Are we on track to end new infections of HIV?
On today’s programme, we are going to examine attempts to end HIV/AIDS as a public health threat by the end of the decade.
The AIDS pandemic is unarguably the worst health threat to confront the population in the modern era. We believe close to 100 million people have died of the disease so far since it first emerged in the early 1900s.
It’s proved a very tough nut to crack; when I first went to medical school in 1993, a patient with advanced AIDS and just weeks away from dying came to speak to us.
That rarely happens in first world countries these days thanks to breakthrough scientific discoveries that have created a host of drugs that, when used in combination, can convert the disease into a chronic condition that one lives with.
Regrettably, many countries don’t have access to these treatments and can’t afford them. So the emphasis is very much on preventing infection rather than trying to cure it.
But, so far, efforts to develop effective vaccines have failed. This year another two vaccine candidates did not make it through clinical trials.
Thankfully, the availability of newer drug regimens, including PrEP - pre exposure prophylaxis are helping us to turn the corner. This involves using anti-HIV drugs to protect vulnerable people from picking up the infection in the first place. New, long-acting forms are becoming available and they’re forming the backbone of an international strategy that aims to bring to an end to new cases of HIV by as soon as 2030.
In this episode
00:48 - What is it like to live with HIV?
What is it like to live with HIV?
Haywood Dikibo
One of the major frustrations holding back progress on reducing the spread of HIV, though, is stigma, which is deterring people from getting tested and contributing to the persistence of the pandemic. I’ve been speaking with Haywood Dikibo who caught HIV in Nigeria...
Haywood - It's very scary back in Africa to be diagnosed with HIV, most times are scared to tell anybody. You are scared of dying, you're scared of everything.
Chris - How did you know you had it?
Haywood - There was a bit of sensitisation as to HIV, and I had just left high school and you know, I just took myself out of fear to the hospital to run a test and was asked to come back the next day. I initially was given a result that said I was positive and only to find out I wasn't. I felt a kind of relief, till I saw my result and it came out positive as well. So that was how I found out.
Chris - How old would you have been at the time that that diagnosis was made?
Haywood - It would have been just before my 17th birthday.
Chris - Was there anyone you could confide in? Friends, other people of sort of similar age, similar situation?
Haywood - Because of the peculiarity of Nigeria at that time where the culture of shame and discrimination was really high. Still is, there was no one I could talk to. I couldn't even get an accountability partner. I had to phone an activist that was in the United Kingdom and to present his number for an accountability partner.
Chris - So you couldn't even tell your family, for example?
Haywood - Oh my, that would've meant me going through another level of trauma.
Chris - So do you think then that this is seriously hampering people seeking testing? Because you were obviously quite forward thinking and thought I want to know, but there must be people who would think confronted by those sorts of barriers and risks, they'd rather not know?
Haywood - Oh yes, this is actually, it actually poses a limitation because you even find situations where the healthcare providers that are supposed to protect and respect confidentiality, also play into stereotyping, discriminating and shaming people living with HIV.
Chris - Have you confided in your family since?
Haywood - So many years ago I did try to make it open to them and they made a joke out of it, not believing, but yes, since I moved to the UK I did. I have communicated because I happen to not, have been the only person. Also counselling, a couple of family members that found out that they were positive.
Chris - I was going to say, did anyone else in your family then come back to you and say, well actually I think I might be in the same boat?
Haywood - Oh yes, some people got back to me. They found out and you know, their stories came out, and I had to encourage them and walk them through the work.
05:49 - Can the UK stop HIV transmission by 2030?
Can the UK stop HIV transmission by 2030?
Richard Angell, Terrence Higgins Trust
In the UK, the Terrence Higgins Trust - which supports people living with HIV - has also embraced the target of aiming to end new cases of HIV in England by 2030. So, how are they are planning on doing it? Here’s Richard Angell, the chief executive of the Terrence Higgins Trust…
Richard - The UK government agreed to make the UNAIDS goal of ending new cases of HIV by 2030 a government goal. We as the charity sector ourselves at Terrence Higgins Trust, our friends at National AIDS Trust and the Elton John AIDS Foundation, came together to create a HIV commission, to really give them a blueprint on how they turn that aspiration into reality. The government's response to that was to draft a HIV action plan that took us from 2021 to where we are today. The newly elected governments here in the UK has committed to renewing that action plan, to learn the lessons of what's been successful on the reduction of transmissions that's taken place to date and really re-focus on the goal of getting to zero, and the kind of strategies it will involve to achieve that.
