HIV in Europe and the UK:
A Different Kind of Progress

In 2024, England met the UNAIDS 95-95-95 targets for the sixth consecutive year. Ninety-five percent of people living with HIV in England are diagnosed. Ninety-nine percent of those diagnosed are on treatment. Ninety-eight percent of those on treatment are virally suppressed. These are not projections or aspirations. They are documented outcomes.

For context: the United States has not met those targets. Florida, dealing with ADAP cuts and coverage gaps, is further from them than England. What England has done — and how it did it — is worth understanding in detail.

The European epidemic: remarkable variation

Europe is not a single epidemic. It is dozens of distinct epidemics with different transmission patterns, different population burdens, and dramatically different trajectories.

The WHO European Region includes 53 countries1 — from Iceland to Kyrgyzstan. The epidemics in Western Europe and Eastern Europe look almost nothing alike. In Western Europe and the EU/EEA, the epidemic is concentrated primarily among gay and bisexual men and migrants, diagnoses have been declining, and treatment access is near-universal. In Eastern Europe and Central Asia, diagnoses are rising, the epidemic is driven by injection drug use and heterosexual transmission, and treatment coverage lags significantly behind.

The UK story: from crisis to model

The United Kingdom's HIV story is one of the most dramatic epidemiological turnarounds in the developed world. In the 1980s and 1990s, the UK was among the worst-affected wealthy countries in Europe2. London, in particular, had some of the highest HIV prevalence rates in Western Europe and was the epicenter of a devastating epidemic among gay men.

What changed was systematic. Not one intervention but a combination of policies, investments, and cultural shifts that compounded over time:

• Universal health coverage — the NHS provides HIV testing, treatment, and care free at the point of use. There is no ADAP equivalent in the UK because everyone is insured. Treatment adherence is not complicated by insurance gaps or formulary restrictions.
• Consistent political will — across Conservative and Labour governments, HIV funding and programming has remained relatively stable. The UK HIV Action Plan 2022-2025 set explicit targets and committed resources to meet them.
• Early and aggressive PrEP rollout — the NHS commissioned oral PrEP in autumn 2020. By 2024, 111,123 people in England were accessing it — a 7.7% increase from 2023.
• Opt-out HIV testing — emergency departments in England now routinely offer HIV tests to all attendees in high-prevalence areas. In 2024, opt-out testing accounted for 8% of all new HIV diagnoses — people who would not otherwise have been tested.
• Strong community organizations — organizations like the Terrence Higgins Trust, NAM aidsmap, and HIV i-Base have maintained sophisticated HIV literacy infrastructure for decades, providing the kind of community-facing information and advocacy that supports people in care.

NHS PrEP: what free access does

The difference between PrEP access in the United States and in England is not primarily scientific. The science is the same. The difference is structural: in England, PrEP is available free through the NHS sexual health clinic network. In the United States, it is available through a system of insurance, assistance programs, and navigating manufacturers' patient assistance programs — a system that leaves many people who need it without access.

The NHS commissioned PrEP in autumn 2020, after years of advocacy3. The impact has been measurable. New diagnoses among gay and bisexual men in England fell 6% from 2023 to 20244. In London, the decline was 8%. Among men who have sex with men, HIV test positivity in London was just 0.2% in 2024.

PrEP uptake in England is not equal, however. Among gay and bisexual men — white and ethnic minority — uptake is around 78-79%. Among Black African heterosexual women, uptake is 34.6%. Among Black African heterosexual men, 36.4%. The pattern is familiar: the populations with the highest clinical need have the lowest uptake of available prevention tools, driven by structural barriers, cultural factors, and healthcare distrust.

London: a specific story

London has a unique place in the global HIV story. It was, for decades, the city with the highest HIV burden in Western Europe5. It was also the city where the most intensive combination of interventions was applied: aggressive testing, early treatment, PrEP, community-led programs, and explicit political commitment from the Mayor's office and NHS England.

