HIV – An update
Three years ago I undertook an internship with MPlus+, an NGO working on HIV prevention in Chiang Mai. The experience taught me a huge amount about the value of intercultural learning, particularly how an understanding of local culture is vital to successfully promoting good health. It also taught me much me much about the benefits of seeing first hand the different strategies countries and organizations take to prevent HIV. I have written about these experiences in previous blogs, and I’d like to now write about what has changed in the time since.
In the three years since, the landscape of HIV prevention and treatment has changed hugely, both at home and abroad. In Ireland, there has been a new wave of activism, and the impact of stigma and discrimination has been brought into open discussion through different platforms. At the same time, there has been a continued increase in the number of diagnoses, and a fall in funding for prevention and testing services. Internationally, the planned cuts to the major HIV/AIDS organizations cast a shadow over prevention and treatment efforts. Lastly PrEP, a relatively new HIV prevention tool, has made a huge impact on reducing new infections in countries where access to it is affordable and readily available.
In the last few years there has been a major worldwide campaign on HIV treatment as prevention known as Undetectable=Untransmittable. The premise of this campaign lies in some very important research which showed that when a person living with HIV is on effective treatment, viral levels drop quickly and dramatically until the person cannot transmit the virus, regardless of risk activity. This means that when someone’s viral load drops to an undetectable level, the virus cannot be transmitted to another person, even without condoms. To complement this, the PARTNER trial, published two years ago, found no linked HIV transmissions between over a thousand sero-discordant couples (where one partner is HIV positive and on treatment and the other HIV negative), after couples had sex (cumulatively) 58,000 times without condoms (http://i-base.info/htb/30108). As such, the Undetectable=Untransmittable campaign has been endorsed by many organizations across the globe including the CDC . This is all very good news.
So why then are we still seeing a rise in new infections? A look at the number of undiagnosed people living with HIV gives us a strong clue. It is estimated that about 30% of people who are HIV positive remain undiagnosed, and as such it is felt that most new infections by unprotected sex are from people who do not know their status. Stigma remains a major barrier HIV testing, and as such it is vital that we tackle this head on in order to ensure we increase testing rates, increase treatment rates and from that reduce the rate of new infections while also ensuring people living with HIV don’t have to put up with unfair, damaging stigma.
According to UNAIDS, stigma and discrimination are still among the foremost barriers to HIV prevention, treatment and care. Part of this stigma is undoubtedly due to a lack of understanding about the changes in HIV treatment and prevention in recent years. As mentioned earlier, a person on effective treatment who achieves an undetectable viral load has a zero percent chance of transmitting the virus, even without condoms. However, this knowledge is not universally known, and people living with HIV often have to put up with outdated and incorrect ideas from both within and outside of the LGBTQ+ community. Additionally, many people are unaware of the huge improvements in HIV treatment in recent years. In the early days of the epidemic, HIV was considered a death sentence, with only supportive care available and most progressing to AIDS with a shortened life expectancy. Nowadays, people living with HIV can expect to live as long as those without it. Similarly, early treatment involved many tablets at different times of the day with lots of side effects, while nowadays people often only need a single tablet daily, with an ever reducing side effect profile. While life long treatment is still required, research for a cure is ongoing with departments and centres around the world working on this challenge. Similarly, there is a constant strive to make current treatments as easy and as effective as possible. Unfortunately, lack of education means stigma still persists in our society to different extents. However, I have been impressed by different efforts from within the community to tackle this head on.
Rapids and POZ NEG
In October I was fortunate to attend Rapids, a piece of theatre at the Project Arts Centre in Dublin which looked at instances of disclosure and the presence of stigma in the lives of men and women who are HIV+ in Ireland today. The performance was powerful and demonstrated the continued need for education in our society, while also showing the increased dialogue that is happening around HIV. In that same month in Dublin, Intertech (A professional network that encourages LGBT+ diversity and inclusion in the Irish technology sector) hosted POZ NEG, an evening of discussion of HIV within the LGBTQ+ community, held in the Google offices in Dublin. The event was hugely popular and again showed an appetite for change in perceptions within the community.
Having experienced the popularity of ‘Miss Healthy Thailand’ and ‘No His-tory but Ours’ (discussed in other blogs) during my time in Chiang Mai, I feel like community led discussions and events are a fantastic way to open minds and reduce stigma in our communities.
Lessons from Abroad and KnowNow
Last year, London’s largest sexual health clinic (Dean’s Street Clinic) recorded a second annual drop of over 30% in new HIV diagnoses. This represents an overall drop of 80% in new diagnoses since 2015 . This is fantastic news and gives great hope towards ending the epidemic. The recipe for this success has been attributed to frequent testing of people had high risk, access to prevention methods, the availability of PrEP and rapid treatment.In Ireland, KnowNow is a fantastic initiative which has been set up in the past few years to increase access to testing in the community. Currently based in Dublin, Limerick and Cork, KnowNow offers confidential and rapid testing across the community from Pantibar and the George to the OutHouse.
This kind of initiative is a great way to reduce the stigma associated with testing and increase the number of people who know their status. The test takes less than a minute to work and as such reduces the anxiety associated with waiting for a result. Unfortunately, overall funding in Ireland for testing has dropped substantially over the last few years, while at the same time rates of new infections have increased.
PrEP - The Gamechanger
Another factor in the success of reduced infections abroad has been the adoption of PrEP. PrEP stands for Pre-exposure prophylaxis and is a tablet taken by someone who is known to be HIV negative to drastically reduce their chance of becoming infected during condomless sex. It can be taken once a day or on an event driven basis (two up to two hours before sex, one each day for two days after). Two recently published studies in this area include the IPERGAYs study in the Francophonie (event-driven PrEP) and the PROUD study in the UK (daily PrEP). The IPERGAYs study, published in the NEJM involved participants taking two doses of PrEP 24 to 2 hours before sex followed by two single doses one and two days after the first dose. The study showed over 90% reduction in new infections compared to the placebo arm. By contrast, the PROUD study, published in the Lancet involved participants taking a single tablet every day and also showed over 90% reduction in new infections compared to the placebo group. Both studies followed on with huge open label studies which confirmed these drastic reductions in new infections when a person was compliant with the medication.
The policy implications of these studies have been huge, but also varied depending on geography. In some countries such as in Scotland, PrEP is available freely to people at high risk of contracting HIV to stop this happening. In many other countries, PrEP is available at a very low cost and thanks to its availability, we have started to see a decrease in new infections across big cities. In Ireland, recent action by the group Act Up saw the price of PrEP drop, although at approximately €100 a month, it remains too expensive for most to justify. More details on PrEP in Ireland can be found on this website.
In summary, the landscape of HIV has continued to change over the last few years. In Ireland, we now have rapid testing available in the community through Knownow, and PrEP available in pharmacies, although at a somewhat prohibitive cost. When we look abroad, we see that access to rapid testing, treatment and prevention tools can be very effective. We saw this beautifully with the dramatic reductions in new infections at London’s Dean Street Clinic. However, Ireland continues to see an increase in new infections, and as such more action is needed to curb the epidemic at home. Despite the improvements in treatment, prevention and testing availability, stigma remains a burden in our society. We must continue to talk about HIV, to educate and be educated in order stamp out this damaging and unhelpful aspect of our culture.
Name: Cormac Everard
Award: Gold Award