Chris - What does the HIV landscape in a country like the UK look like at the moment, in terms of numbers and also rates of new cases?
Richard - In the UK there's about 106,000 people who are living with HIV. All but 5,000 know about it. So, the key task in ending the onward transmission of HIV is to find the 5,150 people across the UK that are living with HIV but don't know about it yet. The trick is to make sure they're testing for HIV. Now obviously to test those 5,000 people, it's tested a much bigger cohort and pool of people to do that. Most of that work is done in sexual health services. We've had some great innovations in recent years that have interrupted people's care pathway and where they're using our health service and inserted a HIV test there, and we found some people who had no idea they might be living with HIV and made sure they are diagnosed and linked to treatment.
Chris - What proportion are homegrown and what proportion are coming in?
Richard - We've had an anomaly in the most recent years, because as the government has changed the visa rules post Brexit, they have been seeking to attract workers from countries that have a high prevalence of HIV. So if you are bringing people in from a high prevalence country it is not surprising if a significant number of them are living with HIV. The experience overwhelmingly is that those people coming to the UK are already on medication and have controlled HIV. So those who are coming into the UK appear in the statistics, as people who are kind of new in the UK with HIV, but they're not bringing in their HIV per se. Then crucially, they're not bringing in transmissible HIV to the UK, but we've got about two and half thousand essentially newly diagnosed people that had a transmission of HIV here in the UK. That number is broadly down on where we've been in previous years, but starting plateau, as we get nearer to zero. The challenge is you need to do more and more tests to find fewer and fewer people.
Chris - How are those transmissions that we are home growing, we can't account for on the basis of people who are coming to the UK with a known diagnosis as you just outlined, how do those transmissions occur, and among which groups?
Richard - Essentially now as likely to be from people who are men who have sex with men, or people who are having sex between men and women, the transmissions amongst introduced drug users is incredibly low. The UK has eliminated vertical transmission, which is what we call mother to child transmission by doing a form of testing that everybody gets in antenatal services when they're pregnant.
Chris - Given that you can define and qualify who the risk groups are so well, you must therefore have some pretty clear ideas as to the best strategy to stop this. What is that strategy?
Richard - The strategies that work are programs that de-stigmatise testing for people and encourage people to take up innovative and online confidential, and free forms of testing. So we run a very successful HIV testing week every year that gets 2500, 1st time testers, and diagnoses a significant number of people with HIV each year. The things that are starting to work as we are looking for cohorts in smaller and smaller proportions, in bigger and bigger population groups, are where we're interrupting people's care pathway. So in 81 A&Es across the country, there is a form of opt-out testing for everyone who goes to an accident and emergency department. That means that if you are turning up in an NHS setting and you're having bloods taken, you'll automatically test it for HIV, Hep C and often Hep B. That is found about 1200 people who have been living with HIV but didn't know about it. We're looking to expand that to multi-year programs, but also to other settings and would like to see anybody who's engaging in a termination of pregnancy or having an abortion automatically be offered a HIV and STI screening test, those who are using dermatology services to make sure they're regularly tested for HIV. Everyone who goes to a sexual health clinic makes sure they leave without or don't leave without getting a HIV test.
Chris - Those are excellent, but also very much reactive to what's gone on. What about the flip side, the proactivity, doing things to stop people catching it in the first place. What sort of strategies have you got there, because you've got to do that as well as just pick people up and put them on treatment?
Richard - Absolutely, so there's key tools to preventing HIV transmission. Firstly, the person living with HIV knows that they're living with HIV, so they can get medication only for their healthcare, but so they can reduce their viral load and make sure they can't pass on HIV to other people. The second is that those who test negative, they can use condoms to stop HIV transmission if they're having sex. If they are having sex without a condom, there is a drug called PrEP. PrEP is a drug you might take daily or around a sex-based event that you might be having in your life. If you take it correctly, it will stop the onward transmission of HIV and if it were to enter your system, it wouldn't be able to take hold in your cells in the way it would with somebody who doesn't take that drug. So it's a really important tool for people and we're doing lots of work to promote that going forward. We're working with the UK Health Security Agency to make sure that those who particularly in the system might identify as having a PrEP need and need to use a HIV prevention tool, that more of those are getting that need.
Chris - How optimistic are you of hitting that 2030 aspiration of eliminating the transmission of HIV? Because as we all know, as you get closer to a target, and we've seen this with things like the eradication of Polio, you get to a handful of cases and then it escapes again, or it gets harder and harder to get those last few. Do you think we're going to make it?
