The latest figures for HIV show a drop in new diagnoses among gay and bisexual men. Public Health England has described this as ‘the most exciting development in the UK HIV epidemic in 20 years’. It is a tribute to the combined achievements of many clinicians, public health and prevention specialists, community organisations and activists, as well as these men who have kept themselves negative. Key factors in this include regular testing and using that contact to plan how to stay negative, and the availability of pre-exposure prophylaxis (PrEP) medicines is also an important help.
However, this data must be seen as an indicator of the reductions that are possible, rather than meaning that the job is done or that a downwards trajectory in new diagnoses will continue in the future. Importantly, so far these reductions have only been seen in one population group (Figure 1)1. The dramatic reductions are also only in London (Figure 2)2 – in fact only in figures reported by 5 of the 30 clinics in London – with other regions seeing much less dramatic falls in new diagnoses or even slight rises. The crucial question is, how can the progress achieved by this small cohort of clinics be extended to all areas and all population groups?
The first thing that needs to be in place, as we recommended in our report, is effective local leadership for HIV services with a clear vision and the authority to draw all the interested services and organisations together as one system, with shared goals and flexible working across them. This is crucial because the challenges of a fragmented system identified in our report remain unchanged. The London figures are skewed by one clinic – Dean St Express – which diagnoses around half the new cases of HIV in England each year and has been recognised by CQC for outstanding leadership. Because of its scale, changes in diagnosis rates in this clinic can be immediately visible in the national statistics, giving an early signal to others of what effective strategy and leadership can achieve.
Recent experience in London illustrates why leadership that co-ordinates efforts across fragmented HIV services is so important. For example, in some parts of the capital it has not been possible to co-ordinate closing sexual health clinics, with simultaneously increasing the provision of online testing to cover lost capacity. This has led to a reduction in access to regular HIV testing – the opposite of what commissioners had planned. London has yet to sign up to the international fast-track cities programme, which supports cities to accelerate the spread of good practice in HIV prevention, treatment and care.
The latest figures underline our findings that progress on HIV needs a strategic perspective, to identify medium- and long-term goals (at a national as well as local level) and maintain focused effort towards them. The reduction in number of people newly diagnosed with HIV is the result of sustained effort and achievements, especially in increasing HIV testing, which was maintained even when services faced operational and financial pressures on both NHS and public health budgets, and needed to go through competitive tendering to retain their contracts.
The sort of national leadership that is now needed is to guide the strategic direction of travel, ensuring context and support for those making local decisions, rather than directing from the centre. For example, when local areas’ strategies to release savings result in sexual health and HIV services being fragmented, national leaders need to look at the whole picture and make sure that, in the long term, this will fit with national objectives of ensuring best outcomes for people and communities while also providing the right training opportunities for a specialist workforce.
Let’s recognise and celebrate the achievements behind these HIV figures, and the hope they raise for further reductions in the future – but also ensure that there is no reduction in effort. This fall in new diagnoses of HIV – because it is so localised, and the underlying challenges still exist – actually increases rather than reduces the need to make progress on our recommendations for the future of HIV services. Now is the time to accelerate, not diminish, the response.