The HIV top 10

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Post by David Menadue and Adrian Ogier28 Feb 2014

1. Removing treatment restrictions

The forthcoming change to the PBS ruling on when someone can start HIV treatment is a major achievement for community advocates around the country.

The change means that people with HIV can start treatment when they wish, not when their CD4 count drops to 500.

Australia follows other countries who made this change when research showed early treatment has significant benefits for an individual’s health.

There is growing evidence that untreated HIV has detrimental health effects at all stages of the disease. Treating it earlier can limit the amount of latent HIV held in reservoirs, reduce the inflammation that HIV causes in the body, and may also prevent the development of other complications such as heart disease, cancer and osteopenia down the track.

CHALLENGE: SOME ARE YET TO BE CONVINCED
Some PLHIV are not ready to commit to a daily pill regimen. Others are doubtful of the merits of early treatment or are overly concerned about drug toxicity – influenced perhaps by the experiences of those who went through the ‘hit hard, hit early’ days when HIV treatment regimens were much harsher.

Some doctors do not believe there is enough clinical evidence to start treatment earlier.

2. Targets to reduce transmissions

At the 2012 Australasian HIV Conference, the community-led Melbourne Declaration set some bold targets. One of these is to halve new HIV infections by 2015. These targets were finally signed on to by federal and state governments at a Health Ministers’ meeting in 2013.

CHALLENGE: MEETING THOSE TARGETS
Last year saw a 10% increase in HIV infections in Australia.

In order to reduce new transmissions, we all need to embrace a number of tactics.

Testing rates within communities at risk need to improve. PLHIV need support to treat earlier.

Everyone needs to play safe.

With compelling evidence that treatment reduces transmission, government needs to support better treatment access, including the use of Pre-Exposure Prophylaxis (PrEP) for those at high risk.

About one-third of new transmissions occur because one party is unaware that they have HIV. Clearly more people need to test more often, but there are also other issues at play.

Assuming someone’s status based on the activity they are prepared to engage in is one of them.

We need strong messages about the ongoing importance of condoms and that treatment as prevention does not remove the risk of transmission during unprotected sex.

3. HIV Rapid testing

In a relatively short space of time, Australia has progressed from having no HIV rapid-testing sites to today when around 40 are operating around the country. Some of these are run out of GP clinics and sexual health services. Others have been set up by community organisations and the tests are administered by trained peers.

Evidence of the impact of these clinics is still to be determined but we do know that they are attracting a sizeable percentage of people who have never tested for HIV before. We also know that users like the service.

A list of rapid-testing sites is available at endinghiv.org.au/test-more/a-test/#wheretotest

CHALLENGE: PEOPLE TESTING TOO LATE
We still have people arriving at hospital emergency departments having developed an AIDS-defining illness without even knowing that they had HIV.

Damage to people’s health can be significant if they don’t take action to avoid immune damage early on. Efforts are needed to reach the estimated 15-30% undiagnosed cases of HIV in Australia.

4. Reducing the cost of antiretrovirals

WA and NT currently do not charge for antiretrovirals (ARVs).

Victorians can receive theirs free if they go to the Melbourne Sexual Health Centre. For the rest of Australia, most PLHIV can now pay one co-payment for a two-month supply of each drug in their combination.

Some progress has been made but PLHIV groups argue that the system should be fairer for everyone regardless of where they live.

A recent study by the Burnet Institute on the cost of ARVs in Victoria concluded that almost a quarter of PLHIV spend more than $800 per year on their HIV drugs alone. This does not include scripts for other common co-conditions such as diabetes, raised lipids or high blood pressure.

Some PLHIV are paying too much for their treatments. Those on low incomes who have other co-conditions tend to carry the greatest burden.

CHALLENGE: A FAIRER SYSTEM FOR ALL
HIV remains a major public health concern and if governments are serious about reducing the barriers to treatment access, they need to come up with solutions to reduce this cost burden.

Positive Life NSW recently lobbied the NSW government to provide ARVs for free or as a second option, a requirement for one co-payment regardless of the numbers of ARVs dispensed.

They were unsuccessful; the argument being that it would set a precedent for other chronic illnesses.

However, there is support from government to revise the system, particularly for those experiencing financial hardship.

So negotiations continue.

5. AIDS 2014

You would have to be living on another planet to not know that the World AIDS Conference is coming to Australia this year.

An estimated 15,000 of the finest minds in HIV clinical research, health promotion, care and support will descend on Melbourne for the week of 21-25 July. AIDS 2014 is a great opportunity to share our achievements and learn about different global approaches to HIV and to enlarge our HIV networks and unite in the response to HIV. (See page 4 for opportunities to volunteer and get free registration.)