Richard - I remain optimistic about ending new cases by 2030 here in the UK and I believe we have the partners in place that share the vision for making it happen. It's our job to convince them to kind of will the means to get that over the line, but let's be honest, it's possible, but not yet probable. We aren't doing enough as a country to get there, but I think we are in pole position to being the first country in the world to make it happen.
13:43 - How did Sydney curb the spread of HIV?
How did Sydney curb the spread of HIV?
Andrew Grulich, University of New South Wales
Can Australia offer some insights for the UK as to how to stop the spread of HIV infection? Healthcare services in New South Wales have managed to successfully reduce new HIV cases in Sydney - where HIV was particularly prevalent - by 88%, describing transmission as “virtually eliminated” from Inner-city Sydney. Will Tingle has been speaking with Andrew Grulich who is an epidemiologist at the Kirby Institute at UNSW - the University of New South Wales…
Andrew - The unique thing about Sydney and Australia of course, is that it has been the epicentre of the epidemic. So it has had quite a few resources focused on it. So if you look around Australia, it probably is the place where there's more funding for community-based organisations responding to HIV. There's more education. The state of New South Wales has a highly organised health system in response to HIV and there's a great partnership between researchers, community organisations, governments and clinicians, which all have their roles to play in achieving this goal.
Will - Did you find that preventative measures or treatment had a greater impact on the reduction of spread of HIV instances?
Andrew - I really don't think you can single out one or the other. There are two sides of the same equation, particularly when we have come to realise that treatment in itself is prevention. That's because once a person with HIV is treated and they're undetectable, and their viral load becomes undetectable, they cannot transmit. So that's a big part of the success. The other major part, the other major biomedical intervention we've had in the last decade was the rollout of pre-exposure prophylaxis to actually negative men. We did that in Australia in a somewhat unique way, in that when we saw its promise in that it's at the individual level, it's close to a hundred percent effective if people take it. The modelling told us that we should introduce it quickly and we should introduce it at scale to try to get everybody at risk of treatment. So we did it in a big bang between 2016 and 2019. Even in those three years, we saw about a 40% decline in HIV transmission.
Will - The advantage of it being a scheme in inner Sydney though, is presumably that the population density is rather high, and so you can keep better tabs on things and keep track of things, and there's better availability of healthcare. Do you think the scheme could have the same amount of success if it was rolled out to less densely populated areas?
Andrew - It's not only rural, it's even in the outer suburbs. We now have a situation since treatment as prevention as PrEP, where prevention is largely biomedical and requires access to medical care, which I mean, we have pretty good access in Australia with universal healthcare, but we're finding that fewer doctors outside of the inner city want to prescribe PrEP, and they're not as well informed about PrEP. So, the challenge is to train healthcare providers, doctors, nurses, pharmacists, so that they know about PrEP and they will be advocates for prep. Because at the moment we're finding it's too hard for gay men in those outer suburbs and in the country, to get themselves and keep themselves on PrEP. I think we've got to also address the stigma that people hold towards people with HIV and even self-stigma. If we could address the stigma and if we could provide better health services, then I think we would be a very long way towards elimination.
Will - So big picture, do you think that elimination of HIV is possible by 2030?
Andrew - So it’s really important that we understand that when we talk elimination, we're not talking about no virus being left in the world because HIV is a condition which, can exist in an asymptomatic state for a decade or more formal elimination as in normal virus as we, as we've got for smallpox is not possible. In fact, the United Nation AIDS Agency definition is a 90% reduction in new infections. We are virtually there in Sydney, and yeah, I do believe we can reach that by 2030 in Australia.
Why is southern Africa's HIV rate so high?
Salim Abdool Karim, University of Kwa-Zulu Natal
One continent stands out as bearing the brunt of HIV disease, and that’s Africa. It accounts for two thirds of the world’s AIDS burden, with 27 million people living with the virus. Most of them live in the south, with disease prevalence being particularly high in Lesotho, Botswana, Zimbabwe, Eswatini and South Africa. In the latter case, in some locales, as many as one in every two young black women attending antenatal clinics are testing positive. So why is this so high, and what measures can be brought to bear to stop the spread. Salim Abdool Karim is a world-leading epidemiologist and virologist at the University of Kwa-Zulu Natal in South Africa; he also chairs the UNAIDS Scientific Expert Panel…
Salim - Globally, we are seeing a steady trend in HIV, of declining incidence rates and prevalence. That's true as much in Africa as it is in most other parts of the world. However, at a global level, there are three groups where incidents has been somewhat more recalcitrant. One of those is in Southern Africa. Now, Southern Africa comprises about half of the global epidemic. And within southern Africa, South Africa accounts for about one fifth of the global burden of HIV. And within South Africa, the group that's at the highest risk of HIV are young women.
