The Aids endgame: how the UK and US are committed to wiping out HIV

But how achievable are these goals? Many in the UK HIV/Aids community believe that, in this country at least, the target is easily within reach.

The UK was one of the first countries to hit United Nations targets to have 90 per cent of people with HIV aware of their status, 90 per cent on treatment and 90 per cent virally suppressed, that is with such low levels of the virus in their blood it is undetectable. In fact, the UK has surpassed these targets and its figures are 92 per cent, 98 per cent and 97 per cent respectively - meeting the 2020 target two years early.

Deborah Gold, chief executive of the National Aids Trust, is optimistic about Mr Hancock’s pledge. “We’re at a very exciting time in England in terms of where we are at in dealing with the epidemic. Ending HIV transmission is certainly within our grasp. But continuing with what we’re doing now will not inevitably lead to that end - we are on a good path but it would be a mistake to think we can just carry that on,” she says.

One of the game changers in recent years has been pre-exposure prophylaxis (PrEP), a pill which, when taken daily by people in high-risk groups, can reduce the risk of infection with HIV by up to 86 per cent.

PrEP is available to anyone who is judged at high-risk of contracting the disease in Scotland and Wales but in England it is only available as part of a trial. Mr Hancock has said that the numbers on the trial will double from 13,000 to 26,000, but there are concerns that this may not be enough.

Debbie Laycock, head of policy at the Terrence Higgins Trust, says that a trial is unnecessary.

“We don’t need a trial, we know PrEP works - gay and bisexual men are being turned away from trials and there have been cases of people getting HIV because they haven’t been able to access PrEP. It’s such an important preventive tool and we haven’t got it into the hands of those who need it,” she says.

As part of his announcement Mr Hancock pledged extra funding to projects targeting vulnerable communities, such as migrants and injecting drug users, and it is reducing infections in these groups - beyond gay men in big cities - that will be key to hitting the 2030 target.

While the number of new infections are declining in all groups in England - the number of new diagnoses fell by 28 per cent between 2015 and 2017 - black and ethnic minority gay and bisexual men often fall under the radar in terms of prevention work. 

Rusi Jaspal, professor of psychology and sexual health at De Montfort University, says that awareness of HIV/Aids among this group is generally low.

In fact, Public Health England data show that the rate of late HIV diagnosis among black and ethnic minority men is high - 69 per cent of all those who were diagnosed late, when the amount of virus in their blood was above a certain level, were black African men.

In a survey of 500 black and ethnic minority gay men, in which Prof Jaspal posed a series of questions on HIV, participants only got an average of 50 per cent right.

“If you don’t know how HIV is transmitted you’re not able to prevent yourself getting it or spreading it. Levels of HIV knowledge among this group are low and among south Asian men they’re the lowest of all,” he says.

Gay south Asian men are less likely to be out, may be conducting their sex lives “underground” using dating apps or frequenting cruising grounds where public health messages are unlikely to be displayed or where safe sex is discussed. They may also be married. 

“If you don’t identify as gay you’re less likely to go out on the gay scene so you simply won't learn about HIV or how it's spread. There’s an element of people closing themselves off to networks,” he says.

“Even though the number of gay men in this group are quite small a single individual could have a vast number of sexual partners so HIV could spread quite quickly,” says Prof Jaspal.

In the US the situation is similar. HIV is no longer spreading through gay communities on the west and east coasts - those most likely to be infected now are black and Hispanic gay and bisexual men living in the southern states.

Greg Millett, director of public policy at the American Foundation for Aids Research, says: “Cities like San Francisco, New York and Seattle can easily end HIV transmission in the next five to 10 years. It’s now important that we extend some of the successes we have seen here to other parts of the States.”

According to US data about 1.1 million people in the US are living with HIV, and about 14 per cent of these are unaware that they are infected. After a period of rapid decline in the number of new infections,  progress in eliminating HIV has stalled and the number of new infections has stabilised at around 39,000 a year over the last three years.

A recent study by researchers at Georgia State University and the University at Albany-SUNY found that the US was unlikely to achieve the ambitious target, but could reduce the number of new infections by 67 per cent over that period. 

Heather Bradley, lead author of the study, said achieving the 67 per cent target would require real changes to the way HIV care is delivered and would require 95 per cent of people with HIV to be receiving treatment.

"The percentage of people diagnosed with HIV who receive care is estimated to be just under 70 per cent. That number been fairly flat over the last five years. Given we have had the stagnation of the programme, increasing that number to 95 per cent would require a huge lift," she says.  

The US government has said it will target funding to the 48 counties where the epidemic is most prevalent, a move welcomed by campaigners who are now eagerly awaiting the budget to be unveiled sometime this month.

 Michael Ruppal, executive director of the Aids Institute, says new, ring-fenced funding is needed. 

"We want a new line item on the budget - not realigning dollars, not stealing from one pot to put in another. The number we have heard most consistently is $250m in the first year. Since this is a 10-year plan it would ramp up the dollars over that time," he says. 

Mr Trump is not a natural ally of the Aids movement or the gay community but the battle against HIV/Aids has always been a bipartisan effort in the US, says Mr Ruppal.

“The messenger always changes the way people hear it. First of all Trump made the announcement not only publicly but at the State of the Union. But from a patient advocacy standpoint anything he mentions around health care is positive.”

He adds that one of the “best things to happen to the HIV community” was the Affordable Care Act, introduced by the Obama administration, and Mr Trump’s attempts to dismantle this can only harm people with HIV.

“That’s the contradiction with this great announcement. On the one had they want to help people but on the other there’s a political movement to tear down all the insurance health care infrastructure that’s been built. The two don’t reconcile," he says.

“We found that five insurers had placed all the HIV drugs on the highest possible tier, which is effectively designing a programme to discriminate and discourage people from picking a plan because it’s too costly," he says. 

Mr Millett also believes that the hostile rhetoric around immigrants will deter many Hispanic and black people from seeking out services.

According to US government data HIV diagnoses among Hispanics/Latino gay and bisexual men increased by 12 per cent between 2012 and 2016 - predating the Trump presidency.

“Immigration policies are not helpful. We’re seeing an increase in new infections among Latino gay men. There are fears among some that if they seek out services they’ll get deported. This is what we’re hearing anecdotally,” he says.

Earlier this week scientists in the UK announced that a patient had been “cured” of HIV after stem cell treatment for cancer. While this is undoubtedly exciting news it is highly unlikely such a hi-tech solution will end the epidemics in either the UK or the US.

Commentators on both sides of the Atlantic agree that what will make an impact are proper, sustained funding and targeting of key populations. In the UK, HIV campaigners are critical of government cuts to public health - £85 million in England this year - which they say will severely affect sexual health services and the prevention work they do.

But what everyone can agree on is that ending the stigma around HIV is vital.

Deborah Gold says: “The key thing would be a vaccine or a cure. But the biggest barrier to resolving HIV is overcoming stigma.”

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