CHALLENGE: CONFERENCES TAKE UP RESOURCES
In a climate of constrained government budgets, HIV agencies around the country have not generally been successful in getting extra funds to help with the demands of this significant international event.

Melbourne HIV community organisations are expected to provide cultural, information and visiting programs for delegates.

Most organisations are struggling to meet registration, travel and accommodation costs. Even exhibiting at the conference is an expensive exercise.

There is the potential for current priorities to be sidelined as resources are stretched to meet conference obligations.

State and federal governments need to contribute more.

6. Research into a cure

We get regular media reports on progress towards an HIV cure. Professor Sharon Lewin from the Alfred Hospital and Burnet Institute in Melbourne is a world-leading researcher into possible ways to eradicate the virus from the body and develop a ‘functional cure’. We will hope some significant announcements on progress in this area will be made at AIDS 2014.

CHALLENGE: CURE STILL YEARS AWAY
Even the most optimistic scientists admit an HIV cure is still some time away. The recent news that two Boston patients, who had been thought to be functionally cured through stem cell transplants, have experienced a relapse where HIV became detectable again, suggests that the progress to a cure may need multiple interventions.

7. People are talking about HIV stigma

A number of recent initiatives – the very successful ENUF campaign from Living Positive Victoria and the Sydney-based TIM website – have started the conversation about HIV stigma, particularly among the gay community. The ENUF campaign has enlisted the help of a range of celebrities and community figures to reduce the stigma PLHIV experience when they disclose their status. A number of theatre projects on HIV stigma are planned for AIDS 2014.

CHALLENGE: MANY DON’T SEE THE RELEVANCE
Many HIV-negative people don’t understand the impact of HIV stigma. They think they don’t know anyone with HIV when most likely they do. It is stigma that prevents friends from disclosing for fear of rejection.

Unless this climate of fear and secrecy is changed, it will remain difficult for people with HIV to disclose their status, including to sexual partners.

8. Successful program for Medicare Ineligibles

In November 2011, NAPWHA and the Kirby Institute, with the assistance of all Australian HIV pharmaceutical companies, set up a free access trial for PLHIV deemed by the federal government to be ineligible for Medicare.

The AHOD Temporary Residents’ Access Study (ATRAS) currently provides free ARVs to 180 HIV-positive people who are not yet permanent residents – commonly those on student or bridging visas.

CHALLENGE: GOVERNMENT NOT YET WILLING TO HELP
PLHIV ineligible for Medicare often delay starting treatment, are forced to purchase ARVs online and may not access their ideal regimen.

The ATRAS program was started out of necessity to help this vulnerable group and while it will last for four years, the program is now fully subscribed.

The first year’s evaluation showed significant improvements in the health and wellbeing of those who participated.

While it is yet to happen, we hope that the federal government will eventually be convinced of the individual and public health benefits of helping PLHIV ineligible for Medicare.

9. Some progress on HIV criminalisation

Victoria has the highest number of prosecutions in Australia for HIV transmissions and exposure.

HIV advocates are hopeful that a Victorian Legal Services Board grant to provide prosecutorial guidelines to prosecutors and lawyers involved in cases of alleged intentional transmission will mark a change in the thinking of the state’s prosecutors.

CHALLENGE: PROSPECTS FOR LEGAL CHANGES ARE UNCERTAIN
There has been slow progress for HIV community advocates working with prosecutors to get an education program off the ground. The complexity of the issue and the need to ensure that the information provided to prosecutors is accurate means that reforming the laws will take time. It is also likely that any proposed reforms to the laws would be reviewed by the Law Reform Commission which would likely involve a community enquiry before a Bill to change the existing laws was drafted.

10. Seventh national HIV strategy in development

News that the federal Minister for Health, the Hon. Peter Dutton, has supported the development of a new HIV Strategy was welcomed by HIV advocates. There was hope that the document would build on the agreements signed at the Health Ministers’ Meeting in 2013 that committed to the targets to reduce HIV infections and increase numbers of people with HIV on ARVs.

CHALLENGE: CONCERNS ABOUT ADEQUACY
Progress on development of the new Strategy has been slow, with concerns that the writing of the document has not included enough community opinion and it will not come with any increased resources.

It seems unlikely to be as strongly committed to the movement to end HIV as the NSW Strategy released last year which has seen great commitment and leadership from NSW Health Minister, the Hon. Jillian Skinner.