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AIDS: are we finally winning the fight?

Ahead of World AIDS Day on 1 December, journalist Juliette Astrup takes a look at the fight against AIDS – from promising new developments and breakthrough treatments to some of the barriers undermining progress.

The battle against AIDS has come a long way since the disease first shook the world in the 1980s, and became a global epidemic within just a few years. 

It still is – 36.7 million people are living with HIV globally (WHO, 2016) – but while stigma and discrimination remain, it is now a long-term condition rather than a death sentence. Patients receiving effective antiretroviral (ARV) treatment are living with HIV into old age, without the same level of fear of passing the infection on to others.

 

Decline in new diagnoses

Here in the UK there is much to feel positive about. New figures from Public Health England (PHE) show an 18% decrease in HIV diagnoses in the UK in 2016 – the largest ever (PHE, 2017). For gay and bisexual men, HIV diagnoses have dropped by 21% – a development hailed as ‘one of the most significant advances in HIV prevention since the beginning of the epidemic’ by the HIV/AIDS charity the Terrence Higgins Trust.

Combination prevention is working, says PHE. The decline in new diagnoses is driven by large increases in HIV tests among gay and bisexual men at sexual health clinics – 143,560 last year, up from 37,224 in 2007 (PHE, 2017).

Other factors include the uptake of ARV therapy following HIV diagnosis, sustained high condom use with casual partners and online purchasing of the pre-exposure prophylaxis (PrEP), which can protect those at risk of contracting the virus (PHE, 2017).

Further underlining this, in September NICE published a quality standard to encourage the uptake of HIV testing, advising that people living in areas with a high prevalence of the disease should routinely be offered HIV tests during healthcare appointments (NICE, 2017).

 

A ‘cancer-model’ treatment

In addition to prevention and treatment, research is bringing about ever more effective drugs. Just weeks ago, a team of US scientists announced news of an engineered antibody that attacks 99% of HIV strains and can prevent infection in primates (Xu et al, 2017), hailed by the International AIDS Society as an ‘exciting breakthrough’. 

And Dr Sarah Fidler, a consultant physician and professor of HIV medicine at Imperial College London, is involved in clinical trials for new medicines that not only suppress the virus but also target the viral ‘reservoirs’ in cells where it lies dormant and can be reactivated if treatment stops. But she says only one man in the world has been cured of HIV, and an out-and-out ‘cure’ may not be feasible for everyone living with HIV.

‘Rather than a cure, it might be more like a cancer model,’ she adds. ‘When treatment finishes, people understand that the cancer could come back – a similar model of treating HIV might be possible in the future. This is a very exciting and interesting area of research.’

 

High number of undiagnosed cases

Even with such advances in medicine, the battle is far from won. While HIV treatment in the UK is excellent, the number of people diagnosed with the disease each year remains high. In 2015, an estimated 101,200 people were living with HIV in the UK, including 13,000 undiagnosed, and rates of late diagnosis remain high (PHE, 2016).

While the stigma around HIV remains a challenge globally, Dr Fidler says that in the UK there is a general awareness and understanding about HIV and its treatment and prevention. But it’s important not to become complacent about it. 

‘We are all pretty bad at taking medication, but interrupting HIV treatment causes the virus to come back in four to six weeks, and it can lead to resistant strains of the virus, so there is quite a lot of anxiety around that “just one pill a day”.’

 

High-risk groups

Dr Fidler adds: ‘In the UK, people get really good access to treatment – but what is still not good enough is the testing. A key thing is to keep having tests. For people in high-risk groups we recommend being tested every three months or after exposures. You can buy self-testing kits, or you can go to one of the many clinics. Without stigmatising them, we need to empower these communities to know their risk so they can do something about it.’

Sadly, efforts to support high-risk groups sometimes fall short. Scotland’s busiest needle exchange service for drug addicts, which opened in Glasgow Central station in 2016 following a spike in HIV cases, has been closed by Network Rail, which owns the building.

There is also concern over access to PrEP, seen as a game-changing tool. While in Scotland PrEP is available on the NHS, and in Wales as part of a large-scale pilot, a similar programme in England is limited to 10,000 people and was delayed by months, only launching in the past few weeks.

And in England, services are facing continued funding cuts, and problems of fragmented and inconsistent commissioning as a result of the Health and Social Care Act.

‘A growing body of evidence has recently demonstrated how changing models of NHS delivery have resulted in the fragmentation of HIV provision, with resulting harm – especially to HIV support services,’ says Rosalie Hayes, policy and campaigns officer at the National AIDS Trust (NAT).

She adds: ‘The success we have recently seen in reducing infections among gay and bisexual men is already at risk as investment in prevention is facing significant cuts. Prevention spending in high-prevalence areas has been cut by almost a third in the past two years’ (NAT, 2017).

She also points to issues around public awareness and says: ‘It’s quite incredible that general understanding about HIV is so far behind. I think that is because treatment has developed so quickly – but also because there hasn’t been a big public information campaign or any comprehensive education about it in schools.

‘The knowledge that when the virus is suppressed a person can’t pass it on is really significant in terms of reducing self-stigma, and it’s important that everyone else knows that as well.’


Useful resources

National Aids Trust guide for care providers for those with HIV. Contains information on confidentiality and disclosure, an important factor for community healthcare workers – bit.ly/NAT_care_providers

2016 PHE report on treatment and viral suppression bit.ly/PHE_HIV

NAT resources for schools – bit.ly/NAT_teachers

The Children’s HIV Association guidance for schools – bit.ly/CHIVA_schools

NAT e-learning resource bit.ly/NAT_elearning


References

National AIDS Trust. (2017) UK investment in HIV prevention 2015-16 and 2016-17: examining UK expenditure on primary HIV prevention and HIV testing. See: nat.org.uk/sites/default/files/publications/NAT_PREVENTION%20REPORT_V2.pdf (accessed 23 October 2017).

NICE. (2017) HIV testing: encouraging uptake: quality standard QS157. See: nice.org.uk/guidance/QS157 (accessed 23 October 2017).

Public Health England. (2017) HIV in the United Kingdom: decline in new HIV diagnoses in gay and bisexual men in London, 2017 report. See: gov.uk/government/uploads/system/uploads/attachment_data/file/648913/hpr3517_HIV_AA.pdf (accessed 23 October 2017).

Public Health England. (2016) HIV in the UK: 2016 report. See: bit.ly/PHE_HIV (accessed October 23 2017).

WHO. (2016) Summary of the global HIV epidemic. See: who.int/hiv/data/epi_core_2016.png?ua=1 (accessed 23 October 2017).

Xu L, Pegu A, Rao E, Doria-Rose N et al. (2017) Trispecific broadly neutralizing HIV antibodies mediate potent SHIV protection in macaques. Science 358(6359): 85-90.

Picture credit | Shutterstock

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