World AIDS Day, which falls on 1 December 2019, serves as a yearly reminder of the global HIV and AIDS epidemic. The most recent worldwide report of the United Nations Joint Programme on HIV/AIDS (UNAIDS) estimated that 37.9 million people were living with HIV in 2018. A reversal in recent years of the upward trajectory of the global HIV/AIDS epidemic is evident in a continued reduction in both new infections and AIDS-related deaths, which is a consequence of advances in HIV treatment and the huge scale-up in treatment access. In 2018, an estimated 1.7 million people were newly infected with HIV which represents a 40% decrease compared to the peak in 1997.
In Scotland, according to the latest quarterly data which covers the period up to 30 September 2019, 5,568 individuals are diagnosed and living with HIV. From January to September 2019, 267 new reports of HIV diagnoses were recorded of which 136 were first-ever diagnoses and 131 were newly reported in Scotland, but previously diagnosed elsewhere. Unprotected sexual intercourse among men who have sex with men (MSM) remains the main route through which new HIV infections are acquired in Scotland (33% in the first nine months of 2019 compared with 21% among heterosexuals and 8% among people who inject drugs (PWID)), however since 2015, there has been an outbreak of HIV among PWID in NHS Greater Glasgow & Clyde with over 145 new HIV diagnoses in this risk group compared to a pre-outbreak annual average of 10 diagnoses. Public health interventions to limit further transmission continue, with there being a sustained focus on testing those at risk, providing outreach treatment services, and community prescribing of HIV medication.
In recent years, advances in, and better access to, HIV treatment have continued to save lives. There was a 60% reduction in the global number of AIDS-related deaths to 770,000 in 2018 compared to the peak of 1.9 million in 2004. According to UNAIDS, 1.6 million more people had access to life-saving antiretroviral therapy (ART) in 2018 compared to 2017, resulting in a total of 23.3 million individuals on treatment worldwide. This is a near three-fold expansion in access to HIV treatment from 8 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.
With the aim of ending the world AIDS epidemic by 2030, the Fast-Track Cities strategy was launched in 2014. This is a global initiative, led by UNAIDS, IAPAC (International Association of Providers of AIDS Care) and the Mayor of Paris, calling on city leaders to sign up to the Paris Declaration and, in so doing, show a commitment to meeting the UNAIDS 90-90-90 targets 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). To date, over 300 cities globally have signed up to the initiative.
In Scotland, a Fast-Tracking Scotland project was launched by the third sector organisation, HIV Scotland, in October 2018. The ambition is to make Scotland the first Fast-Track country where all cities in a single country sign the Paris Declaration. On World AIDS Day 2018, Glasgow became the first of Scotland’s seven cities to do so, followed by Aberdeen, Dundee and Edinburgh to date. Work is now underway to develop local strategic plans to ensure that the objectives of the Fast-Track initiative are met.
Scotland, as a whole, has now achieved the key UNAIDS 90-90-90 targets ahead of 2020. As of 31 December 2018, it was estimated that there were 5,881 people living with HIV (PLHIV) in Scotland and, of these, 91% (5,352) had been diagnosed. Of those 5,352 diagnosed as PLHIV, 90% (4,799) were receiving ART and, of these, 94% (4,530) had an undetectable viral load. By comparison, 79% of those individuals infected worldwide knew their HIV status at the end of 2018, 78% of whom were accessing treatment and, of those receiving treatment, 86% 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.
Although access to, and uptake of, treatment in Scotland is very good, there is evidence that public health action is needed to further increase access to, and provide opportunities for, HIV testing. In 2018, more than a quarter (28%) of those newly diagnosed was at a late stage of infection, at which point treatment may be less effective on a weakened immune system. In addition to early and more frequent testing opportunities, prevention efforts are as important as ever. Between January and September 2019, 26% of first ever diagnoses had been acquired in the previous three to four months, indicating that new transmissions are occurring. The prevention toolkit in Scotland was strengthened in July 2017 when HIV pre-exposure prophylaxis (PrEP) became available via the NHS for individuals attending sexual health clinics who are at high risk of acquiring HIV through sexual transmission as assessed using eligibility criteria. During the first year of Scotland’s PrEP programme, almost 2,000 individuals were prescribed PrEP, the majority of those being MSM. The largest proportion (39%) of those prescribed PrEP were aged 20-29 at their first prescription and almost a third (28%) were aged 40 or above. For approximately one-fifth of those prescribed PrEP during the first 12 months, this was the very first time, or the first time in the previous 10 years, that they were attending sexual health services. Uptake data for the first 24 months of the programme are due to be published by Health Protection Scotland (HPS)/Information Services Division (ISD) on 17 December 2019.
Since the discovery of HIV in 1983, and more than twenty years on from the introduction of freely available, highly effective, life-saving, ART in the UK, the associated public health challenges have changed considerably, yet the importance of prevention messages and early testing for those at risk remain. It is hoped that by adopting a multi-agency partnership approach to support wide-ranging improvements in the sexual health of its people, Scotland can maintain, and possibly exceed, the global targets set.