Australia’s most populous state, New South Wales (NSW), has reported a steep drop in HIV diagnoses in gay and other men who have sex with men (MSM) in the last year, and particularly since the beginning of 2017. This is despite an equally notable increase in HIV testing, which took a sharp upward turn around March 2016, at the time the EPIC-NSW demonstration study of pre-exposure prophylaxis (PrEP) started in the state. The quarterly figures for HIV diagnoses reported in 2017 are the lowest since records began in 1985.
These declines are seen as vindications of NSW’s policy which aims to virtually eliminate HIV transmission by 2020. This combines increasing HIV testing (including distributing self-sampling kits), the PrEP study, and rapid referral and treatment of those diagnosed.
The strategy also includes education campaigns about the effectiveness of testing and treatment: this has resulted in the proportion of MSM in opinion surveys who agreed with the statement “HIV treatments significantly reduce the risk of passing on HIV” from 33% in February 2013 to 83% in September 2016. There was an increase during the same period from 48% to 86% in the proportion of people agreeing that “everything has changed, we can now dramatically reduce HIV transmission.” Nonetheless, 94% of people in September 2016 still agreed that “condoms continue to be the most effective way of preventing HIV transmission”, a virtually unchanged proportion from 2013.
Particularly notable is a large drop in recent HIV infections in MSM. HIV infections that were determined to be less than three months old by an incidence assay declined by 40% in the first half of 2017, relative to recent infections in the first halves of the years 2013-16. And there was a 58% decline in the proportion of gay men diagnosed with HIV who had had a negative test in the previous 12 months.
Ninety-five per cent of people who have been diagnosed are on treatment, with 59% placed on antiretroviral therapy within six weeks of diagnosis, and of those on treatment, 94% are virally undetectable.
In contrast, the absolute number of infections in heterosexuals remained steady between 2011 and mid-2016 but actually increased in the last year. The proportion of people diagnosed who were heterosexuals increased by 46% relative to the average number in the previous five years, as diagnoses in MSM have declined.
There was also an increase in the proportion of people diagnosed with advanced HIV infection (with a CD4 count of below 200 cells/mm3), including amongst MSM. The average age of people diagnosed with advanced HIV has increased in the last two years due to a sharp increase in late diagnoses in people aged over 50.
People born overseas, including MSM, have also seen no decrease in diagnoses.
More detailed figures: tests
In the second quarter of 2017 (April-June), 138,952 HIV tests were taken in NSW. This represents a 5.5% increase in the number of tests taken in the same period in 2016 and a 33% increase compared with the same period in 2012.
The average number of HIV tests taken by MSM per year increased among all health facilities from 0.73 in the first quarter of 2013 to 1.97 in the second quarter of 2017. Among publicly funded sexual health clinics, the number increased among high-risk gay men (those with more than 5 partners in the last 3 months, 20 partners in the last 12 months, or a sexually transmitted infection in the last 2 years) from 1.83 a year in 2011 to 2.25 in 2016 and then to 3.67 in the second quarter of 2017. In lower-risk gay men the figures increased from 1.21 to 1.72 and then to 2.35 for the same three periods. There was a distinct upward inflection in the number of tests performed per year starting in March 2016, when the EPIC-NSW trial started.
More detailed figures: diagnoses
In the full year from July 2016 to June 2017 there were 288 new HIV diagnoses in NSW, 19% less than the average number of diagnoses in the previous five years. In MSM the number was 217 diagnoses vs 289 averaged over the previous five years, a decrease of 25%.
Taking just the second quarter of 2017, there were 72 new diagnoses compared with 85 averaged over the same period in the last five years, a decrease of 25%, and a 32% decrease in MSM.
There was a 33% decline in people diagnosed in early-stage infection (infected within the last three months) and, as noted above, a 40% decrease in MSM. However, there was, at the same time, a 30% increase in people diagnosed in advanced infection.
Most advanced infections were diagnosed in people over 50. Before 2016, people in their forties had by far the highest rate of diagnoses with CD4 counts below 200 cells/mm3: around 50%. However, the proportion of late diagnoses in the over-50s then started increasing. In 2017, 59% of people over 50 diagnosed with HIV had CD4 counts under 200 cells/mm3, compared with 33% in 2015. This may be because more HIV testing means that long-undiagnosed chronic infections in older people are finally being detected.
