“There is no magic bullet, but in the United Kingdom we have some incredible health-care providers who work very well with community members, which is an important part of our success.”
Mr Matthew Hodson, Executive Director of the HIV information charity NAM aidsmap, shares insights into how the United Kingdom has managed to meet and surpass the 90–90–90 targets to address the AIDS epidemic, initially set by the Joint United Nations Programme on HIV/AIDS (UNAIDS) for 2020.
He says nonjudgmental health services promote trust, which in turn leads to an increase in the number of people getting tested. “I think there are some wonderful examples of HIV clinicians in this country who are very involved with the communities, who are passionate about improving the lives of people living with HIV, and who aren’t overly paternalistic in their approach to their patients, and I think that makes an enormous difference in terms of trust.”
The 90–90–90 targets set out by UNAIDS refer to 3 targets for 2020: 90% of all people living with HIV know their HIV status, 90% of all people with diagnosed HIV infection receive sustained antiretroviral therapy, and 90% of all people receiving antiretroviral therapy have viral suppression. To accelerate action, UNAIDS has adjusted these targets to 95–95–95 by 2030.
The United Kingdom’s achievement stands in contrast to the rest of the WHO European Region. New data from WHO/Europe and the European Centre for Disease Prevention and Control (ECDC) showed a 24% drop in the rate of newly diagnosed HIV cases between 2019 and 2020 – largely due to reduced testing for HIV following disruptions to health services during the COVID-19 pandemic. Data indicate that the number of people in the Region with undiagnosed HIV is on the rise.
Combining interventions
In 2019, 94% of people living with HIV in the United Kingdom knew their status. Of those, 98% were also receiving treatment, and 97% of those being treated were virally suppressed. The United Kingdom reached each of the 90–90–90 targets 2 years ahead of the 2020 goal.
“We haven’t pitted one aspect of HIV prevention against the others,” Mr Hodson points out. “Instead, there’s been a sense that we need to do everything together, and it’s with that synergy that we’re going to get results.”
He goes on to highlight a wide variety of interventions that have collectively had a positive impact in the United Kingdom. These include access to post-exposure prophylaxis (PrEP) and the speed with which newly diagnosed people now receive treatment. Awareness about transmission risks has also improved, and many more people now know that those with HIV can have families and live long and healthy lives.
Maintaining political will
A reduction in stigma around HIV combined with a publicly funded health system that has relatively few barriers to care has helped shape the United Kingdom’s success. Good data-monitoring systems also allow information to be shared constructively between clinicians, researchers and epidemiologists.
Looking ahead, Mr Hodson stresses that political will needs to remain strong in order for the United Kingdom to reach its commitment to eliminate HIV by 2030. “As the pool of undiagnosed infections in the country gets smaller, the number of people you have to test to pick up a single reactive result is probably going to get bigger, and then it becomes an expense issue and that can be a challenge.”
Another challenge is that HIV care in the United Kingdom is often specialized in sexual-health or hospital settings, rather than in primary health-care settings. “Because our levels of HIV diagnosis are so high, it’s harder to find the people who perhaps don’t see themselves as at risk or are unaware that testing and HIV treatment is available to them free of charge,” explains Mr Hodson.
Making the right choices
Following the United Kingdom’s success, experts from Public Health England were included in WHO groups to help develop WHO HIV guidelines, and in technical expert platforms to ensure that the WHO HIV guidelines address the needs of more countries in the Region.
The United Kingdom is now ready to intensify its efforts and work towards achieving its political commitment to eliminate HIV by 2030.
Dr Valerie Delpech, Head of the HIV Team at the UK Health Security Agency, reflects, “It’s about empowering people, because empowered patients are much more likely to be able to make the right health choices for themselves. I think this is part of the reason why our treatment uptake is high and why our retention in care is high, and therefore viral suppression is really high among people in the United Kingdom.”
She adds, “We are proud that the United Kingdom met the UNAIDS 95–95–95 targets in 2020, and we have made strong progress in our aim to end HIV transmission by 2030. Our data show that national efforts invested in providing comprehensive combination prevention, and in particular HIV testing and early treatment, are working in England. The scale-up of PrEP among people at higher risk of HIV has clearly amplified our response to end HIV transmission.”
Dr Delpech concludes by pointing to remaining challenges: “We also know that progress is unequal, with the decline in HIV transmission mostly seen in gay and bisexual men who are white and live in London. More must be done to reduce HIV transmission across the United Kingdom, regardless of ethnic group, age, level of HIV exposure and where people live.”
On World AIDS Day 2021, WHO emphasizes the important role of the community in maintaining HIV services, as well as the need to confront the special challenges presented by the COVID-19 pandemic for people living with HIV. Equal access to HIV prevention, testing, treatment and care should be assured at all times. Countries should be prepared, with mechanisms in place, to always maintain these services while working in solidarity with the community.
