Can Australia be the first country to eliminate HIV transmission?

Almost 40 million people are currently living with HIV globally, and 2019 saw 1.7 million newly infected people.
 
At a local level, 28,180 people in Australia were estimated to be living with HIV at the end of 2018. There were 833 new notifications in 2018 and 963 notifications in 2017, making newly diagnosed HIV notifications in Australia the lowest since 2010.  
 
The National HIV Strategy 2018–22 sets the goal of virtually eliminating HIV transmission by 2022.
 
But experts are uncertain Australia is on track to meet this target.
 
Recently presenting at the Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM) joint Australasian HIV, AIDS and sexual health conference, a panel of experts discussed where Australia sits in its efforts to be the first country to eliminate HIV transmission.
 
Dr Skye McGregor, an epidemiologist at the Kirby Institute, said in her presentation that although Australia has seen recent successes in driving down diagnoses, there is still a long way to go to reach HIV elimination. She also noted it is important to define the ‘virtual elimination’ target.
 
‘Elimination of transmission doesn’t translate to zero new cases of HIV, rather the absence of sustained endemic community transmission,’ she said.
 
‘To measure elimination of transmission, we require more granular data to interpret trends in HIV notifications, and we really need to understand the likely place of acquisition of HIV.
 
‘This will help us to differentiate the locally acquired versus overseas acquired, with a focus on newly acquired notifications.’
 
According to Dr McGregor, the current timeline of 2022 is ‘perhaps a bit optimistic’. Progress still needs to be made in at-risk sub-populations through diversifying testing methods and setting targets with local context that can be tracked annually through surveillance reports.
 
‘There have been decreases [in new transmissions] since 2016, but we are still way off from elimination of transmission. We need to … focus more on the public health problem and, once that has been achieved, we can focus more on elimination,’ she said.
 
The national strategy incorporates impact targets that aim to achieve the disease threshold outcome which, Dr McGregor highlights, are ‘very important for understanding our progress and achievement’.
 
‘For Australia, these are to reduce the incidence of transmissions in men-who-have-sex-with-men – there was a 53% decrease in 2018 compared to 2016 – and other priority populations, as well as sustain virtual elimination in sex workers, people who inject drugs, and mother-to-child transmissions,’ she said.
 
‘The second set of targets as part of the national strategy are process targets – inputs required to achieve those desired impact outcomes in terms of disease control, elimination and eradication.
 
‘These include 95% of people diagnosed, on treatment, and with an undetectable viral load. And to align with the public health definition, the process targets of increasing pre-exposure prophylaxis [PrEP] coverage by 75%, increasing people with HIV reporting a good quality of life, and reducing reported associated stigma by 75%.’

New ASHM guidelines set a global standard for healthcare providers to discuss HIV prevention with all patients.
 
Dr McGregor said current estimates show these targets are on track, with 90% diagnosed and on treatment in 2019, and 97% with an undetectable viral load.
 
But there is still some progress to achieve the PrEP coverage target, with only 21% coverage in 2018, despite new research from the Kirby Institute that men-who-have-sex-with-men who are HIV-negative prefer PrEP over condoms, with daily usage or on-demand PrEP jumping from 1% to 31% over the previous five years.
 
‘We really need to move into a phase of maintenance of a high level of accessible prevention and treatment services if we do achieve elimination of transmission,’ Dr McGregor said.
 
‘We need to have high-quality, ongoing surveillance and monitoring, so if there are increases then we can quickly respond.’
 
Sexual health physician Dr Jason Ong agrees.
 
He said in his presentation that although Australia is faring well in terms of global HIV rates and the epidemic curve is decreasing, he agrees the country has some way to go before becoming the first to virtually eliminate transmissions.
 
‘I don’t think we can get to zero with our current technology and understanding of HIV, but we might be able to virtually eliminate HIV from other sub-groups,’ he said.
 
‘To break that down, it is feasible [to virtually eliminate HIV] for blood transfusions which have very low levels, mother-to-child transmissions, and people who inject drugs.
 
‘But it is much harder for sexual transmission – this is our challenge, as [this group has] a lot more infections and we are way off our targets at the moment.’
 
Dr Ong said Australia needs better and clearer elimination targets, particularly in the area of sexual transmissions. He also noted the country’s progress has not benefited everyone equally, with certain groups remaining at higher risk of transmission and associated stigma.
 
‘One thing I don’t want us to forget is that elimination also includes elimination of stigma and criminalisation associated with HIV infection,’ he said.
 
Examining Australia’s progress of HIV elimination comes with the launch of ASHM’s updated national guidelines for U=U – the first in the world to remove any uncertainty from the message that patients maintaining a ‘durable viral suppression’ (defined as less than 200 HIV RNA copies per mL of blood) eliminates the risk of sexual transmission of HIV.
 
An HIV-prevention method, U=U (undetectable equals untransmissible) is when people who take antiretroviral therapy for HIV daily as prescribed, and who achieve and maintain an undetectable viral load, cannot sexually transmit the virus to an HIV-negative partner.
 
The guidelines draw on the latest evidence to set a global standard for healthcare providers to discuss U=U with all patients, including those newly diagnosed with HIV.
 
ASHM research also shows that for people who are diagnosed with HIV, the first conversation they have with their primary healthcare provider – usually their GP – is a significant predictor of a range of positive health outcomes, including their understanding and to remove any stigma attached.
 
‘Our previous guidance used the phrase “effectively no risk” to talk about U=U, but with increasing evidence that how clinicians talk to their patients about U=U has a huge impact on their wellbeing, we realised the new guidance needed to be direct and unambiguous,’ ASHM CEO Alexis Apostolellis said.
 
‘While ASHM has been proud to be a global leader in advocating the U=U message to clinicians, this update is the first time we have stated unequivocally that U=U eliminates the risk of sexual HIV transmission.’
 
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