Chris - Is the reason that South Africa has such high prevalence, because it's also slightly unusual amongst African nations in being quite moneyed and therefore one of the few countries that could afford quite aggressive treatment for HIV earlier on in the pandemic? So you've kept people alive and well who otherwise might not have been in a less well developed setting.
Salim - In most of Southern Africa, the higher rates of HIV in young women are being driven by what is referred to as age disparate sex. Put another way, this is about teenage girls who are having sex with men who are about 10 years or so older than they are. But another way, we have what you call the cycle of HIV transmission. Men in their late twenties, early thirties are having sex with these teenage girls. So these young girls below the age of 25, these young girls then grow up and when they reach their late twenties and thirties, they have a very high prevalence of HIV. In some communities in Kwa-Zulu Natal, over half of the women in their thirties have HIV. These women are now having sex with men that they are going to marry as their husbands or their long-term partners. And so these women then infect men in their thirties.
Salim - These men in their thirties have sex with teenage girls. They infect the teenage girls. Those girls grow up when they reach 30, they infect the next group of 30-year-old men who infect the next. So this cycle continues. The problem you have is that when you look at the technologies to prevent HIV, what you used to euphemistically call the ABCs, Abstinence, Be faithful, Condoms and circumcised, those technologies essentially are under the control of men. So we didn't really have technologies that women could use to control their risk until a long comes PrEP. Pre-exposure prophylaxis is used in over a hundred countries throughout the world and it now gives women the power and the ability to control their risk of HIV. A challenge though is that it's very hard for somebody, especially a young teenage girl, to contemplate that she's going to get HIV and so she better go and take the time to stand in the queue. You know, take the bus, go to the clinic, get the tablets that she's got to take every day. Now that could possibly change, because we have newer technologies, in particular an injection that you can take once every six months. This particular injection, if taken once every six months, was shown to be a hundred percent effective in young women. That's a very powerful tool.
Chris - Is there a risk though, that if people use things like these pre-exposure prophylaxis approaches, that they are then less careful and you prevent one disease and HIV is very important, yes. But are people then placing themselves at risk of others because they're not using condoms or other barrier methods for example?
Salim - In most of the places where we do reproductive health promotion, it does not lead to, you know, everybody just having sex. But what does happen is that when these educated individuals do have sex, they understand the importance of protection. Now we have seen with pre-exposure prophylaxis that there are in certain instances, a situation where we see an increase in the prevalence of gonorrhoea. In other words, we are seeing sexual activity and we are seeing a risk of other sexually transmitted infections. Overall, the key goal, which is to reduce the prevalence of HIV, which is the disease that can't be cured, the focus is on trying to bring down the number of new infections with HIV.
Chris - You mentioned earlier the role that circumcision can play. It's going to be quiet on that front because a lot was said about that, about 10-15 years ago when these various manoeuvres were put in place to try to do this. How's that working out, has that made a difference?
Salim - So three clinical trials undertaken in the early two thousands all showed quite consistently that circumcision is effective in preventing HIV in men, protection is around 60% or so. So on that basis, huge programs were put in place to roll out circumcision. And when we rolled out circumcision, we rolled it out to those men we thought were at highest risk. The uptake is a challenge, and what we found was the ability to roll it out at scale was a challenge, you know, as to start doing hundreds of thousands of circumcision, not easy to do. So circumcision has had a role to play in particular communities where a circumcision can make a difference. As an overall population strategy, it has not been as effective as we would like it to be. So that's why newer technologies like pre-exposure prophylaxis become more important when we are now aiming towards the 2030 goal of ending AIDS as a public health threat.
26:16 - Southern Africa's solutions to the HIV epidemic
Southern Africa's solutions to the HIV epidemic
Boghuma Titanji, Emory University
The southern region of Africa, the epicentre of the epidemic, faces unique problems - including a very high caseload amongst adolescents and young women. So, what are the solutions? We put in a call to Boghuma Titanji - a Cameroonian-born doctor and infectious disease specialist at Emory University - to tell us what we do and don’t have in our arsenal when it comes to fighting the spread of HIV…
Boghuma - One of the biggest barriers remains the fact that we don't actually have a vaccine that effectively prevents HIV acquisition. So what we really have at our disposal remains, getting as many people who are living with HIV on antiretroviral therapy, but also being able to provide Pre-Exposure Prophylaxis modalities to individuals who are at higher risk for acquiring HIV, and we are not hitting the targets where these are concerned.
