In a sense, the National Sexual Health and HIV Strategy was out of date before it was even issued. It was certainly overtaken by events. Its appearance took place during the most rapid period of transformation the UK HIV epidemic has ever been through.

HIV prevalence in the UK doubled in the five years between 1999 and 2004. From infecting one in 1,000 people living in the UK, it now infects one in 500. In 1999, 3,000 people were diagnosed with HIV; in 2004, 7,500 were diagnosed.

In 1999 diagnoses of HIV among heterosexuals overtook those among gay men; in 2001 diagnoses among heterosexual women overtook those among gay men; and in 2004, for the first time, more heterosexuals than gay men were being seen for HIV treatment and care in the UK.

This increase is largely accounted for by heterosexual Africans who caught HIV in high-prevalence countries and have come to the UK as asylum seekers, workers or students. Other European countries have seen a similar transformation in the makeup of their HIV positive population, but none as dramatic a change as the UK. The Eurosurveillance website comments that, of the European countries that have comprehensive HIV reporting: “Trends…are largely driven by the United Kingdom, which accounts for 28% of the population but for 53% of all reported HIV infections in recent countries.”

This is not because diagnoses among gay men have gone down. In fact the yearly total of diagnoses among gay men has increased by 60%, from 1400 to 2200, during that time. Most of this is accounted for by more gay men coming forward for testing and there being fewer undiagnosed; about 25% of UK gay men who have HIV were undiagnosed in 2004 as opposed to 33% in 1999. However this also adds to the strain on services. There is certainly no evidence that the infection rate among UK gay men is slowing down, and tentative evidence of the opposite (see epidemiology).

In addition to HIV, the last 10 years have seen big increases in sexually transmitted diseases. Between 1996 and 2004, gonorrhoea diagnoses doubled, chlamydia diagnoses more than tripled, and syphilis diagnoses went up 17-fold in men, 8-fold in women, and 29-fold in gay men. Taking the long view, these are increases from a historically low point in the early 1990s, and no not come near the STI rates of the 1970s, but the Government appears to have failed to anticipate any increases at all.

The author of the Sexual Health and HIV Strategy himself, Professor Michael Adler, told the BBC in 2003 that the $47.5 million allocated for the entire Strategy in 2000 would not even pay for one part of it, the chlamydia screening programme. And in 2004 he told the British HIV Association Conference in Cardiff that part of an extra £15 million allocated on top of the Strategy money to modernise GUM services had not got to the clinics but had been diverted to finance other areas by PCTs.

There has been almost no progress towards achieving the target of getting everyone seen within 48 hours at STI clinics. Figures released in June 2005 showed that only 38% of GUM clinic patients in England were seen within 48 hours, and that another 29% were not seen within two weeks. Even eight per cent of cases classed as ‘emergencies’ had to wait more than two weeks.

The chlamydia testing programme has gone ahead, as has the ‘Sex Lottery’ campaign – only to receive criticism from activists, including NAM, that it gave the impression that white teenagers were a risk group for HIV and that it was not targeting prevention campaigns at those who needed them most (see “Where it’s Really Hurting”, The Guardian, 10 September 2005). And the first national sexual health campaign since the ‘Iceberg and Tombstone’ ads of March 1987 has, at the time of writing, been postponed from November 2005 to spring 2006 amid worries that GUM clinics could not cope with the expected influx of new patients.

The upsurge in cases among Africans led to stories in the media in 2004 that “health tourists” posed both a public health and an economic problem to the UK. The government responded by:

• imposing visa restrictions on Zimbabweans, who had been the largest single group of immigrants from a high-prevalence country.
• increasing deportations and turning down asylum appeals on the basis that HIV treatment was now available in countries of origin .
• in April 2004, rescinding a concession that allowed visitors to the UK without residency status to receive HIV treatment if they had managed to stay in the UK for more than a year.

This resulted in an HIV ‘underclass’ of anything from 1,000 to 4,000 people with HIV who are able to receive emergency treatment for TB and other AIDS-related conditions, but who cannot access antiretrovirals on the NHS. In addition a large proportion of people with HIV in the UK are now unemployed, not because they are too ill to work, but because they are not allowed to.

The geographical spread of people with HIV in the UK has also changed, partly owing to the dispersal of HIV positive immigrants away from London. Sixty per cent of new HIV diagnoses were made within London in 2000; in 2004 the proportion was 41%.

HIV organisations in the UK have had to respond fast to a quickly-changing client group. The Terrence Higgins Trust has established itself as the main HIV service provider in parts of the UK such as the West Midlands, Yorkshire and the west of England, but elsewhere and in Scotland independent organisations such as George House Trust and Waverley Care have had to change the services they provide very quickly.

In London mergers between local organisations continue to occur, with the latest being the 2005 merger between the London East AIDS Network and the Globe Centre to form Positive East. The THT continues to be the biggest service provider in London, but the UKC (UK Coalition of People Living with HIV and AIDS) has expanded from its original remit as an advocacy and information organisation to provide a range of training and re-employment services as the lead organisation for Ensuring Positive Futures, a partnership of six HIV organisations.

The closure of Blackliners in March 2003 left a gap in HIV service provision for Africans and Caribbeans, and small African organisations originally only serving people from certain parts of the continent, or certain parts of London, such as HAAZ (the HIV/AIDS Association of Zambia) UAAF (the Ugandan AIDS Action Fund) and IVO (the Innovative Vision Organisation) have had to scale up rapidly to provide services to a standard funders expect. In the regions, there has not been the same growth in African-specific organisations apart from the consolidation of the already-existing Black Health Agency and its associated AIDS Helpline in Manchester. Rather, already-existing organisations face having to cater for two widely-different groups of people with HIV within their existing structures.

With more NHS restructuring on the horizon (there are plans to take back commissioning of services to the 28 Strategic Health Authorities that have previously only had a monitoring and guidance function), voluntary organisations continue to face an uncertain financial and organisational future in a country with an increasingly large, diverse and marginalised population with HIV.

Will the UK continue to reach out to marginalised groups and protect them from HIV as it dared to do for Edinburgh heroin users in 1985? Will it continue to provide universal free treatment? Or will it become an increasingly American-style society where the groups most likely to get HIV are the very ones who are left untargeted by prevention messages and who cannot get NHS treatment?