Substantial decreases in HIV diagnoses in key cities show the way to elimination of new HIV diagnoses in gay men, a workshop at the 22nd International AIDS Conference (AIDS 2018) in Amsterdam heard. Public health officials, clinicians and community leaders presented data from Sydney, London and New York which all showed remarkable declines in new HIV diagnoses amongst gay men. Yet each city also highlighted groups which had benefited more and less from this decline, giving clues to ways in which a combination prevention programme could be optimised and targeted.
Key factors the cities shared included increased rates of testing, both lifetime and frequency; co-ordinated and promoted testing campaigns; improved real-time data flow and quality; stakeholder engagement, including clinics and communities; earlier treatment access and availability of pre-exposure prophylaxis (PrEP). Political leadership at all levels was also highlighted.
For Sydney, Andrew Grulich of the Kirby Institute presented data showing that the average number of HIV tests per year by men who have sex with men (MSM) at high risk of acquiring HIV increased from 1.79 to 3.44 between 2011 and 2016, while the percentage of MSM on treatment within six months of diagnosis rose from 60% in 2013 to 97% in 2017.
For London, Valerie Delpech of Public Health England showed that while the perceptible decline in new MSM diagnoses was first noticed in central London clinics in 2016, by using CD4 back-calculations, the decline in new infections can be traced back to 2013. This coincided with a substantial increase in community testing campaigns and earlier treatment, while the emergence of unofficial but widespread PrEP use amongst gay men from 2016 accelerated the trend.
Charles King of Housing Works presented New York data showing a 16% increase between 2007 and 2016 in those who had ever had an HIV test and a level of 77% (of those diagnosed) having suppressed viral load in 2016. Testing frequency and time to treatment also improved.
Each presenter credited political leadership, including changes in both Sydney and London which re-energised central planning and service co-ordination. “The role of community and civil society has been critical” said Delpech. However, divergences in which groups benefited most also gave pointers to potential problems.
In all three cities, the decline was most marked in central urban districts where gay community engagement was greatest; in Sydney this was a remarkable 52% in the city centre compared to only 7.3% in the suburbs. This suggested that community attachment and cohesion may play a role.
New York saw a much greater decline in onward transmissions amongst people injecting drugs than amongst MSM, though it was unclear where chemsex sat within this. In Sydney, the decline was only amongst Australian-born MSM, while foreign-born MSM saw a small but continuing increase in the level of diagnoses.
Delpech suggested that the change to genuinely universal access to free HIV treatment in England had played a part in their success amongst all groups, including undocumented migrant MSM. However, England's continued failure to provide free access to PrEP, except for those on the IMPACT trial from late 2017, was noted.
“Testing is a vital tool whether the result is positive or negative” stated the UK's Professor Jane Anderson, pointing out that a negative result is also an opportunity for intervention. “Viral suppression is the foundation for ending HIV,” said King. Grulich talked about the importance of having rolled-out PrEP in one year to 25% of all sexually active MSM in New South Wales. But each continent's experience gave clearer clues than ever to how HIV might be eliminated, at least amongst those at greatest risk in cities. Combination knowledge, alongside combination prevention, may be the answer.
Rapporteur summary
Focusing mainly on London, New York and Sydney, scientific evidence was presented to understand recent reported (through clinic / province / national level surveillance) declines in HIV transmission observed in gay men. Purpose = transfer knowledge of the range of interventions that have helped bring this decline.
Highlights: Valerie Delpech (PHE, UK), Andrew Grulich (UNSW Australia), and Charles King (Housing Works, USA) presented data highlighting recent declines in new HIV diagnoses among gay men. Charles King argued “viral suppression is the foundation for ending HIV”. Data on testing rates and frequency clearly highlighted importance of repeat testing among gay men at risk in eliminating HIV in these settings. Jane Anderson (Homerton University Hospital, UK) – argued having a diagnosis was key as both negative and positive diagnoses have treatment and prevention implications – also argued we need to move away from the idea that testing is to find positive diagnoses. Karen Price (ACON, Australia) stated that “We can have every tool in the toolbox but we also importantly need the leadership of people living with HIV to move forward”. Karen and Charles presented the “Ending HIV equation” which consists of test often + treat early +stay safe.
Critical assessment: This session highlighted well the importance of combination prevention and having a multi-faceted approach with stakeholder engagement in a range of settings (gay community connectedness; clinician leadership; user friendly accessible clinics; national / state / city political buy-in / leadership). The session also made clear the importance of having clinic / surveillance data to inform and implement change, and to avoid potential erroneous conclusions. For example, applying CD4-back-calculation & monitoring early-infection in some settings suggested declines in transmission dated back to around 2012 rather than 2015/16 (as suggested by diagnoses data), thereby predating the roll-out of PrEP.
Authors
Brian Rice
[link url="http://www.aidsmap.com/HIV-elimination-in-gay-men-what-is-working/page/3314283/"]Aidsmap material[/link]
[link url="http://programme.aids2018.org/Programme/Session/1247"]AIDS 2018 session summary[/link]