Chris - What sort of levels are we getting to?
Boghuma - Most countries in Africa are approaching the 80% treatment coverage targets for adults, but it's important to note that when it comes to paediatric HIV, that number and those targets are unfortunately not being met with only about 50% of children living with HIV in Africa currently being on antiretroviral therapy. Where pre-exposure prophylaxis is concerned, the numbers there are a little bit more dire in terms of the regions hitting their targets and actually getting pre-exposure prophylaxis readily available to populations that are most likely to benefit. In Eastern and Southern Africa, these targets are on track to meet the goals that were set to be achieved by 2025, but in Western and Central Africa we still have significantly low levels of PrEP coverage. The target for PrEP coverage set for 2025 was the hope to get 21.5 million people on PrEP, but currently there are only about 3.5 million people who are receiving pre-exposure prophylaxis for HIV.
Chris - What's the barrier to getting to the number we want, why are we at the number we currently are?
Boghuma - I would think that one of the biggest barriers is really there's still a lot of stigma and discrimination that is associated with having HIV or being, someone who is in a group that may be at higher risk for acquiring HIV. Additionally, there have been issues around funding for pre-exposure prophylaxis with some countries not necessarily having the requisite resources to actually make these prophylactic treatments available on a broad scale. In terms of meeting the targets for treatment, the biggest barriers remain testing people and actually having people know their HIV status.
Chris - What do you think we can do about this? Where do you think the solution lies? Because you've outlined what the frustrations are but it's not obvious what we do then to solve that.
Boghuma - One of the key developments that gives me a lot of hope is the advent of long-acting PrEP modalities, which bring with them a layer of flexibility in terms of options and choice for people who are likely to benefit from pre-exposure prophylaxis. Now having this degree of flexibility and choice means that you are removing barriers, either people having to go to a healthcare facility to be able to pick up medication or just being able to use pre-exposure prophylaxis in a manner that is more discreet than having to take a pill a day.
Chris - Is this a short-term sticking plaster or is this part of a longer term strategy to try to bear down on transmission and ultimately stop it or is it both? Because one could see that if we could drive the number of people who are actively acutely infected right down, we actually really do slow down the transmission of the disease because people are most infectious with HIV when they're first infected.
Boghuma - That is absolutely correct. I think that it is both, but I would caveat that with the fact that we've now had pre-exposure prophylaxis for 12 years in the form of a once daily pill and still we are seeing approximately 120,000 new infections of HIV in Western and Central Africa per year. Now, although the modalities that I have described hold the potential of reducing the transmissions, they would only be able to have maximum impact if we are actually able to get them to the people that need them. Additionally, to your point about people with low viral loads or undetectable viral loads not being able to pass on the virus, that's why it's important that even if we're focusing on pre-exposure prophylaxis to prevent acquisition of HIV, we must also ensure that we are effectively treating the people who have HIV, to make sure that their viral loads are undetectable so that they also cannot transmit.
Chris - Is there a risk when we give wide scale use of drugs in the same way that with antibiotics, the more we use antibiotics, the more antibiotic resistance that we're going to see. If we are not careful with how we deploy drugs at this problem, there is a chance we could accelerate the rate of antiretroviral drug resistance and therefore we could pull the rug from under the use of those agents, not just in the African countries where they're being deployed, but potentially all over the world if those resistant forms spread.
Boghuma - That is absolutely correct and we have already seen reported in the clinical trials for some of the long-acting preventative modalities that exist, reports of individuals who have acquired drug resistance to these medications when they acquired an HIV infection while using them reassuringly, the rates of this occurrence have been low and I think that with having long-acting, pre-exposure prophylaxis, the one thing that we get is we know that the individual is taking the drug, because unlike the pills where you are really relying on an individual being able to take one pill every day, oftentimes in unsupervised settings, and you're trusting them to adhere to the therapy to maximise its effectiveness.
Chris - Are you optimistic in terms of where we are at the moment with the interventions we do have and the challenges that you have outlined that we need to surmount but are surmountable? Do you think we're going to get there?
Boghuma - I am cautiously optimistic. I think that we have the tools to effectively stop HIV transmission, but whether we have the will is something that remains to be seen and I think that a huge part of that will is being able to bridge the funding gap that would allow us to actually implement these tools and strategies and get them to where they are able to have maximal impact.
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