World AIDS Day, held annually on 1 December, serves as a yearly reminder of the global HIV and AIDS epidemic. In June 1981, the first reports of Acquired Immune Deficiency Syndrome (or AIDS) were published. The case definition for AIDS (established by CDC in 1982), and the subsequent surveillance of the condition, led to the discovery and characterisation of the infectious agent, HIV, in 1983.
According to the latest worldwide report of the United Nations Joint Programme on HIV/AIDS (UNAIDS), almost 37 million people were thought to be living with HIV in 2017. The upward trajectory of the global HIV/AIDS epidemic has been halted and reversed in recent years. This is evident in a reduction in both new infections and AIDS-related deaths as a consequence of advances in HIV treatment and the huge scale-up in treatment access. In 2017, an estimated 1.8 million people were newly infected with HIV (approximately 180,000 of whom were children); this represents decreases of 16% and 35% in diagnoses among adults and children, respectively, since 2010. Worldwide, young women are disproportionately affected by HIV with around 7,000 women aged 15-24 years becoming infected with HIV every week.
In 2014, UNAIDS launched the ‘Fast-Track’ strategy which aims to end the world AIDS epidemic by 2030. As part of the strategy, 90-90-90 targets have been set which require that, by 2020, 90% of people living with HIV know their HIV status, 90% of people who know their HIV-positive status are on treatment, and 90% of people on treatment have a suppressed viral load. In 2017, globally, 75% of those individuals infected knew their HIV status, of whom 79% were accessing treatment. Of those receiving treatment, 81% had achieved viral suppression. While considerable progress has been made, UNAIDS has warned that the current rate of decline in the number of new infections, for example, will be too slow to reach the Fast-Track Target of 500,000 new infections per year by 2020. Therefore, further efforts are required to diagnose and treat those who are infected if these targets are to be met.
Advances in HIV treatment, and the scale-up of access to treatment in recent years, continue to save lives. In 2017, the number of AIDS-related deaths halved from the peak of 1.9 million in 2004 to 940,000. According to UNAIDS, 2.3 million more people had access to life-saving antiretroviral drugs in 2017 compared to 2016, resulting in a total of 21.7 million individuals on treatment worldwide. This is a remarkable expansion in access to HIV treatment, more than doubling from 8.0 million in 2010. If the increasing rate of access to treatment is sustained, then there is the potential to achieve the UNAIDS target of 30 million on treatment by 2020.
A ‘treat all’ strategy is now recommended by both UNAIDS and the World Health Organisation (WHO) (related guidelines available from WHO) which calls for treatment initiation at the time of diagnosis for all HIV infected individuals. While such a strategy undoubtedly saves more lives, it also presents strategic, logistical and financial challenges in many countries. Yet it is expected that this approach will be cost-effective in the long-term as new infections will be averted and infected individuals will be retained in care, enabling them to stay healthier for longer with fewer morbidities and deaths. The 2015 British HIV Association (BHIVA) guidelines for the treatment of HIV-1 positive adults with antiretroviral therapy similarly recommend starting treatment soon after diagnosis, where possible, regardless of CD4 count.
The latest quarterly data on confirmed HIV-positive diagnoses and an overall update on HIV infection in Scotland are published this week on our website.
From January to September 2018, there were 213 reports of HIV infection, which include 141 (66%) individuals newly diagnosed and 72 (34%) reports for individuals who had been previously diagnosed before moving to Scotland. In 2017, 361 HIV-positive reports were recorded by HPS; this represents an increase compared to 2016 (321) and a return to the annual average of 360 observed in the preceding five year period. It should be noted that, over the last ten years, the number of new diagnoses has been slowly decreasing, notably among men who have sex with men (MSM) and those who acquire the infection through heterosexual intercourse, with a total of 228 in 2017 compared to 291 in 2009.
Unprotected sexual intercourse among MSM remains the main route through which new HIV infections are acquired in Scotland, however, it should be noted that, since 2015, an outbreak of HIV among people who inject drugs (PWID) in NHS Greater Glasgow & Clyde has resulted in an increase in the number of new HIV diagnoses in this group although transmissions are still occurring. Public health interventions to limit further transmission include: i) a sustained focus on testing those at risk, ii) the provision of outreach treatment services, and iii) community prescribing of HIV medication. Notably, the innovative model of care implemented has been highly successful with very high levels of PWID currently engaged in HIV treatment and care.
To the end of September 2018, an estimated 5,265 individuals have been diagnosed and are living with HIV in Scotland; however, there are also individuals who have the virus but who are unaware of their infection. Using newly published UK data on undiagnosed HIV infection, an estimated 91% of the estimated population living with HIV have been diagnosed; this suggests that one in eleven (9%) of those infected (around 500 people in Scotland) remain undiagnosed. The good news is that this indicates that we have now reached the first of the UNAIDS 90-90-90 targets, that is 90% of those living with HIV being aware of their status. While we should celebrate the prevention effort, we must continue to encourage and promote testing opportunities particularly as the evidence suggests that most new infections are a result of transmission from individuals who are unaware of their status. Opportunities for testing are available at specialist services (including sexual and reproductive health clinics), in the primary care setting, in community venues, via home sampling kits and also by purchasing self-testing kits which are available on-line. At a European level, health care practitioners are encouraged to unite their efforts to offer HIV and hepatitis testing to at-risk individuals during European HIV-Hepatitis Testing Week which runs this week (from 23-30 November 2018). Initiated in 2013, this annual event aims to consolidate efforts to promote testing and to raise awareness of the benefits of early diagnosis. More information is available on the European Testing Week website
Twenty-two years on from the introduction of freely available, highly effective, life-saving, antiretroviral treatment in the UK, access to treatment and care in Scotland is good: in the past year (from 1 July 2017 to 30 June 2018), 4,734 individuals attended specialist services for HIV treatment and care; of those attending, 98% received antiretroviral drugs. Therapy continues to be successful: 97% of patients undergoing treatment had evidence of viral suppression at their last attendance. Thus, continuing high levels of care and treatment are being provided for the increasing number of people diagnosed and living with HIV in Scotland and, in so doing, the UNAIDS targets of 90% of those diagnosed receiving antiretroviral therapy (ART), and 90% of all those receiving ART gaining viral suppression, have been achieved. Yet, public health action is still needed to widen further the access to, and increase opportunities for, HIV testing. In 2017, 43% of those newly diagnosed were at a late stage of infection at which point treatment may be less effective on a weakened immune system.
Prevention of HIV transmission remains a public health challenge both worldwide and here in Scotland. Since July 2017, HIV pre-exposure prophylaxis (PrEP) has been available through the NHS in Scotland for individuals attending sexual health clinics who are at high risk of acquiring HIV through sexual transmission as assessed using eligibility criteria. Almost two thousand individuals were prescribed PrEP in the first year of the programme, the majority of whom were MSM. The year one report on the implementation and evaluation of PrEP in Scotland will be published in early 2019.
The Scottish Government’s Sexual Health and Bloodborne Virus Framework (REF) aims to reduce the number of HIV transmissions and the number of infected individuals who remain undiagnosed, while maintaining the high-quality services which provide treatment and care for those living with the virus.
Through multi-agency partnership and the monitoring of high level outcomes, the framework supports improvements in sexual health and wellbeing and addresses the impact of blood borne virus infections in Scotland. The news that Scotland has achieved the UNAIDS 90-90-90 targets is very welcome with the data indicating 91% know their diagnosis, 98% are on sustained antiviral therapy and 97% have evidence of viral suppression.