HIV can be eliminated among gay men in UK, say experts
The number of men testing positive for HIV fell dramatically in England last year, revealing the remarkable impact of targeted interventions for men who have sex with men.
New HIV infections among gay and other men who have sex with men (referred to as MSM) fell by 32% across five high-volume London sexual health clinics between October 2015 and September 2016, when compared to the previous year.
The fall in new HIV infections among MSM, the group most affected by HIV in the UK, can be attributed to increased levels of HIV testing, particularly repeat testing, and swift treatment initiation. While data regarding access to pre-exposure prophylaxis (PrEP) is currently limited, the experts from Public Health England (PHE) suggest that it may have also contributed to the decline.
The analysis, led by PHE, was published in a rapid communication in the journal, Eurosurveillance, to help confirm and explain the positive trends London clinics reported back in December 2016, when the news first broke.
They found that across England new HIV infections among MSM fell by 17% nationally and 25% in London – between October 2014 and September 2015, and October 2015 and September 2016 – with the majority of the decline concentrated in five London clinics. Among heterosexuals over the same two periods, the number of new HIV infections remained the same.
The number of MSM testing for HIV also dramatically improved, increasing by 50% between January and March 2013, and July and September 2016. This increase was propelled by a large number of MSM returning for HIV testing. In fact, repeat testers increased by 60% over these periods while the number of new testers remained stable.
As of 2012, PHE guidelines call for all people living with HIV to be put on treatment, regardless of their CD4 count. Since then, the number of people left untreated fell by 27% in England, with the biggest decline at the high-volume clinics (51%), compared to other London clinics (17%) and outside of London clinics (16%).
The five London clinics also had quicker linkages to care, where it took an average of 120 days between diagnosis and treatment initiation, compared to 190 days and 260 days for other London clinics and clinic outside of London respectively.
The decline in the HIV epidemic among gay men also corresponds with increased access to PrEP, either through the PROUD study, or bought direct from the internet.
PHE noted that data on PrEP access was limited – with little data for those many men who have taken control of their own health by buying PrEP online. But PHE suggests there is no doubt PrEP has contributed to the fall in new infections.
Valerie Delpech, head of HIV surveillance for Public Health England, said “basically we are witnessing a phenomenal experiment. We are observing it. What we are seeing is the first downturn of the HIV epidemic in gay men.”
What the high-volume clinics tells us, is that if increased HIV testing, particularly among high-risk MSM, and wide-scale immediate ART initiation is replicated elsewhere, there could be a substantial reduction in HIV transmission among MSM nationally.
The authors also conclude that if the ‘PrEP Impact Trial’ – a three-year trial that will include 10,000 participants in England – is started promptly, there could be a “very large reduction in HIV transmission among MSM.”
While gay men have the largest burden of HIV in the UK, the HIV epidemic is nonetheless diverse, with people from the black African community also carrying a significant burden of HIV.
While the paths to vulnerability and infection differ greatly between these two groups, larger lessons can be learnt from the experiences of the five London clinics, having revealed the remarkable benefits of targeted and intensified interventions to reach key affected populations.
In addition, PrEP trials here in the UK have largely focused on MSM. Broadening this out to see if other population groups, such as black African women, could benefit from this intervention needs to be explored in the oncoming trial.
Delpech said: “There is absolutely no reason why we cannot scale that up to further reduce new infections in gay men – and also in all people who may be at risk of HIV in the UK, regardless of gender, ethnicity or sexuality.”