As reported, the proprtion of people diagnosed who were heterosexual has increased. While there were only 20% as many heterosexual diagnoses as ones in MSM between 2011 and 2016 (roughly 15 per quarter compared with roughly 75 in MSM), approaching half as many diagnoses were in heterosexuals in the second quarter of 2017 (21 vs 48 in MSM).
There was also an increase in the proportion of people diagnosed who were born abroad, from an average of 45% in the first halves of the years between 2011 and 2016, to 56% in the first half of 2017. The absolute number of diagnoses in these periods has remained the same (80) but the proportion has increased because diagnoses have decreased in Australian-born MSM.
More detailed figures: PrEP and condoms
As stated already, the EPIC-NSW PrEP study started in March 2016 and the latest figures are that 6336 people in NSW are enrolled on it. Most of these are MSM but it includes 66 non-MSM, of whom 59 are trans women or men, or non-binary people. People in their 30s are most likely to join the study: 35% of the total, but 27% are people in their 20s and 37% people over 40. Sixty-two per cent were born in Australia (vs only 44% of those diagnosed with HIV).
There is no evidence of sexually transmitted infections significantly increasing in people on the PrEP study. The average proportion of people diagnosed with syphilis per quarter was 1% and chlamydia 9%; there is a suggestion that gonorrhoea might have increased slightly, from 8.4% per quarter in April-June 2016 to 10% in April-June 2017, but this is not statistically significant.
However, condom use in the MSM population in general has declined quite significantly. The Sydney Gay Community Survey is conducted every year in February-March. In 2016, the proportion of MSM (not just those on PrEP) reporting condomless anal sex with casual partners was 41%: in 2017 it was 52%.
Reactions
NSW health chief Dr Kerry Chant said that the figures demonstrated NSW’s “Continuing leadership in HIV prevention – we are experiencing one of the most rapid decreases in new HIV notifications among gay and bisexual men anywhere in the world.”
Nicholas Parkhill, the Chief Executive of NSW’s main HIV NGO, ACON, said: “By continuing to promote testing and using new biomedical technologies through an integrated and co-ordinated approach, we’re very optimistic that HIV transmission data will continue to trend downwards and we will move closer to our collective goal of virtually ending HIV transmission by 2020.”
And Professor David Cooper, Director of the Kirby Institute that is running the EPIC-NSW trial, said: “The rapid rate of decline in HIV diagnoses…is unprecedented internationally, and can be attributed to a high uptake of a combination of HIV prevention strategies and in particular to the rapid scale-up of targeted PrEP implementation.”
General PrEP availability stalled
Despite this evidence of success, the Australian Pharmaceutical Benefits Advisory Committee (PBAC) has deferred a decision on whether to provide PrEP publicly and not as part of a trial. Both Gilead Sciences and the generic company Mylan put bids to supply PrEP before PBAC, but PBAC has deferred a decision on general public provision because they say they need more information on the likely number of people who will eventually use PrEP and its cost-effectiveness.
Darryl O’Donnell of the Australian Federation of AIDS Organisations said: “Given PrEP is so effective, people will be deeply frustrated at the outcome. HIV will be needlessly transmitted while we wait for equitable and affordable access. And without access, Australia will not achieve its target of ending HIV transmission by 2020.”
56 Dean Street, London
Inspired partly by the Australian strategy and partly by the fact that London’s HIV clinics were among the first worldwide to report declines in HIV diagnoses in gay men at the end of last year – apparently due to a similar combination prevention strategy – the 56 Dean Street clinic in London has launched a new website section called DEAN STREET ZERO. This aims to educate and inform its users and particularly gay men about the new HIV prevention tools and how the risk of acquiring or transmitting HIV can be drastically cut by using the right ones.
See dean.st/zero/
The full New South Wales report can be read at www.health.nsw.gov.au/endinghiv/Documents/q2-2017-nsw-hiv-data-report.pdf