Eliminating HIV transmission is close, but we're not there yet

Sydney: HIV diagnoses in Australia have nearly halved in the last decade, with only 555 HIV diagnoses reported in the 2022 surveillance data.

In areas of inner Sydney, the decline has been even more significant, with new infections falling by 88 per cent — meaning HIV has been virtually eliminated in these areas.

If this trajectory continues, Australia will have made major progress towards eliminating HIV transmission nationwide and meeting the UN goal of ending AIDS as a public health threat by 2030.

Although these gains are to be celebrated, Australia may still fall short of the target of a 90 per cent reduction by 2030, largely due to inequities in the delivery and uptake of HIV prevention and treatment strategies.

To support progress in reducing HIV transmission and care of people living with HIV, Australia needs to ensure ongoing and expanded investment in appropriate HIV responses.

As the world marks World AIDS Day on 1 December, it serves as both a celebration of the progress made and also a reminder to refocus efforts to overcome longstanding inequities and eliminate HIV transmission for all.

Reductions have been most significant among diagnoses reporting male-to-male sexual contact as the likely route of HIV transmission, with a 57 per cent decrease between 2013 and 2022.

The majority of diagnoses in Australia are still attributed to male-to-male sexual contact, but this proportion has declined over time, down from 70 per cent in 2013 to 57 per cent in 2022.

While the number of diagnoses among people reporting heterosexual contact has consistently been lower — 166 in 2022 — there has been less change over time in this group. As a result, they make up an increasing proportion of the total — nearly a third in 2022.

Compared to Australian-born populations, overseas-born Australians have had slower reductions in HIV diagnoses, but they are still declining — down 33 per cent, compared to 55 per cent in Australian-born populations.

There are several likely reasons for these ongoing discrepancies: barriers to accessing appropriate prevention and treatment, including lack of culturally appropriate health services and resources and subsidised PrEP not being available for people ineligible for Medicare; the ongoing effects of stigma, particularly in situations where open discussions about sexual health are not encouraged; and the negative impact of existing legal frameworks, including around HIV disclosure and migration, that may disincentivise HIV testing.

HIV diagnoses among sex workers and people who inject drugs — other priority populations globally affected by HIV — have remained low in Australia, unlike in other parts of the world. This can be accredited to the intense focus and investment in community partnerships from the earliest days of the HIV epidemic.

All these declines need to be considered in the context of the COVID-19 pandemic and the resulting interruptions to HIV testing and healthcare access, restrictions of people's movement and changes in people's sexual behaviours.

There is now an opportunity to focus on nuanced public health messaging to ensure people are re-engaging in regular HIV testing, as well as using effective prevention options such as condoms, pre-exposure prophylaxis (or PrEP), in which HIV-negative people take treatment to prevent them acquiring HIV if exposed, and treatment as prevention, in which an HIV-positive partner reaches an undetectable viral load, preventing HIV transmission.

It is important to remember that elimination of HIV transmission does not mean elimination of HIV altogether. HIV is a lifelong, incurable infection that requires continuous investment in public health responses and services, as well as ongoing efforts to find a cure.

Doing so is crucial both to ensure people living with HIV have the opportunity to live healthy and fulfilling lives, and at the same time to reduce the risk of HIV transmissions.

Ensuring communities affected by HIV are at the centre of the response in Australia is essential and reflected in the 2023 World AIDS Day theme of 'Let Communities Lead'.

In Australia, researchers are indebted to the community of people with and affected by HIV, for their relentless advocacy and engagement in the development and critique of high-quality research and public health policy.

Australia's response to HIV has been internationally recognised, and characterised by a successful partnership among communities, academia, clinicians and government.

Early investment in needle and syringe programs, affordable and accessible HIV testing, subsidised access to antiretroviral therapy and PrEP have relied on community advocacy, government investment, and strong epidemiological and clinical evidence.

This partnership is ongoing, as shown in the recent expansion of subsidised treatment to include people ineligible for Medicare.

But more could still be done to achieve Australia's goal of virtually eliminating HIV transmission by 2030, and this can only be done with equity and partnerships as guiding principles.

Sustained and expanded access to HIV testing, including self-testing and opt-out testing strategies — in which patients choose to opt out of routine testing for HIV, rather than opt in — are needed, which would ensure that people receive a timely HIV diagnosis, supporting rapid engagement in treatment and care.

Delivery of treatment in a range of settings, including culturally sensitive and appropriate services, would support greater health-service engagement, particularly for Aboriginal and Torres Strait Islander peoples and people from culturally and linguistically diverse backgrounds.

Expanded access to PrEP for people ineligible for Medicare would support reductions in HIV diagnoses among people born overseas.

Education programmes and open discussions around sexual health and HIV will assist in reducing stigma and discrimination, which continue to significantly affect people with and at risk of HIV.