High-income countries with people at high risk of HIV should replicate a groundbreaking trial in Australia, which has seen new infections fall by 25% in one year following the rapid rollout of free HIV medication, researchers say.
When taken daily the pre-exposure prophylaxis drug known as PrEP is almost 100% effective in preventing HIV-negative people from acquiring the virus. In 2016, NSW became the first Australian state to trial PrEP on a large scale. In the course of just one year 9,714 HIV-negative people at high risk of acquiring HIV were enrolled in the trial, and given PrEP for free. The program was funded by the NSW government.
Professor Andrew Grulich, from the Kirby Institute at UNSW Sydney, led a study that followed 3,069 gay and bisexual men from the trial, who were aged over 18, for one year. All men were tested every three months. Only two of the men acquired HIV, and neither of those had been taking PrEP as prescribed.
In the year following the trial, statewide new HIV infections in gay and bisexual men fell by one-third, from 149 infections in the 12 months prior to the trial to 102 in the 12 months after. The declines were highest among Australian-born gay and bisexual men (48.7%) and gay and bisexual men living in the “gay suburbs” of Sydney (51.8%). Grulich described the speed of the decline in HIV infections in gay and bisexual men, considered a high-risk group for infection in Australia, as a world-first.
While PrEP has been widely available in the US since 2012, it is not always accessible, with the cost prohibitive to many of those without health insurance. Uptake was initially slow, though it is increasing thanks to education, trials and subsidy schemes. In England, the NHS announced it would provide PrEP to high-risk patients through a study that began in 2016, but the rollout is slower than in Australia, with an aim to enrol 10,000 men over three years.
The rapid, targeted and large-scale uptake of the Australian study made it unique, and the findings have been published in international medical journal The Lancet HIV.
“We think our results can be generalised to other countries with similar epidemics, and that’s high-income countries where a large proportion of HIV is in gay and bisexual men,” Grulich told Guardian Australia. “We’ve shown you can quickly and substantially impact on HIV infections by introducing interventions at scale, targeting large proportions of people at risk.”
While regular surveillance reports on HIV rates in NSW have reported rapid declines, the study published in The Lancet reveals why those declines occurred. The researchers worked closely with gay and bisexual community groups to educate men about PrEP and to ensure they knew how to access it. These groups helped to create demand for PrEP and to enrol people in the study. Doctors were also informed.
“States that don’t invest in a community-based response will have more difficulty in achieving high-level uptake,” Grulich said. “We can’t expect all gay men to suddenly know about this drug and present to a doctor and ask for it.”
The study identified some concerns. For example, lower reductions in HIV infections were seen in men from culturally and linguistically diverse backgrounds and in those who lived outside of major cities, who were not as well connected to gay communities. Work is now being done to target those groups.
The trial ceased enrolling men in April, when the Australian government began subsidising PrEP through the Pharmaceutical Benefits Scheme. Grulich said this move would see further reductions in new infections across the country by removing the price barrier, but he said targeted education would be critical to achieving the rapid results shown in his study.
In a comment piece that accompanied the study, Professor Sheena McCormack, with the Medical Research Centre’s clinical trials unit in the UK, said in contrast to Australia, most countries are unlikely to reach the United Nations HIV targets by 2020. She wrote that testing for HIV was also crucial to meet the targets – those with HIV who are properly treated with medication cannot pass the virus on once their viral load is undetectable.
“New South Wales has shown how effective the combined efforts of government leadership, civil society, and a state-wide sexual health service can be at achieving high coverage with a new technology,” she wrote. “Others need to follow suit.”