Increased testing and combination prevention efforts mean the UK joins a select list of other countries in achieving the 90-90-90 targets 2 years before the 2020 goal. Tony Kirby reports.
Public Health England (PHE) has announced that, in 2017, the nation achieved the UNAIDS targets of 90% of all people with HIV diagnosed, 90% of those diagnosed on antiretroviral treatment, and 90% of those on treatment virally suppressed. In the UK, 92% of people with HIV are diagnosed, 98% of those diagnosed receive antiretroviral treatment, and 97% of those on treatment are virally suppressed, meaning that 87% of all people with HIV in the country are virally supressed (the UNAIDS target for which is 73%). The UK joins a select list of countries to achieve this target before the 2020 deadline; Botswana, Cambodia, Denmark, Eswatini, Namibia, and the Netherlands have also attained 90-90-90.
The UK’s achievement, announced in PHE’s report Progress towards ending the HIV epidemic in the United Kingdom, represents further good news for the UK, which has seen a sharp decline in new HIV diagnoses in the past 2 years. The 4363 new HIV diagnoses in 2017 represent a 17% decline from the 5280 reported in 2016.
“The success in declining diagnoses among gay and bisexual men in the UK follows a reduction in transmission that began in 2012, attributable to combination HIV prevention”, says Nick Phin, deputy director of the National Infection Service at Public Health England.
He explains that substantial factors driving the downward trend include increases in HIV testing among gay and bisexual men attending sexual health services (from 79·598 in 2013 to 116·071 in 2017), repeat testing in men at higher risk, continuing advocacy for condom use, and steady improvements in the prompt uptake of antiretroviral therapy after earlier HIV diagnosis. Pre-exposure prophylaxis (PrEP) use has also steadily increased in the UK over the past 4 years. However it is not yet available on the UK National Health Service. Currently, people in the UK can only access PrEP through the ongoing PrEP Impact Trial or by buying it privately online.
Despite its success, Phin says that the UK has further work to do. He says “in 2017, 43% of new HIV diagnoses were made at a late stage of infection. While numbers of late HIV diagnoses have declined, there continue to be opportunities for early diagnosis that can reduce transmission of HIV further. This year we have continued to encourage sexual health clinics and other health-care services to proactively offer and recommend an HIV test to all patients who could be at-risk.”
Also of concern is the UK’s system of devolving responsibility for HIV prevention and testing services to local authorities, all of which are under financial pressure and are cutting funding for sexual health services. There have been repeated warnings from experts in sexual health that these funding pressures threaten progress in HIV and other sexual infections. “There have been some missed opportunities in HIV testing in some regions of the country and we would encourage local authorities and service commissioners to investigate these and consider what may be done to close the gaps”, says Phin.
Other countries that are nearing achievement of 90-90-90 are Germany, Ireland, Italy, Lesotho, Luxembourg, Portugal, and Singapore; and dozens of others have achieved one or more of the 90 targets. Globally, in 2017, three of four people living with HIV (75%) knew their status; of these, 79% were on treatment, and, of those, 81% were virally supressed. These figures mean that 47% of all people living with HIV are virally suppressed, well short of the UNAIDS target of 73%.
Julio Montaner, director of the British Columbia Centre for Excellence in HIV/AIDS in Vancouver, Canada, was the architect of the 90-90-90 target, which was an extension of the treatment-as-prevention paradigm he pioneered more than a decade ago. He is not optimistic that the world will reach the UNAIDS goal. “At the present rate, I have serious doubts we will meet the global 90-90-90 target by 2020 and, as such, we will miss an opportunity to truly deliver on the promise of all the scientific advancements in HIV we have collectively achieved over the last three decades”, says Montaner.
At the time of going to press, the G20 world’s wealthiest nations were meeting in Buenos Aires, Argentina. Montaner says that. In light of overall global funding for HIV stalling in recent years, or even falling, “it is critical for the G20 to redouble their financial commitments to HIV/AIDS, but I have limited hope this is actually going to happen.”
By Tony Kirby