of acquiring HIV through sexual transmission as assessed using eligibility criteria. Almost two thousand individuals were prescribed PrEP in the first year of the programme, the majority of whom were MSM. The year one report on the implementation and evaluation of PrEP in Scotland will be published in early 2019.
The Scottish Government’s Sexual Health and Bloodborne Virus Framework (REF) aims to reduce the number of HIV transmissions and the number of infected individuals who remain undiagnosed, while maintaining the high-quality services which provide treatment and care for those living with the virus.
Through multi-agency partnership and the monitoring of high level outcomes, the framework supports improvements in sexual health and wellbeing and addresses the impact of blood borne virus infections in Scotland. The news that Scotland has achieved the UNAIDS 90-90-90 targets is very welcome with the data indicating 91% know their diagnosis, 98% are on sustained antiviral therapy and 97% have evidence of viral suppression.
Progress of EU transport sector towards environment and climate objectives
A new report published by the European Environment Agency (EEA) shows that emissions from the EU transport sector are not reducing enough to limit its environmental and climate impacts in Europe.
The report also shows that greenhouse gas (GHG) emissions from transport have increased over the last three years, whilst average CO2 emissions of new passenger cars increased for the first time in 2017.
The sector remains a significant source of air pollution, especially of particulate matter (PM) and nitrogen dioxide, although these emissions have been reduced in the last decade. It also is the main source of environmental noise in Europe.
Source: EEA, 22 November 2018
Food Standards Scotland and the Food Standards Agency report: new evidence on E. coli O157 in cattle
On Monday 26 November 2018, Food Standards Scotland (FSS) and the Food Standards Agency (FSA) published a report which provides important new evidence on E. coli O157 - a bacterium carried by cattle which can cause serious illness when it enters the food chain.
The research, which was undertaken over a four-year period by a consortium of scientists led by the Roslin Institute, the Moredun Research Institute and Scotland’s Rural College, shows that the overall prevalence of E. coli O157 in cattle is similar across Great Britain, and has remained relatively consistent in Scotland over the last decade. However, cattle in Scotland has been found to have a higher level of a certain subtype of E. coli O157 - PT21/28 - which is associated with super-shedding in cattle (the passing of large volumes of the bacteria in faeces). As this subtype is also known to cause more severe human infection, it may be that local exposure to this particular subtype is a potential factor for the rates of human E. coli O157 infection in Scotland being around three times higher than in England and Wales.
The research also trialled a vaccine, developed to limit E. coli O157 excretion from and transmission between cattle. Results indicated that the vaccine may be effective in reducing human exposure and infection from E. coli O157. However, before a vaccine can be marketed, further work is needed to assess if it is practical to be used on-farm and if it is an effective public health intervention.
The report can be accessed on the Food Standards Scotland website
Source: FSS, 26 November 2018
ECDC publishes two guidance documents for HIV and hepatitis
The European Centre for Disease Prevention and Control (ECDC) has launched two separate pieces of guidance aimed at European countries to help tackle hepatitis and HIV.
This first piece of guidance covers integrated viral hepatitis and HIV testing which provides options and ideas based on the latest scientific evidence for national or local hepatitis B (HBV), hepatitis C (HCV) and HIV testing guidelines and programmes. The guidance outlines whom, where, how and when to test for viral hepatitis and HIV and offers options for testing strategies that are applicable to all healthcare settings and beyond (e.g. self-sampling and self-testing).
Due to higher risk of infection, population groups suitable for targeted HBV, HCV and/or HIV testing include, amongst others, men who have sex with men, homeless people, sex workers, people who inject drugs, pregnant women or haemodialysis patients.
Best practice examples in the guidance provide approaches for primary healthcare settings, hospitals, STI clinics, pharmacies, prisons as well as for community settings, including drug and harm reduction services.
The ECDC Guidance advocates for a concerted effort to scale up integrated testing strategies or programmes for hepatitis B, hepatitis C and HIV to try to reduce the large number of those that are currently infected but undiagnosed. Such integrated testing strategies or programmes should apply the six core testing principles and respect the individual needs of those tested:
- testing should be accessible, voluntary, confidential and contingent on informed consent;
- appropriate information should be available before and after testing;
- linkage to care is a critical part of an effective testing programme;
- normalising HBV, HCV and HIV testing in all healthcare settings;
- those carrying out HIV, HBV and/or HCV testing should receive appropriate training and education; and
- an effective national testing strategy, including a monitoring and evaluation framework, is critical in responding to HBV, HCV and HIV infection.
Success in increasing the testing uptake should contribute considerably to the elimination of HIV and to combat viral hepatitis as a public health threat by 2030 as outlined in the Sustainable Development Goals.
This guidance can be accessed on the ECDC website at: ECDC website
Secondly, guidance has been published which aims to provide EU/EEA countries with an evidence-based framework to help develop, implement, monitor and evaluate their own national HBV, HCV and HIV testing guidelines and programmes.
This guidance can also be accessed on the ECDC website
Source: ECDC, 23 November 2018
World Malaria Report 2018
The World Malaria Report 2018 shows that after an unprecedented period of success in global malaria control, progress has stalled.
Data from 2015–2017 has highlighted that no significant progress in reducing global malaria cases was made in this period. There were an estimated 219 million cases and 435,000 related deaths in 2017.
The World Malaria Report 2018 draws on data from 91 countries and areas with ongoing malaria transmission. The information is supplemented by data from national household surveys and databases held by other organizations.
As a result of the stalling of progress, WHO and its partners are joining a new country-led response (launched 19 November 2018) in order to scale up prevention and treatment. More information can be accessed on the World Health Organization (WHO) website
Source: WHO, 19 November 2018
Publication of HIV infection in Scotland: quarterly report to 30 September 2018
The latest HIV surveillance report, published today, provides a summary of HIV diagnoses data in Scotland to the end of September 2018. By this date, HIV-antibody positive test results for 213 individuals not previously recorded as HIV-positive were received from NHS Scotland laboratories. It is estimated that there are 5,265 individuals living in Scotland who have been diagnosed HIV-positive. Attendance is high with 4,734 HIV-infected individuals currently attending specialist services for monitoring and treatment. Across Scotland, 98% of individuals attending for monitoring are receiving anti-retroviral therapy.
A more detailed examination of the surveillance report is provided in the final current note of this weekly report