HIV and AIDS in the North West of England 1999
Jim McVeigh, Penny A. Cook, Pauline Rimmer, Qutub Syed, Mark A. Bellis

EXECUTIVE SUMMARY

This report, the fourth annual report of the North West HIV/AIDS Monitoring Unit, presents data on HIV positive individuals accessing treatment and care in the North West Region. This year the quality and completeness of much of the data from the statutory sector has been improved enabling a more in-depth analysis and a greater range of tabulated information. In addition, we are now able to provide maps and data illustrating not just the Health Authority but also the Local Authority of residence of HIV positive individuals accessing statutory treatment centres in the North West of England.

During 1999, a total of 1,410 individuals living with HIV or AIDS presented to statutory treatment centres in the North West Region.This figure represents a 16% increase in the numbers reported in 1998 (1,218), a significantly higher increase than in previous years and much higher than national predictions. Data for 1999 now indicate an increase of 50% in the number of HIV positive individuals accessing treatment services in the North West of England over the last five years (fig. 1.12).

A total of 40 statutory treatment centres within the North West provided treatment and care for HIV positive individuals resident in every district within the Region. The predominant method of exposure to HIV in the North West continues to be homosexual sex, accounting for two thirds of all cases presenting to North West treatment centres in 1999 (fig. 3.2). There are however, considerable variations within the Region, with over three-quarters of HIV and AIDS cases resident in Salford & Trafford being attributed to homo/bisexual exposure, compared to fewer than half the cases resident in Sefton (fig. 3.4). The relatively high levels of exposure via homosexual and bisexual sex amongst men is reflected in the gender distribution of HIV and AIDS cases, with males representing 88% of those accessing statutory services in the North West (fig. 3.5). Heterosexual sex continues to be the second largest exposure group, accounting for 18% of all cases in 1999 (fig. 3.4). This represents a slight proportional increase when compared to data from previous years, following trends for the United Kingdom as a whole. Manchester Health Authority continues to report the highest numbers of HIV positive individuals and AIDS cases in the North West, accounting for over a quarter of all cases (fig. 3.3) and new cases of HIV and AIDS presenting to statutory treatment centres (fig. 2.2).

A total of 277 new HIV and AIDS cases were reported during the year (HIV positive individuals presenting to statutory treatment centres in the North West Region for the first time in 1999), representing 20% of all cases, a similar proportion to previous years. The majority of these cases were infected via homo/bisexual sex (62%), with 23% attributed to heterosexual exposure (fig. 2.3). The level of heterosexual exposure continues to rise, as reflected in national data, where heterosexual exposure has now become the largest category for those newly diagnosed as HIV positive (fig. 1.6). The number of new cases exposed via other infection routes (injecting drug use, blood/tissue and mother to child) remain relatively low. While the largest proportion of new cases presenting for treatment and care during 1999 were categorised as asymptomatic (46%), the small number of deaths amongst new cases (seven), were individuals who presented at later stages of HIV disease (six of the seven first presented as AIDS cases). This illustrates the continuing need to attract HIV positive individuals into service at an early stage of disease progression to maximise the efficacy of treatment and improve prognosis.

The significance of the worldwide HIV pandemic has been illustrated by the United Nations acknowledgement of its potential impact on world peace and global stability (section 1). This global pandemic has a specific impact on HIV and AIDS in the North West of England, as reflected in the number and pattern of HIV infections reported as having been acquired abroad. Over a fifth (21%) of all HIV positive individuals accessing treatment and care in the North West were reported to have been exposed to HIV outside the United Kingdom (fig. 3.12). Heterosexual sex continues to be the major method of exposure to HIV in those infected abroad (54%), a significantly higher proportion than those exposed to HIV via heterosexual sex within the UK (10%). Over 40% of North West infections abroad were acquired in Africa, predominantly in sub-Saharan Africa (fig. 3.13a). A quarter of infections acquired abroad were attributed to Europe, with Spain accounting for the highest number of these cases (fig. 3.13b). The level of exposure abroad within new cases is even higher, accounting for 27% of HIV positive individuals accessing treatment and care for the first time in 1999 (fig. 2.11).

