The tide turns on HIV
The goal to virtually eliminate HIV transmission in New Zealand by 2025 suddenly looks attainable. Dr Peter Saxton explains why.
Last year Aotearoa New Zealand became one of the first countries in the world to publicly fund the HIV prevention drug called pre-exposure prophylaxis or “PrEP”. We desperately needed that decision - it followed our worst ever year of the HIV epidemic, with 244 new diagnoses.
PrEP virtually eliminates the risk of contracting HIV sexually when taken consistently and correctly. It’s most effective when taken every day.
It might just have worked: on top of new campaigns that urge condom use, more frequent HIV testing and early treatment for those living with HIV, access to PrEP looks like it has tilted us over the epidemic tipping point back towards decline.
Figures released today show that new HIV diagnoses have dropped by a quarter overall since 2016 (from 244 to 178) and by almost 40 percent among gay and bisexual men infected in New Zealand (from 98 to 60). The goal to virtually eliminate HIV transmission by 2025 suddenly looks attainable – but relatively slow uptake of PrEP points to roadblocks ahead.
Re-energised 'Ending HIV' prevention campaigns have been ubiquitous in epicentres like central Auckland: on billboards, buses, social media and at community events; cheeky and risqué but relevant and evidence-based. Safe sex messages can test the boundaries of public morality but for HIV they have profound social and economic pay-offs: challenging irrational HIV stigma and avoiding $800,000 in lifetime treatment costs by Pharmac for every infection averted in someone young and sexually active.
How can New Zealand deliver appropriate healthcare when the target population is invisible?
The PrEP-condom-HIV treatment combo is a model public health approach. PrEP is targeted to the small number of people most at risk: by protecting the most vulnerable early, you protect the rest of society. Condoms on the other hand are practical, verifiable, universal precautions: anyone can use them; you can see them; and you avoid awkward conversations about who’s been doing what with whom– information that’s increasingly hidden in a post-internet dating world. Meanwhile, treatments for HIV keep people well and can also make people non-infectious to their sexual partners.
This pragmatic ‘combination prevention’ approach shuts down opportunities for HIV to spread through communities, leaving the virus with nowhere to go.
And yet, if we’re to fully realise its HIV-busting potential, we need to make sure everyone who is eligible for PrEP is getting it. That will take a small revolution in sexual healthcare.
In a study published this year we estimated that around 5800 individuals are eligible, but Pharmac data suggest uptake is a third of this figure. Why?
More people at risk need to know about PrEP, and the stigma attached to using it has to be confronted. But dismantling barriers to PrEP access is also critical: we need sexual health services to be properly resourced, we need innovation, and we need GPs to learn about and offer PrEP to their patients.
That in turn raises a fundamental question plaguing healthcare for sexual orientation minorities: how many GPs know who their gay patients are? Research by our group in 2015 suggests that only half do. How can New Zealand deliver appropriate healthcare when the target population is invisible?
For that matter, if a vaccine against HIV (or gonorrhoea) was available tomorrow, how long would it take to get coverage?
One possible answer is that PrEP uptake has been excellent and swift among early adopters already hooked into community and health systems, but now the hard work begins. Equity is important here: have the benefits of PrEP been experienced evenly by all ages and ethnic groups? Does getting PrEP to prevent HIV require people to engage with health systems that can be racist, homophobic and inaccessible to those who need it?
We’re following a group of 150 early adopters taking PrEP, half of whom were non-European. That study already tells us that the individuals taking PrEP are highly motivated to avoid HIV. They want to keep themselves and their partners safe. They often spoke altruistically about playing their part in a broader HIV prevention movement. Some also spoke about how PrEP profoundly reduces the anxiety surrounding intimacy that is faced by communities like gay and bisexual men where HIV is more common.
As we have argued, introducing PrEP quickly to saturate those most at risk will help interrupt HIV transmission in New Zealand sooner. We also need high quality intelligence to guide decision-making as each incremental reduction in HIV transmission will become more difficult. Importantly, government funding for safe sex surveys that was stopped in 2014 urgently needs to be reinstated so we can confidently advise prevention agencies about whether practices are changing. Every dollar invested to support HIV prevention pays big dividends as Pharmac spent $35.6 million on treating HIV in 2017.
New Zealand was a world leader in HIV prevention in the 1980s and this generation can get us there again. This will require the same spirit of collective action that is now focused on the bold but realistic goal of virtually eliminating HIV.
Dr Saxton’s HIV prevention research has been funded by the Ministry of Health, Health Research Council, New Zealand AIDS Foundation and PHARMAC.