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Monitoring the progress of HIV programmes is vital, as services are scaled up to include increasing numbers in need of care. Globally, the presence of multiple donors at all levels of HIV care has produced vast monitoring systems. Within HIV-treatment programmes in low and middle-income countries, directly assessing long-term outcomes such as survival is problematic, so indicators are used to monitor the progress of the treated population. However, the internal, external, construct validity and predictive value of current indicators have never been evaluated. Although the burden on facility staff compiling routine monitoring reports is vast, there is uncertainty as to which indicators best monitor patient progress. This burden will grow as increasing numbers of life-cohorts are created for monitoring purposes leading to data inaccuracies and compromising the internal validity of reported indicators. Furthermore, a number of fundamental indicators, including survival and retention, may not capture the construct they intend to measure, compromising the ability of programme managers to obtain reliable estimates regarding the welfare of their population in care. It is not known which indicators can predict the longer-term outcome of the patient population, and as such, can enable managers to respond to predictors of failure early. An evaluation of current indicators is urgently needed to ensure that reported facility-level data accurately reflect the welfare of the treated population and comparisons of programme performance are meaningful.

Between a quarter to a third of HIV-positive African residents in the UK, and nearly half of HIV-positive African men who have sex with men, may have acquired their HIV infection in the U-K, which is substantially higher than previously estimated. These estimates are likely to worsen given the increasing HIV prevalence and assortative sexual mixing in this community, especially among heterosexuals. HIV prevention interventions for Africans must focus on reducing transmission within the UK as well as addressing infections acquired abroad.

Our findings show that despite the numerous advances in the management of HIV disease, this has not resulted in earlier presentation in Africans or non-Africans. African patients are still presenting with significantly more advanced disease than non-Africans, and are more likely to have AIDS at presentation in 1998-1999 than in 1982-1995. An urgent need exists to identify the factors associated with delayed presentation, both to optimize clinical outcomes and reduce the possibility of onward transmission.