Can the UK stop HIV transmission by 2030?

In the UK, the Terrence Higgins Trust - which supports people living with HIV - has also embraced the target of aiming to end new cases of HIV in England by 2030. So, how are they are planning on doing it? Here’s Richard Angell, the chief executive of the Terrence Higgins Trust…

Richard - The UK government agreed to make the UNAIDS goal of ending new cases of HIV by 2030 a government goal. We as the charity sector ourselves at Terrence Higgins Trust, our friends at National AIDS Trust and the Elton John AIDS Foundation, came together to create a HIV commission, to really give them a blueprint on how they turn that aspiration into reality. The government's response to that was to draft a HIV action plan that took us from 2021 to where we are today. The newly elected governments here in the UK has committed to renewing that action plan, to learn the lessons of what's been successful on the reduction of transmissions that's taken place to date and really re-focus on the goal of getting to zero, and the kind of strategies it will involve to achieve that.

Chris - What does the HIV landscape in a country like the UK look like at the moment, in terms of numbers and also rates of new cases?

Richard - In the UK there's about 106,000 people who are living with HIV. All but 5,000 know about it. So, the key task in ending the onward transmission of HIV is to find the 5,150 people across the UK that are living with HIV but don't know about it yet. The trick is to make sure they're testing for HIV. Now obviously to test those 5,000 people, it's tested a much bigger cohort and pool of people to do that. Most of that work is done in sexual health services. We've had some great innovations in recent years that have interrupted people's care pathway and where they're using our health service and inserted a HIV test there, and we found some people who had no idea they might be living with HIV and made sure they are diagnosed and linked to treatment.

Chris - What proportion are homegrown and what proportion are coming in?

Richard - We've had an anomaly in the most recent years, because as the government has changed the visa rules post Brexit, they have been seeking to attract workers from countries that have a high prevalence of HIV. So if you are bringing people in from a high prevalence country it is not surprising if a significant number of them are living with HIV. The experience overwhelmingly is that those people coming to the UK are already on medication and have controlled HIV. So those who are coming into the UK appear in the statistics, as people who are kind of new in the UK with HIV, but they're not bringing in their HIV per se. Then crucially, they're not bringing in transmissible HIV to the UK, but we've got about two and half thousand essentially newly diagnosed people that had a transmission of HIV here in the UK. That number is broadly down on where we've been in previous years, but starting plateau, as we get nearer to zero. The challenge is you need to do more and more tests to find fewer and fewer people.

Chris - How are those transmissions that we are home growing, we can't account for on the basis of people who are coming to the UK with a known diagnosis as you just outlined, how do those transmissions occur, and among which groups?

Richard - Essentially now as likely to be from people who are men who have sex with men, or people who are having sex between men and women, the transmissions amongst introduced drug users is incredibly low. The UK has eliminated vertical transmission, which is what we call mother to child transmission by doing a form of testing that everybody gets in antenatal services when they're pregnant.

Chris - Given that you can define and qualify who the risk groups are so well, you must therefore have some pretty clear ideas as to the best strategy to stop this. What is that strategy?

Richard - The strategies that work are programs that de-stigmatise testing for people and encourage people to take up innovative and online confidential, and free forms of testing. So we run a very successful HIV testing week every year that gets 2500, 1st time testers, and diagnoses a significant number of people with HIV each year. The things that are starting to work as we are looking for cohorts in smaller and smaller proportions, in bigger and bigger population groups, are where we're interrupting people's care pathway. So in 81 A&Es across the country, there is a form of opt-out testing for everyone who goes to an accident and emergency department. That means that if you are turning up in an NHS setting and you're having bloods taken, you'll automatically test it for HIV, Hep C and often Hep B. That is found about 1200 people who have been living with HIV but didn't know about it. We're looking to expand that to multi-year programs, but also to other settings and would like to see anybody who's engaging in a termination of pregnancy or having an abortion automatically be offered a HIV and STI screening test, those who are using dermatology services to make sure they're regularly tested for HIV. Everyone who goes to a sexual health clinic makes sure they leave without or don't leave without getting a HIV test.

Chris - Those are excellent, but also very much reactive to what's gone on. What about the flip side, the proactivity, doing things to stop people catching it in the first place. What sort of strategies have you got there, because you've got to do that as well as just pick people up and put them on treatment?

Richard - Absolutely, so there's key tools to preventing HIV transmission. Firstly, the person living with HIV knows that they're living with HIV, so they can get medication only for their healthcare, but so they can reduce their viral load and make sure they can't pass on HIV to other people. The second is that those who test negative, they can use condoms to stop HIV transmission if they're having sex. If they are having sex without a condom, there is a drug called PrEP. PrEP is a drug you might take daily or around a sex-based event that you might be having in your life. If you take it correctly, it will stop the onward transmission of HIV and if it were to enter your system, it wouldn't be able to take hold in your cells in the way it would with somebody who doesn't take that drug. So it's a really important tool for people and we're doing lots of work to promote that going forward. We're working with the UK Health Security Agency to make sure that those who particularly in the system might identify as having a PrEP need and need to use a HIV prevention tool, that more of those are getting that need.

Chris - How optimistic are you of hitting that 2030 aspiration of eliminating the transmission of HIV? Because as we all know, as you get closer to a target, and we've seen this with things like the eradication of Polio, you get to a handful of cases and then it escapes again, or it gets harder and harder to get those last few. Do you think we're going to make it?

Richard - I remain optimistic about ending new cases by 2030 here in the UK and I believe we have the partners in place that share the vision for making it happen. It's our job to convince them to kind of will the means to get that over the line, but let's be honest, it's possible, but not yet probable. We aren't doing enough as a country to get there, but I think we are in pole position to being the first country in the world to make it happen.