The results in London have been striking. New diagnoses among people living in London fell 5% between 2023 and 2024. Over the past decade, new diagnoses in London have consistently declined faster than in the rest of England. Undiagnosed HIV prevalence in London fell from 0.74 per 1,000 to 0.31 per 1,000 between 2014 and 2019 — a 58% reduction.

London is now the reference point for what urban HIV epidemic control looks like when it is actually resourced and prioritized. Cities like San Francisco and New York have achieved comparable outcomes through similar combinations of testing, treatment, and PrEP — but the US has not made those investments universally available.

The persistent problem of late diagnosis

Despite England's achievements on treatment and viral suppression, one number stands out as a stubborn failure: in 2024, 42% of new HIV diagnoses in England were at a late stage6 — meaning the person's CD4 count was already below 350 at the time of diagnosis, indicating significant immune damage had already occurred.

Late diagnosis is expensive in human terms: it means someone lived with HIV, unaware, for long enough for their immune system to be significantly compromised. It means they may have transmitted HIV to partners without knowing. It means their treatment path is harder and their long-term prognosis is worse than if they had been diagnosed earlier.

Late diagnosis rates are highest among heterosexual men (52%), heterosexual women (46%), and older people. They are lower among gay and bisexual men (around 30%) — largely because that community has high rates of regular HIV testing. Closing the late diagnosis gap requires reaching populations that don't self-identify as being at HIV risk, including people born abroad (who account for 60% of UK diagnoses) and heterosexuals in lower-prevalence areas.

Eastern Europe: a different epidemic

Eastern Europe and Central Asia represent the starkest failure in the global HIV response outside sub-Saharan Africa. New HIV infections in this region have increased over the past decade, not decreased7. Treatment coverage lags far behind Western Europe. And the epidemiological drivers are almost entirely policy-created.

The epidemic in Russia — which dominates the regional figures — is driven primarily by injection drug use and heterosexual transmission among partners of people who inject drugs8. Russia's response has been characterized by criminalization of drug use, rejection of harm reduction (including needle exchange programs and opioid substitution therapy), and restrictions on HIV civil society organizations. The predictable result is an epidemic that continues to grow despite the existence of effective tools to stop it.

Ukraine's epidemic has been additionally complicated by the ongoing conflict, which has disrupted HIV supply chains, displaced people who were in care, and overwhelmed the health system. UNAIDS and MSF have documented significant treatment interruptions among Ukrainians living with HIV since 2022.

What the United States can learn from Europe

The UK experience offers several direct lessons for the US HIV response — particularly relevant for states like Florida that are dealing with ADAP cuts and coverage gaps10:

• Universal coverage removes the biggest single barrier to consistent treatment. ADAP works but it is fragile. A system where HIV care is guaranteed regardless of insurance status would produce outcomes closer to England's.
• Opt-out testing works. England's emergency department opt-out testing program found HIV in people who would never have sought a test. In Florida — where late diagnosis rates are high — this approach could diagnose significant numbers of people currently living with undiagnosed HIV.
• Free PrEP access expands prevention beyond the people already engaged. The US has struggled with PrEP coverage, cost, and stigma. England's NHS model demonstrates that when cost is removed, uptake increases — though disparities persist and require targeted effort.
• Consistent political commitment compounds over time. England's results didn't happen in one year. They are the product of sustained investment and political will across multiple administrations. The US domestic HIV response needs the same.

Persistent disparities: the work that remains

England's headline numbers are impressive. But the UK Health Security Agency data for 2024 documents persistent and in some cases widening disparities that the headline numbers obscure.

Among Black African heterosexual men in England, new diagnoses increased 15% between 2023 and 20249. Among 15-24 year olds, HIV testing rates fell 7% — the only age group where testing has not recovered to pre-COVID levels. PrEP uptake among Black African heterosexuals remains around 35% — roughly half the rate among white gay and bisexual men.

The lesson from England — and from the US — is that population-level progress does not automatically reduce disparity. It can mask it. The communities carrying the heaviest burden are often those for whom universal programs work least well, and for whom targeted, culturally appropriate, community-led programs are essential. Meeting 95-95-95 at the national level while 42% of new diagnoses are late is not epidemic control. It is a beginning.