HIV seems like a scourge of the eighties, but today new HIV diagnoses and the costs of medication are escalating out of control in New Zealand. The world’s most dangerous infectious disease epidemic of the modern era is being revived, fuelled by invisibility, indifference and inaction.
HIV has a terrifying ability to evolve and evade control when our guard is down. The virus has killed 40 million people worldwide. 2.5 million people contracted HIV in 2015. Three decades later we still have no vaccine and no cure.
The fact is HIV is exceptionally well adapted to spread between humans. The virus is transmitted through sexual behaviour and injecting drugs, behaviours that are not easy to change. Infection is often asymptomatic, so people need to be tested to confirm if they have the virus. HIV is most infectious shortly after someone becomes infected, when they are probably unaware that they have it. Finally, HIV is subject to cultural taboos, triggering embarrassment and discouraging open conversations.
So despite three decades of scientific knowledge we’re again witnessing expanding epidemics across the globe; from mature epidemics in the UK to new epidemics like the Philippines, where transmission since 2005 has been explosive.
The latest trends here are alarming. Last year New Zealand recorded the highest number of annual HIV diagnoses ever, the fourth increase in a row. In gay and bisexual men, who account for 80% of our epidemic, annual HIV cases contracted locally are now four times higher than at the epidemic low point in 2000.
Treatment expenditure is also soaring, doubling in the last 6 years from $16.8 million in 2011 to $32.8 million in 2016. It’s estimated that one person diagnosed with HIV at age 20 could cost Pharmac over $800,000 in antiretroviral treatments over their lifetime. It’s why HIV prevention makes great fiscal sense: for every infection averted we’d be able to fund other much needed medication for New Zealanders.
It’s disappointing because we’ve got a proud record that risks being squandered. When HIV first made it to New Zealand over thirty years ago, the country responded boldly. Interventions were based on evidence and we agreed on rational policies, bi-partisan political engagement and urgency. Moralism was rejected in favour of science and cooperation.
The result was an international infection control success story: New Zealand was one of the first countries in the world to report a decline in AIDS. We had among the lowest rates of HIV diagnoses in gay and bisexual men internationally, and we still have the lowest rate of HIV among people who inject drugs.
HIV’s comeback is driven by a roll-call of big issues confronting contemporary societies.
Internet dating’s hyper-connectivity has been exploited by HIV and other sexually transmitted infections, spreading through sexual networks in clusters and to individuals previously distant from transmission epicentres.
Social media could be used to empower HIV prevention but Google, Facebook and Apple have blocked condom and HIV testing advertisements due to their “offensive content”. That means content has to be clinical and sanitised, reducing its relevance to target audiences.
Pornography is increasingly accessible and unregulated, but tends to promote condomless sex.
Pharmaceuticals have thankfully transformed life expectancy to near-normal with early diagnosis. But they also make HIV seem less visible and less threatening, and their expense ties up scarce health resources, leaving less money for safe sex programmes and research.
Stigma compounds that invisibility, silencing the voice of people living with HIV and deterring those at risk from seeking testing and prevention resources.
And rising consumption of recreational drugs, particularly methamphetamine, can facilitate unprotected sex and increases HIV transmission risks if unsterilised injecting equipment is shared.
The upshot is that nowadays HIV prevention operates in a very challenging environment. The accumulation of these small shifts and unintended consequences has allowed HIV to persist and reassert itself.
Likewise we shouldn’t forget why HIV is described as “the most political of diseases”. Controlling HIV means confronting established societal power structures head on, be they gender (men controlling women’s sexual norms), age (adults limiting young people’s access to sex education) or sexuality (gay communities denied sufficient resources because of heterosexism and homophobia).
In New Zealand, the greatest disparities in HIV are found among sexual orientation minorities. Our country has a favourable history promoting equal rights for gay communities so it’s unacceptable that the health status of the same groups doesn’t appear to enjoy the same commitment. If studies suggested that 1 in 15 heterosexual participants had HIV, with 1 in 5 of these undiagnosed, I’m left wondering if there’d be more urgency to respond?
What’s exciting and frustrating HIV experts here is that New Zealand could turn this around quickly. Scientific developments in the last two years mean that it is possible to virtually eliminate HIV transmission in New Zealand within 15 years. These developments centre on continued safe sex promotion, more frequent HIV testing, and adding two new tools to the mix.
The first tool is immediate antiretroviral treatment for people who test HIV positive. That’s because recent studies show that immediate rather than delayed treatment considerably improves long term health, and also suppresses the amount of virus in the body (called the HIV viral load) to the point where a person is almost uninfectious. In the “PARTNER” prospective cohort study, no linked transmissions were found from the HIV positive participants who had fully suppressed virus to their uninfected partner, even after 58,000 sex acts that didn’t involve condoms.
The second tool is offering the same HIV treatments as daily pre-exposure prophylaxis (PrEP) to the small number of uninfected individuals at very high risk of contracting HIV. Several studies have shown that PrEP reduces the risk of acquiring HIV by 86-92%, benefitting these individuals and also preventing chains of transmission to others: a population effect.
The World Health Organisation recently recommended immediate treatment on diagnosis, and countries such as the United States, France and Norway offer funded access to PrEP. In contrast, New Zealand government agencies have been slower to act, not yet approving immediate treatment or endorsing PrEP.
We urgently need re-engagement and action on HIV. We need to evolve and modernise our responses just as HIV has evolved from a frightening disease causing panic and fear, to a silent epidemic flying under the radar but harming our communities and health budgets.
At a time when we finally have the tools necessary to eradicate transmission, we literally can’t afford complacency to undo all the good work of our predecessors.
Peter Saxton is a Senior Research Fellow with an interest in HIV prevention and sexual health. He has a PhD in public health and is the inaugural New Zealand AIDS Foundation Fellow at the University of Auckland.
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