Today is World Aids Day: a time to show solidarity with people living with HIV/Aids across the world, and remember those we have lost. But solidarity and remembrance have limited purpose if they’re not combined with a meaningful commitment to fighting this epidemic. Earlier today, the government published new data that shows it’s not on track to meet its long-term commitment to end new HIV transmissions by 2030. This goal should be entirely achievable– yet without immediate action, it risks slipping even further out of reach.
For years the numbers of new diagnoses of HIV have been steadily declining. But in 2021, HIV cases increased for the first time since 2014. This won’t come as a surprise to anyone who works in the sector. Sexual health services are funded by local authorities, which have been hit by years of austerity-driven public health cuts (the sector has had its funding cut by 24% in real terms since 2015). This period of chronic underinvestment has been made much worse by the impact of the Covid pandemic.
This is now affecting clinics’ ability to provide basic services. Many people are encouraged to attend sexual health services for an HIV test because they’ve been notified that they might be at risk of acquiring HIV after sexual contact with someone recently diagnosed with it. This is similar to contact-tracing for Covid-19.
Last year, the number of people who attended a sexual health service after being alerted in this way was less than half that in 2019. The proportion of those diagnosed with late-stage infection rose from 35% in 2019 to 40% in 2021. These people are more likely to already have been unwell at the time of diagnosis and to experience worse long-term health. Having not been on treatment, they would have been more likely to pass on HIV, unknowingly, over a longer period of time. Most troubling of all, there has also been a sharp increase in the number of people who have already been diagnosed with HIV but have not stayed in the healthcare system. This could pose severe consequences to their health.
The data shows that existing inequalities are deepening even further. Distance and travel time to sexual health clinics is far greater outside London, and access to testing, treatment and PrEP is more difficult. And while HIV is likely to be falling among gay and bisexual men, there is no such reduction for heterosexual adults. Altogether, this is a disturbing outlook. If we want to end new transmissions, testing and effective treatment are essential tools. But lack of funding and resources are holding us back. These figures are from 2021. In 2022, the problems caused by the Covid pandemic were further compounded by the mpox (monkeypox) outbreak, when sexual health clinics were forced to deliver diagnosis and treatment with no additional resources, and to undertake a severely underfunded ongoing vaccination campaign. This means the current situation is likely to be even worse, with a long backlog building up, no capacity to manage it, and even fewer resources to go around.
Our other most effective prevention tool is PrEP; a preventive medicine that, when taken properly, is almost 100% successful at preventing transmission. But as it stands, PrEP is failing to reach its potential. According to a report we co-authored earlier this year, almost two thirds of people trying to access PrEP found themselves unable to do so. And this data applies to people who are already trying to access PrEP. There are significant numbers of people who would benefit from the treatment but are simply not aware of its existence. Here, significant racial and gender disparities come into play. Not a single local service we spoke to reported more than a handful of women using PrEP, for instance, despite the fact that women – and particularly women from ethnic minority backgrounds – account for a growing number of new HIV diagnoses.
The 2030 goal is not a pipe dream. There’s still time to change course, and plenty of reasons to be optimistic. This week NHS England published the wildly successful results of its new scheme (launched as part of the HIV Action Plan) to test for HIV on an opt-out basis in hospital emergency departments. The scheme is available in the areas of highest HIV prevalence (London, Manchester, Brighton and Blackpool), and offers an HIV test to every single person who had a blood test for any reason at an A&E department. In the space of just 100 days, 128 people were diagnosed with HIV, reaching people who had been living with the virus without realising it.
These people will now be able to access treatment for themselves, and will avoid passing the virus on to others. A further 65 people were found who had previously been diagnosed with HIV but had slipped through the cracks of the healthcare system. This represents a significant opportunity to re-engage people with treatment. The demographics of people identified through the scheme are those less likely to come forward for testing at sexual health clinics and who may not realise they are at risk.
This scheme has been an unambiguous success. It should be available more widely. Areas such as Birmingham, Coventry and Bristol face similarly high levels of HIV, but lack of funding prevents the programme from being made available. There are no downsides to scaling up opt-out testing and PrEP: not only will it improve countless people’s lives but, at the risk of making a more cynical argument, it will save the NHS money in the long run if people are engaged in treatment more quickly or prevented from acquiring HIV in the first place.
So, while this latest data is disappointing and enormously frustrating, it only strengthens the moral imperative to do better this World Aids Day. More than 40 years after it started, we have the power to end new HIV transmissions in Britain within this decade. So many of us have lost friends and family members over the last 40 years. With this opportunity in front of us, it would be unforgivable to let it slip through our fingers. We have the tools to ensure nobody else acquires an avoidable infection or dies an avoidable death. We have the tools, and we know exactly what to do. It remains only to do it.
Deborah Gold is chief executive of the National Aids Trust