HIV and behaviour - research in the UK
An estimated 73,000 adults are living with HIV in the UK, according to 2006 figures, but around a third of those people haven’t been diagnosed and don’t know they’re infected. Black and ethnic minority populations accounted for just over half of all 7,000 new cases in 2006. Among many other aspects of HIV research, such as the molecular basis of the condition, treatments and diagnosis, MRC scientists are also researching social and behavioural factors.
A person infected with HIV (human immunodeficiency virus) is infected for life – there’s no cure. Over time, as the immune system weakens, a person with HIV may develop infections or cancers. HIV can be passed on only if infected blood, semen, vaginal fluids or breast milk enters another person’s body.
The UK House of Commons Select Committee on Health in 2003 said that sexual health in the UK is “in crisis”, and the UK Health Protection Agency (HPA) describes the most recent data on sexually-transmitted infections (STIs) as “worrying”. There are “undiminished and high levels of HIV” among gay men, according to the HPA.
Among all newly diagnosed persons in 2006, 59 per cent were heterosexuals. Most of these were almost certainly acquired in sub-Saharan Africa reflecting the impact of the African HIV epidemic and diaspora on the UK1. However, there is evidence of a steady rise in diagnosed HIV likely to have been acquired in the UK among black and minority ethnic groups. Late diagnosis of HIV remains a problem in these populations, not just for the individual, but also because of the increased risk that the person will pass the infection on.
HIV drugs – antiretrovirals – have been successful in prolonging the lives of people with HIV. However, as a result of this, the number of infected people rises every year. Also, resistance to these drugs is increasing.
Science into policy
From 1986, the UK Health Departments provided funding to the MRC for a programme to tackle the spread of, and social and behavioural factors associated with, the HIV/AIDS epidemic. This programme initiated a large number of studies which informed national policy-making and placed the UK at the forefront of HIV/AIDS research. It included the National Survey of Sexual Attitudes and Lifestyles (NATSAL) in 1990 (funded by the Wellcome Trust) and in 2000 (funded by the MRC).
The MRC also funded anonymous testing programmes. In the mid-1980s, scientists recognised the need to obtain accurate estimates of HIV prevalence and to monitor transmission. Tests for antibodies to HIV had been available since the mid-1980s, but there were concerns that voluntary testing for HIV would be unrepresentative of true figures.
Anonymous testing, which capitalised on blood specimens left over after diagnostic testing for other purposes, was proposed and, after extensive consultation, deemed to be both legal and ethical. By the end of 1998, survey teams at the HPA and Health Protection Scotland had tested over five million specimens2. Scientists soon found that the majority of HIV transmission took place through male homosexual intercourse3 and also that many HIV infections were undiagnosed, both in pregnant women and in those who attended clinics with a sexually-transmitted infection.
NATSAL results have been used in recent analyses, carried out by MRC scientists, of HIV prevalence. Dr Daniela de Angelis, who holds joint appointments with the HPA and the MRC Biostatistics Unit in Cambridge, publishes methods for estimating HIV prevalence, diagnoses, size of risk groups and undiagnosed infections, which the HPA uses for its reports1,4.
Professor Sheila Bird at the Biostatistics Unit, together with her late husband Dr. Graham Bird – then head of the HIV Immunology Unit in Edinburgh – led work to assess HIV prevalence and risk behaviours in prisoners5, which was subsequently rolled out across Europe. Prisoners do not routinely provide blood samples and the team required frank information about behaviours such as injecting drugs inside prison. The prisoners were invited to complete an anonymous questionnaire and to provide a saliva sample for HIV testing. Participation was high and results showed that prisoners were aware of their HIV status to the same extent as the general population. The major route of infection, however, was a history of injecting drug use.
High risk research
Individual studies funded by the MRC include research on monitoring the disease within the population, the spread of disease and clinical and health services research. Most deal with people at high risk for HIV and other STIs.
Dr Lucy Platt, of the London School of Hygiene and Tropical Medicine, has funding for a project on the risk of HIV among female sex workers from Eastern Europe. The majority of London’s sex workers are migrants and many of them enter the UK against their will or under false pretences. Women from Eastern Europe and the former Soviet Union make up a significant proportion of all female sex workers in London. This study will provide the first estimate of HIV and STI prevalence and risk among sex workers.
Out of Africa
The impact of HIV among black Caribbeans in South London is being studied by Dr Philippa Easterbrook at King’s College London. The team aims to assess the current status, future course and impact of HIV infection in this community, through a study of 600 known HIV-infected patients of black Caribbean origin enrolled from sexual health clinics. It is the first study of its kind and has achieved high rates of enrolment despite the stigma associated with HIV. The team has found a high proportion both of HIV infections acquired in the UK and of those with recent sexual contacts in the Caribbean.
Health practice models in sub-Saharan Africa, where almost two-thirds of all people with HIV live, can help the UK crisis. MRC researcher Dr Audrey Prost and colleagues at University College London have researched the feasibility of adopting in the UK a Kenyan model for voluntary counselling and testing for HIV6. Despite concerns about HIV-related stigma, confidentiality and the ability of community-based services to maintain professional standards of care, the team has concluded that the model would be acceptable in London. There is currently a pilot project in Brent, north-west London.
Undiagnosed
In 2005, the team distributed anonymous questionnaires to gay men and collected saliva samples, testing for HIV antibodies. They found that the HIV prevalence was 4.4 per cent and, of those who were HIV-positive, 40 per cent were undiagnosed7. Most of these men had tested negative in the previous year. Those who tested positive were much more likely to have many sexual partners.
The team concluded that there is an urgent need for HIV prevention efforts to address the high level of undiagnosed infection and incorrect assumptions of status. Now regular testing is being promoted in Glasgow and Edinburgh and the results have been incorporated into a review of the Scottish Executive’s HIV strategy.
There are also high levels of undiagnosed HIV infection in other UK cities8. The city with the highest HIV prevalence was Brighton, where one in seven of the 400 men who agreed to anonymous HIV antibody testing was found to be HIV-infected. In London, the figure was one in eight of a total of 1,500 men, and 44 per cent of these were unaware of their status.
References
MRC, November 2007