Matthew Hodson, Executive Director of NAM/aidsmap, explains the many advances in HIV prevention and asks whether the end of HIV is in sight?
World AIDS Day is upon us again. Like many, I use this time to remember the friends and colleagues I lost to AIDS and HIV-related illness. I can’t recall that loss now though without also celebrating the astonishing progress we have made in treating and preventing HIV. I remember all too well the years of funerals and grief. It is wonderful that now there is talk that we could finally end HIV, but how close are we to that goal?
Undetectable = uninfectious
For decades the number of new HIV diagnoses went up each year, particularly for gay and bisexual men. This prompted howls of dismay. But hidden behind those numbers something rather wonderful was happening. The gap between a receiving a positive diagnosis and beginning HIV treatment got smaller, as our understanding of the benefits of early intervention increased. This meant that the proportion of people who were living with untreated HIV also became smaller.
When HIV treatment is effective it suppresses the virus to a level so low that we can’t pass it on to our sexual partners. More than 93% of people who are living with diagnosed HIV in the UK now have viral levels below the point where transmission is even possible. Effective HIV treatment means that condoms aren’t necessary to prevent HIV transmission. The goal of treatment is to keep people with HIV healthy. The side effect of HIV treatment is that we become uninfectious. How great is that?
According to back calculations the number of new HIV infections actually started falling in 2013. This was the impact of treatment as prevention. We achieved this reduction before we even had PrEP.
PrEP = protection
The idea of a pill that stops almost all risk of HIV would have been greeted with street parties in the 1980s and early 1990s. Now we have that pill – but stigma and commissioning hurdles mean that not enough people are benefiting. The UK’s PROUD study reported 86% PrEP efficacy and no infections at all in the men who took PrEP as directed. A cash-strapped NHS prevaricated, stalled and denied, until it was taken to court and forced to, at the least, consider providing PrEP.
Fed up of waiting for the NHS to supply PrEP, Greg Owen and his activist chums at iwantprepnow.co.uk helped gay men to source their own supply. The pincer movement of people with HIV becoming increasingly unlikely to pass the virus on during sex, allied with a highly effective way for HIV negative men to ensure that they can’t acquire HIV, has led to the dramatic drops in HIV diagnoses that we have celebrated over the last couple of years.
We could be doing even better. With the limited number of places on the trial, and some clinics already full, I know of men who have acquired HIV after being turned away. England is lagging behind our neighbours in Scotland and Wales, and way, way behind our Australian cousins. If we are serious about ending HIV, full free PrEP rollout for all who would benefit is urgently needed.
Condoms still count
Away from the spotlight in recent years, and without the glamour of novelty, condoms still play a significant role in preventing HIV. For years they were pretty much the only prevention method that sexually active men could rely on. They stopped people getting HIV and stopped those people passing on HIV. Without them the horrific losses of the early days of the epidemic would have been more extreme. We might have become a far smaller, even more frightened community. More people use condoms than use PrEP – and they have the great advantage of being the only HIV prevention method that also stops other STIs.
It’s not over yet
We’ve seen HIV rates plummet in cities around the world and now we’ve seen it happen in England too. Combination HIV prevention works. So, is the end of HIV in sight? With the right levels of commitment, backed up by investment in prevention and treatment, we should be able to come close to hitting that target. We are making progress but there is much more to be done. We owe it to those that we have lost, as well as to the generations yet to come, not to falter now.
The fear, ignorance and prejudice that people with HIV face need to be tackled as effectively as the virus has been. Our goals for the next decade should be: no new HIV infections, no AIDS-related deaths and no HIV stigma – not just for gay and bisexual men in the UK but for all people, everywhere in the world. Only when we have achieved that will we truly be able to say that we have defeated HIV.