This year, ethnicity of individuals was provided for 98% of cases, with the vast majority being self-classified as white (88%). However, 10% of all HIV positive individuals accessing treatment and care services were self-defined as belonging to Black and ethnic minority communities, a substantial over representation when compared to the 3.8% of the North West population who are self-defined as being from Black or ethnic minority communities (fig. 3.8). Within new cases of HIV and AIDS, the proportion of individuals from Black and ethnic minority communities is even higher (15%). This illustrates a continuing change in the ethnic distribution of HIV and AIDS in the North West of England (fig. 2.7) and is an area where prevention activities need to be maintained and further strengthened (fig. 2.10). The characteristics of HIV positive individuals from ethnic minority communities, in particular those from Black African communities, are significantly different to their White counterparts. While homo/bisexual sex represents the largest category of exposure to HIV amongst those self-defined as White, heterosexual exposure is the predominant infection route amongst Black Africans (figs. 2.8 and 3.10), resulting in higher numbers of females infected (figs. 2.9 and 3.9) and the consequent higher levels of mother to child transmission (fig. 3.10). There are also considerable differences in the stage of HIV disease at which Black Africans first access HIV services, with a substantially higher proportion of individuals from this community first presenting with AIDS. This later presentation is a particular cause for concern as it may have a significant detrimental impact on their prognosis.

During 1999, the majority of individuals (65%) were receiving triple or more combination therapy, including 12% who were receiving quadruple therapy or more when they last attended for treatment and care in 1999 (fig. 3.16). This level of treatment rose as high as 88% in those living with AIDS, with only a third of asymptomatic cases receiving triple or more combination therapy (fig. 3.17). The number of HIV positive individuals receiving triple or more antiretroviral therapy during 1999 increased by 22% when compared to data from 1998, a greater increase than the (16%) rise in the number of individuals accessing treatment and care in the North West. Thus levels of combination therapy prescribing are increasing faster than the rate at which new HIV cases are being reported. The improved prognosis of HIV positive individuals across all clinical categories of HIV disease, together with relatively low numbers of individuals at early stages of HIV disease receiving combination therapy, has implications for a potential increase in demand and supply of combination therapies. This has both planning and funding implications for the care of HIV positive individuals across the Region.

Manchester Health Authority provided treatment and care for the highest number of HIV and AIDS cases in the North West. However, not all individuals resident in a particular district receive their treatment from within that Health Authority. Fewer than half (40%) of the individuals presenting for treatment and care in Manchester were residents of that district, with a similar situation being apparent in Stockport (49%), Liverpool (46%) and Sefton (20%) Health Authorities (fig. 3.21 and fig. 3.22). The majority of individuals attended only one treatment centre in the North West during 1999 (83%). However there are considerable variations between districts, with residents of Manchester having a proportionately higher number of individuals attending more than one treatment centre (28%).

This year, we are able to provide information relating to the level of inpatient and outpatient care provided by statutory treatment centres across the whole of the Region (previously only available for treatment centres based in Merseyside and Cheshire). During 1999, North Manchester General Infectious Disease Unit (NMG), the treatment centre with the highest number HIV positive attendees (fig. 3.23), provided the highest number of outpatient visits, day cases, inpatient episodes and inpatient days (fig. 3.29). In addition to providing an overview of HIV care provided at specific centres and by the Region as a whole, these data illustrate the changing levels of care required by HIV positive individuals as their disease progresses. Analyses of these data indicate demands on outpatient care peak for individuals categorised as AIDS and demands for day cases and inpatient care peak in HIV positive individuals who died during the year (fig. 3.30). Ongoing monitoring of HIV treatment and care requirements will also assist in the detection of any alterations in the level of demand for services, for example due to further developments in therapies.

This year the level of voluntary sector monitoring has been expanded to include seven voluntary agencies based in the North West of England (section 4). The data illustrate the important contribution to the care of HIV positive individuals made by the voluntary sector, with 26% of North West voluntary sector clients not presenting to statutory treatment centres within the North West during 1999 (fig. 4.7). This has particular significance for regional funding, as individuals accessing voluntary agencies but not the statutory sector are not included in the regional statistics provided to the Department of Health, the basis of the new National HIV funding formula.

The monitoring of HIV/AIDS care has been expanded to cover hospices across the Region (previously only available for hospices based in Merseyside and Cheshire) in 1999. The four contributing hospices provided inpatient care for seven HIV positive individuals residing in four Health Authorities across the Region, accounting for a total of 118 inpatient days (fig. 5.1). All of these HIV positive individuals also attended statutory treatment centres in the North West during 1999. In addition, for the first time this year, specialist drug services contributed data on clients whom they knew to be HIV positive (fig. 5.2). Only seven agencies, based in six Health Authorities reported HIV positive clients and provided attributable data on 32 individuals. Over half of these individuals were residents of Manchester, reflecting the distribution of HIV positive injecting drug users accessing the statutory sector (fig. 3.4). The vast majority of HIV positive drug service clients (94%) were also seen in the statutory sector.

We hope that the tables and figures provided within the report answer most of your HIV related information requirements. However, additional analyses and a further breakdown of the data can be provided on request. As ever, we value your suggestions as to any developments that would improve the usefulness of the report in future years.