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Rapidly declining HIV infection in MSM in central London

2017; Elsevier BV; Volume: 4; Issue: 11 Linguagem: Inglês

10.1016/s2352-3018(17)30181-9

2405-4704

Nneka Nwokolo, Andrew Hill, Alan McOwan, Anton Pozniak,

Sex work and related issues

In 2016, there were 1·8 million new HIV infections worldwide. Although the annual number of new HIV infections has fallen by 16% since 2010, the rate of decline is far too slow to meet the fast-track target of 500 000 new infections per year, agreed at the UN General Assembly in 2016.1UNAIDSUNAIDS data 201.http://www.unaids.org/en/resources/documents/2017/2017_data_bookGoogle Scholar We still have no cure or effective vaccine to prevent HIV. There are, however, many HIV prevention approaches available, including rapid treatment of those diagnosed with HIV to render them uninfectious—the treatment as prevention strategy. This has been an important UNAIDS policy to diminish the global burden of HIV by achieving the 90-90-90 metric by 2020 and embraced by the fast-track cities campaign.2UNAIDSFast track cities: ending the AIDS epidemic.http://www.unaids.org/sites/default/files/media_asset/20141201_Paris_Declaration_en.pdfGoogle Scholar In some countries where 90-90-90 has been or has almost been achieved, incidence rates have not declined meaningfully,3Abdool Karim S Is the UNAIDS target sufficient for HIV control in Botswana?.Lancet HIV. 2016; 3: e191-e196Summary Full Text Full Text PDF PubMed Scopus (4) Google Scholar but in others such as Swaziland, where there is a comprehensive test-and-treat programme linked to prevention including voluntary medical male circumcision, incidence has fallen by 44%.4Nkambule R, Nuwagaba-Biribonwoha H, Mnisi Z, et al. SubstantialPprogress inCconfronting the HIVEepidemic in Swaziland. 9th IAS Conference on Science. July 23–26, 2017. Paris, France: abstr MOAX0204LB.Google Scholar Until 2015, new HIV infections in the UK were relatively stable, with a total of 6286 infections in that year.5Public Health EnglandHIV in the UK—2016 report.https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/602942/HIV_in_the_UK_report.pdfGoogle Scholar In 2016, Public Health England reported an 18% reduction in new diagnoses, with a 21% decrease among gay and bisexual men, a group in whom diagnoses had steadily been increasing since 2007.6Public Health EnglandHIV in the United Kingdom: decline in new HIV diagnoses in gay and bisexual men in London, 2017 report.https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/648913/hpr3517_HIV_AA.pdfGoogle Scholar The reduced incidence in gay and bisexual men was most pronounced in London, in whom there was a 29% decrease with an overall decline in infections in gay men outside London of 11%. The accepted explanation for this significant change was a large increase in HIV tests among gay and bisexual men attending sexual health clinics (from 37 224 in 2007 to 143 560 in 2016), including repeat testing in higher risk men and improvements in the uptake of ART after HIV diagnosis. However, increased screening probably provides only a partial explanation. 56 Dean Street, a sexual health service in London, diagnoses one in three new HIV infections in the capital and sees a quarter of newly diagnosed individuals in the UK. Since 2015, the clinic has seen an 80% reduction in diagnoses (figure). Similar trends have been seen in four other large London clinics.7Brown AE Mohammed H Ogaz D et al.Fall in new HIV diagnoses among men who have sex with men (MSM) at selected London sexual health clinics since early 2015: testing or treatment or pre-exposure prophylaxis (PrEP)?.Euro Surveill. 2017; 22 (pii=30553.)Crossref Scopus (81) Google Scholar The decline in new infections seen at Dean Street occurred against a background of a significant increase in testing in high-risk gay men in 2014–15 which subsequently stabilised. Other important factors might have also played a part. Patients at the clinic commence HIV treatment within a median of 7 days of diagnosis. Whether this contributes substantially to a decrease in transmission deserves further study because knowledge of HIV status alone is associated with a reduction in risk behaviour for a variable period of time after diagnosis.8Fox J White PJ Macdonal N et al.Reductions in HIV transmission risk behaviour following diagnosis of primary HIV infection: a cohort of high-risk men who have sex with men.HIV Medicine. 