HIV: A prescription for prevention

On June 5, 1981, the US Centres for Disease Control and Prevention (CDC) published a report describing cases of a rare lung infection in five young, previously healthy, gay men in Los Angeles. They all had other unusual infections as well, indicating that their immune systems were not working. The culprit: a virus that attacked immune cells. By 1987 the Human Immunodeficiency Virus (HIV) and its evil twin, AIDS (Acquired Immune Deficiency Syndrome), had reached pandemic status. According to the World Health Organisation, more than 70 million people have been infected with HIV, and it's claimed the lives of nearly 40 million people worldwide.

Billions of dollars and 15 years of intense research finally yielded an effective treatment in 1996, and the number of new AIDS cases in the US began to decline for the first time. In 1997, combination antiretroviral therapy became the official global standard of care. An HIV infection was no longer a death sentence.

A closer look at the numbers, however, shows that although HIV may have fallen off the urgency radar, the epidemic is far from over. With the social, economic and health havoc it wreaks, HIV remains one of the world’s most significant public health challenges.

More than 1000 people are diagnosed with HIV every year in Australia.

Statistics show that in the past decade, instead of continuing to decrease, the incidence of new HIV infection has stabilised or, in some countries, increased. Even in Australia, which historically has had a proactive approach to HIV prevention, more than 1000 people are diagnosed with HIV every year. At the end of 2016, there were an estimated 26,444 people living with HIV in Australia.

Joel Murray’s^* diagnosis came in 2010 when he was his mid-20s, in a period when he was engaging in a lot of risky sex. “I wasn’t shocked; I realised it was a consequence of my behaviour. I knew quite a bit about HIV; I knew it was a chronic, treatable condition. What I hadn’t anticipated was the impact that the HIV diagnosis would have on my anxiety and mental health.” He fell out of employment and struggled with stigma, both internal and external.

Improving the prevention toolkit

At that time, the only way to prevent HIV infection was using a condom. Now, there’s another option: daily use of a pill containing two of the antiretroviral drugs used to treat HIV. Known as PrEP, for Pre-Exposure Prophylaxis, this preventative treatment reduces a person’s chance of HIV infection by up to 99 per cent in people with high medication adherence. “It’s incredibly efficacious in preventing HIV,” says Associate Professor Edwina Wright, an infectious diseases physician and clinical researcher at the Alfred Hospital, the Burnet Institute and the Peter Doherty Institute, all of which have taken a leading role in HIV prevention in Australia.

The first study that showed that the drug actually worked came out in 2010. To get PrEP in Australia, you can get a private prescription – which costs about $800 a month – or import cheaper, generic drugs from international pharmacies. “The World Health Organisation has said this should be available to all people at risk of HIV. This is standard of care,” says Wright. “But it's taken a very long time to get this new intervention out to people.”

On February 9, 2018, the Federal Pharmaceutical Benefits Advisory Committee made a decision to list PrEP on the Pharmaceutical Benefits Scheme (PBS), meaning that within months, it will be available by prescription from any GP in Australia and subsidised by the government. PrEP guidelines co-authored by Wright and studies conducted by her team at Alfred Monash helped pave the way for the recent decision.

"We’ve never had anything to prevent HIV like this before, ever."

“Our first study, VicPrEP, was a small study designed to look at how people experienced PrEP, and what their behaviour was,” says Wright. “We found that Victorians were incredibly responsible with taking the medication.” They also found that PrEP use correlated with an increase in sexually transmitted infections (STIs). “Some of this is due to increased testing, and some of it is because people change their behaviour and use condoms less,” says Wright. “But the key thing to grasp is that we’ve never had anything to prevent HIV like this before, ever. So you don’t throw the baby out with the bathwater.” Unlike HIV, many STIs can be treated with antibiotics.

Following VicPrEP, “we wanted to provide a big intervention at the state level and see if it would drive down HIV infection rates”, Wright explains. That study, called PrEPX, was launched in July 2016 and has enrolled 4100 gay and bisexual men across Victoria. The study was subsequently expanded to South Australia and Tasmania. NSW is also running a similar study called EPIC, involving 8000 people. “Nearly half of the 31,000 gay and bisexual men in Australia who are estimated to be eligible for PrEP, meaning their behaviour would merit using PrEP, are on it,” says Wright. “In the world’s eye, we’ve done really well.” Although Wright says it’s too soon to say if infection rates are going down in Victoria, the NSW study showed PrEP use was accompanied by a 30 per cent drop in new infections.

Eradicating HIV and AIDS

In 2014, all Australian states and territories pledged to end new HIV infections by 2020. The United Nations AIDS program is aiming for no new infections and no AIDS worldwide by 2030. The PrEP intervention is part of Australia’s effort to meet its ambitious goal. This is important, because even though HIV infection can be controlled by the antiretroviral drug regimen, it's not a cure. “If you’re HIV-positive you still carry an increased risk for other illnesses in the future – things like cardiovascular disease and kidney disease,” says Wright. “Your immune character changes, and it never returns to normal.” The economic cost of this compromised health status adds up over the years, both for individuals and health providers.

In many countries around the world, the social cost is also high. “There are real issues around job opportunities and safety if a person is found out to be HIV-positive. You also face a lot of stigma from your own family, from your religion. It’s simply not as easy as taking a tablet every day,” says Wright.

Joel Murray says that if PrEP had been available in 2010, he would have used it. “I think I would have made that choice because I had identified myself to be taking risks,” he says. “I was one of those people who got tested every three months. I wanted to be sure I didn’t pass on any STIs to my partners. I guess I was a bit more concerned about protecting other people than I was about protecting myself.”

"It’s taken away some of the fear of sex."

Wright explains that PrEP is just one part of a larger picture in which treatment and vaccination also will play important roles in bringing new HIV infection rates down to zero. Recent research has shown that once an HIV-positive individual is on treatment, their chance of transmitting the virus to a partner is essentially nil. “I think there’s been a real shift in people feeling less afraid,” says Wright. A new 'U=U' campaign to change public perception has been rolled out in the US, with the blessing of the CDC. In this formula, the first U stands for ‘Undetectable’ and the second for ‘Uninfectious’.

“I know quite a few people who use PrEP,” says Murray. “For a lot of them, it’s taken away some of the fear of sex. Some of them have also become amazing allies of people living with HIV. They understand that people living with HIV can’t transmit the virus while on effective treatment, so they’ve become not only champions of PrEP, but also champions of treatment as effective prevention.”

The effort to eradicate new HIV infections will need to enlist doctors and activists in reaching beyond the gay and bisexual community, says Wright. “Twenty per cent of new diagnoses are in heterosexuals,” she says. “I suspect really they’re not thinking HIV at all. We need to make sure we have PrEP offered to the right people, and that GPs have HIV risk on their radar.”

Murray concurs. “I think Australians see it as a gay disease, and that’s just not true. It’s wonderful that we’ve got PrEP, I think it’s a really important tool in tackling the transmission of HIV, but I’m concerned about people who might be at risk who aren’t part of the gay community. They’ll continue to get HIV because they might not have access or information on PrEP. HIV’s lifetime is not over yet.”

* Joel Murray is a senior policy officer at Living Positive Victoria and an HIV advocate.