How did Sydney curb the spread of HIV?

Can Australia offer some insights for the UK as to how to stop the spread of HIV infection? Healthcare services in New South Wales have managed to successfully reduce new HIV cases in Sydney - where HIV was particularly prevalent - by 88%, describing transmission as “virtually eliminated” from Inner-city Sydney. Will Tingle has been speaking with Andrew Grulich who is an epidemiologist at the Kirby Institute at UNSW - the University of New South Wales…

Andrew - The unique thing about Sydney and Australia of course, is that it has been the epicentre of the epidemic. So it has had quite a few resources focused on it. So if you look around Australia, it probably is the place where there's more funding for community-based organisations responding to HIV. There's more education. The state of New South Wales has a highly organised health system in response to HIV and there's a great partnership between researchers, community organisations, governments and clinicians, which all have their roles to play in achieving this goal.

Will - Did you find that preventative measures or treatment had a greater impact on the reduction of spread of HIV instances?

Andrew - I really don't think you can single out one or the other. There are two sides of the same equation, particularly when we have come to realise that treatment in itself is prevention. That's because once a person with HIV is treated and they're undetectable, and their viral load becomes undetectable, they cannot transmit. So that's a big part of the success. The other major part, the other major biomedical intervention we've had in the last decade was the rollout of pre-exposure prophylaxis to actually negative men. We did that in Australia in a somewhat unique way, in that when we saw its promise in that it's at the individual level, it's close to a hundred percent effective if people take it. The modelling told us that we should introduce it quickly and we should introduce it at scale to try to get everybody at risk of treatment. So we did it in a big bang between 2016 and 2019. Even in those three years, we saw about a 40% decline in HIV transmission.

Will - The advantage of it being a scheme in inner Sydney though, is presumably that the population density is rather high, and so you can keep better tabs on things and keep track of things, and there's better availability of healthcare. Do you think the scheme could have the same amount of success if it was rolled out to less densely populated areas?

Andrew - It's not only rural, it's even in the outer suburbs. We now have a situation since treatment as prevention as PrEP, where prevention is largely biomedical and requires access to medical care, which I mean, we have pretty good access in Australia with universal healthcare, but we're finding that fewer doctors outside of the inner city want to prescribe PrEP, and they're not as well informed about PrEP. So, the challenge is to train healthcare providers, doctors, nurses, pharmacists, so that they know about PrEP and they will be advocates for prep. Because at the moment we're finding it's too hard for gay men in those outer suburbs and in the country, to get themselves and keep themselves on PrEP. I think we've got to also address the stigma that people hold towards people with HIV and even self-stigma. If we could address the stigma and if we could provide better health services, then I think we would be a very long way towards elimination.

Will - So big picture, do you think that elimination of HIV is possible by 2030?

Andrew - So it’s really important that we understand that when we talk elimination, we're not talking about no virus being left in the world because HIV is a condition which, can exist in an asymptomatic state for a decade or more formal elimination as in normal virus as we, as we've got for smallpox is not possible. In fact, the United Nation AIDS Agency definition is a 90% reduction in new infections. We are virtually there in Sydney, and yeah, I do believe we can reach that by 2030 in Australia.