2009; 10: 432438xCrossref Scopus (128) Google Scholar Another important factor that needs to be considered as a major contributor to the decline in diagnoses is the use of HIV pre-exposure prophylaxis (PrEP). In the Autumn of 2014, the PROUD and IPERGAY PrEP studies were stopped early, after both showed an 86% reduction in HIV acquisition risk for people taking tenofovir disoproxil fumarate plus emtricitabine versus placebo.9McCormack S Dunn D Desai M et al.Pre-exposure prophylaxis to prevent the acquisition of HIV-1 infection (PROUD): effectiveness results from the pilot phase of a pragmatic open-label randomised trial.Lancet. 2016; 387: 5-60Summary Full Text Full Text PDF Scopus (1190) Google Scholar, 10Molina J-M Capitant C Spire B et al.On-Demand Ppreexposure Pprophylaxis in Mmen at Hhigh Rrisk for HIV-1 Iinfection.N Engl J Med. 2015; 373: 2232-2246Crossref Scopus (1029) Google Scholar Gay men began to purchase generic PrEP from India as it is not available through the UK health system. This was facilitated by community activists who set up I Want PrEP Now offering advice and links to online pharmacies for people seeking to purchase PrEP on the internet. At the same time, 56 Dean Street launched a service offering support and monitoring for people buying generics online, including drug concentration testing to ensure authenticity. In addition, Dean Street PRIME, an intervention for people with at least a 10% chance of seroconversion, gave priority access to testing for STIs and postexposure prophylaxis and tailored online support to reduce HIV transmission risk. The clinic based its efforts to reduce new HIV diagnoses on the San Francisco Getting to Zero campaign which has resulted in a significant fall in HIV diagnoses in that city. A study of PrEP is about to start in England, with plans to enrol 10 000 patients over the next 3 years; but whether this trial will be large enough to cope with demand is unclear. Australia, a country with a population size a fifth of that in the UK, has already recruited over 11 000 patients to the PrEPX-SA and EPIC-NSW trials; in New South Wales the EPIC-NSW trial was enlarged from 3700 to 6300 to cope with demand, while in Melbourne PrEPX-SA has already fully enrolled and a waiting list of patients hoping to join. Despite not being a fast-track city, London has experienced significant reductions in HIV diagnoses in gay and bisexual men. Although the relative contributions of strategies are hard to pinpoint, the reductions seem to have been achieved through a combination of reducing the community viral load by targeting high-risk men to facilitate regular repeat HIV testing and increasing early diagnoses followed by the offer of immediate antiretroviral treatment. Importantly, what seems to have made the difference is the addition of targeted prevention and supporting the early adoption of generic PrEP sourced in the community by gay men themselves. Controlling the epidemic in high risk gay men in London is tantalisingly close to being achieved, but other groups in the UK such as black Africans remain at significantly high risk of HIV acquisition. The strategies of test, treat, and prevent need to be applied to the HIV epidemic whatever its shape or form if we are to stay on track to end AIDS. NN, AH, and AM declare no competing interests. AP has received grants and personal fees from ViiV, Merck, Janssen, BMS, and Gilead and is chair of the European AIDS Clinical Society antiretroviral guidelines subcommittee. Towards no missed opportunities: the experience of 56 Dean StreetIn the era of HIV combination prevention including testing, condoms, treatment-as-prevention, and pre-exposure prophylaxis (PrEP), many HIV infections are potentially preventable. Following implementation of combination prevention, 56 Dean Street (London, UK) has seen a decline in new HIV diagnoses from 679 in 2016 to 129 in 2020.1,2 Full-Text PDF For the greatest impact, end caps on PrEP access nowNHS England announced in January that it will fund an increase in the number of participants in the Pre-exposure prophylaxis (PrEP) Impact Trial from 13 000 to 26 000. Although approved in principle, the trial oversight board said on January 23 that it needs to further engage with local authorities and trial sites before an exact timescale for the increase is fixed. Scheduled to end in 2020, the 3-year trial has been oversubscribed by men who have sex with men (MSM), with capacity reached in many clinics and potential participants turned away. Full-Text PDF