The move to declare the Aids epidemic over is not so much to a success story as a deliberate strategy to refocus the attention away from Aids and onto HIV. Photograph: David Crosling/AAP
The announcement this week from the Australian Federation of AIDS Organisations that Aids is no longer a public health issue speaks to the strength of the country’s healthcare system, with treatment for HIV cheap and easily accessible.
But the move is not so much a success story as a deliberate strategy to refocus the attention away from Aids and onto HIV. While other countries to have tackled Aids have not felt the need to declare the epidemic over, Australia has been less successful than other developed countries at preventing new HIV infections, with no decline in the number of transmissions for the past decade.
Aids has in fact been declining as a public health focus in Australia for many years. The effectiveness of antiretroviral therapy in controlling HIV and preventing Aids from ever developing, and in reversing many (but not all) Aids cases, means that Aids has not been a notifiable disease since 2010.
For this reason exact figures on the number of Aids diagnoses in Australia each year are unknown, but it would be less than 100 and Aids-related illnesses would account for only a handful of deaths, the director of the Peter Doherty Institute for Infection and Immunity, Professor Sharon Lewin, said.
At the peak of the Aids epidemic in the early 1990s, about 1,000 people died from Aids every year, although Lewin said it’s difficult to make comparisons given the definition of Aids has also changed since then. But what is clear is that while Aids is rare, HIV isn’t declining, with just over 1,000 new diagnoses each year.
“The main challenge in Australia is stopping new HIV infections and making sure everyone knows their HIV status and if they have it, gets treatment, because proper treatment reduces their chance of transmitting the virus by 95%,” Lewin said.
“As more and more people go onto treatment and as we have more ways to prevent transmission, we should be seeing declines in HIV diagnoses. Many other cities have noticed a decline. But Australia hasn’t seen a decline in a decade, and that’s a really poor outcome.”
The goal of ending new HIV infections by 2020, signed up to by every Australian state and territory minister, will become unrealistic unless something is done to stop the virus from being spread, experts like Lewin fear.
In San Francisco, new HIV infections fell by almost 19% between 2013 and 2014, from 371 to 302. The city’s success has been put down to a four-pronged strategy agreed to by public and private medical providers, government agencies, researchers and universities, and advocates.
First, those with a new diagnosis are rapidly placed onto antiretroviral treatment, often the same day. Those people at substantial risk of contracting HIV are offered pre-exposure prophylaxis (PrEP) treatment, which significantly reduces chances of acquiring the disease.
A committee has also been tasked with ensuring people stay on their treatments without lapsing, or go back onto treatments if they have. And lastly, there has been a concerted effort to reduce HIV stigma in San Francisco, given this also breaks down barriers to seeking and receiving treatment.
In some ways, protection from HIV works like herd immunity from infectious diseases such as measles and chickenpox, in that once 95% of the population are immune to those diseases, those who are not vaccinated are protected. With HIV, 95% of people with the disease need to be on proper treatment in order for new infection rates to start to decline. But the problem with HIV in Australia is that roughly 15% of people with the virus do not know they have it. And of those who have been diagnosed, only 85% are receiving treatment.
Lewin, a world-leading HIV researcher, said for HIV rates to decline in Australia, not only did more people need to get tested and treated, but PrEP treatment needed to be made much more widely available to at-risk people and communities, something San Francisco has excelled at.
Last week, the Pharmaceutical Benefits Advisory Committee met to discuss whether the PrEP drug Truvada should be subsidised by the government, and the outcome is expected to be published next month. The drug retails overseas for roughly $1,000 per month. Currently, it is only available to Australians participating in clinical trials.
“Cities with declining HIV rates didn’t see that decline until they introduced PrEP, and San Francisco was one of the earliest cities to role it out and make it available readily to a concentrated population,” Lewin said.
The Victorian Aids Council CEO, Simon Ruth, said adding to the difficulty in reducing HIV transmissions was the view among the general population that HIV, like Aids, was now rare.
“But HIV is not rare,” Ruth said. “It is still a major concern for health, so we’re trying to move away from some of the language around Aids to focus on the issue of HIV, which is an ongoing issue.”
Ruth said to bring HIV rates down, awareness campaigns needed to target people beyond just men who have sex with men.
While men who have sex with men are at most risk of contracting HIV, accounting for 70% of new diagnoses in Australia in 2014, heterosexual sex accounted for almost one-fifth of new cases. The gay community has had the message of safe-sex and HIV risk drilled into them and tend to be proactive about mitigating risk, while less targeted groups, including heterosexuals, sometimes underestimated theirs.
According to a study published in the journal Sexual Health, less than half of heterosexual Australians aged between 16 and 69 who were sexually active used condoms in 2014.
Anecdotally, those working in the HIV sector say they are seeing increasing numbers of young Australians travelling overseas during their gap year or for working holidays contracting HIV, unaware that HIV may be more common among the straight community in other countries.
Associate Professor Mark Stoové, head of the HIV and Justice Health
Research programs at the Burnet Institute, said there had been instances of “cluster HIV outbreaks” among Australian miners sent overseas by their company to work in countries with a higher prevalence of HIV.
“We also see over-representation of HIV in people from culturally and linguistically diverse backgrounds and non English-speaking backgrounds, so we need to be vigilant in targeting health messages to those groups as well,” he said.
Rates of HIV diagnosis are also greater among Indigenous Australians, and they also receive testing and treatment later than non-Indigenous Australians.
But Stoové added that just because Aids was no longer an epidemic, it was important not to neglect those Australians who only accessed healthcare once they developed Aids-relate illnesses, such as cancers and tuberculosis.
“We still need attention on those who do present with Aids even though they represent a smaller and smaller population,” he said.
“We do need to understand more about why these people are only presenting to healthcare by the time they have an Aids-defining diagnosis, despite the fact we have a first-class healthcare system and free or very low-cost HIV testing and very strong treatment and referral networks.
“We can’t take our eye off the ball of those Aids cases still coming up, and we need to understand what the barriers have been for those individuals.”