Fri 5 Jun 2015 In: Health and HIV View at Wayback View at NDHA
Yesterday, it was announced that the annual number of HIV diagnoses amongst men who have sex with men has increased over the past three years to become the highest since the HIV epidemic reached New Zealand. In a strongly-worded criticism of the current NZ AIDS Foundation-led prevention campaigns which place maximum emphasis on condoms as the best prevention measure, HIV-positive gay man and ex-NZAF chair Michael Stevens took prevention programme strategists to task for what he believes is their narrow and unchanging approach. This morning, Dr Peter Saxton, Director, Gay Men’s Sexual Health research group at the University of Auckland, explains why he totally disagrees. This afternoon, Shaun Robinson, Executive Director of the NZAF, responds, looking at New Zealand's HIV epidemic amongst gay and bi men, and its prevention strategies, from a different perspective. Responding to HIV Shaun Robinson Michael Stevens makes some useful points in his response to the latest HIV statistics. There are also some points that need to be put into perspective. We all agree that increasing numbers of new HIV diagnoses is not good, and must be taken very seriously. Eighty-six gay and bisexual guys contracted HIV in New Zealand in 2014, 17 more than the same figure for the year before. This is the third year that we have seen an increase following the very large decrease in 2011. Does this mean that the New Zealand AIDS Foundations prevention programme is not working? I don’t think so. Let’s keep this in perspective, for a start New Zealand has achieved one of the lowest rates of HIV in the world at 6.5% for gay and bisexual men. This is considerably lower than in countries which have moved away from condom promotion and put a lot of emphasis on treatment as prevention and PrEP e.g. Australia 14%, San Francisco 24% and London close to 20%. It is the condom culture that had created this low prevalence in New Zealand and this makes this country one of the safest places for gay and bisexual men to have sex because your chances of unknowingly having sex with someone with HIV are half that of Australia for example. There are considerable pressures pushing the number of HIV diagnoses up, slowly rising numbers of people living with HIV, a sense that HIV is not a big deal, increased testing which uncovers HIV contracted years ago … are just a few. We need everything at our disposal to combat the epidemic. But we need to be very careful and strategic about how the various prevention tools are used. I agree that there are several methods of preventing the spread of HIV. But they are not all equally useful. The key question is how we use these in a combination that will take things forward not backwards. Let’s look at Treatment as Prevention (TasP). It is true that if a person with HIV is on medication and has achieved consistent undetectable viral load their chances of passing on the virus reduce dramatically. NZAF wants this prevention benefit as well as the health benefit for the individual. That is a key reason why NZAF has been ramping up HIV testing and advocating for the removal of the PHARMAC threshold for access to treatment. But there is a fundamental problem with trying to use this as a means of stopping the spread of HIV – the virus is most infectious in its early stages and that is also when it is hardest to detect in a test. So testing and treatment alone will never be enough to stop HIV, and if condom use falls while we are trying to increase testing then we will go backwards. Then there is PrEP, the use of HIV medications (Truvada) by people who don’t have the virus to stop themselves being infected. There is definitely a place for this in the New Zealand context. But there are a lot of ifs, buts and maybes. For a start PrEP, like TASP, does nothing to protect against other STIs which are wide-spread and serious for gay men. Then there are potential side effects and long term toxicity dangers such as liver damage – if you already have HIV then you have no choice but to take meds and manage the side-effects and risks, but it’s quite a stretch to say large numbers of HIV negative gay men should do that. Then there is adherence, you have to take the pills as directed – if people don’t, PrEP won’t work and there is the risk of a Truvada resistant strains of HIV developing, which would be a disaster. And there is cost – PrEP is very expensive and is not funded anywhere in the world except by private health insurance in the USA and on trial projects in different parts of the world. Just this week an English study discussed in AIDS Map showed that if condom use reduces because people switch to PrEP then it is not cost effective for wide scale use. Yes there are some guys who don’t wear condoms and put themselves and others at risk and they definitely should have access to PrEP under the supervision of sexual health doctors. NZAF is working with MoH, Pharmac and Auckland Sexual Health to try and get a PrEP project of this nature off the ground in New Zealand. Anywhere in the world where communities are considering these prevention approaches it is acknowledged that if condom use declines then things will go backwards. By comparison to TASP and PrEP, condoms still have huge benefits: their use is already wide-spread, you can see them (you can’t see undetectable viral load or that someone has taken PrEP regularly) they protect against most STIs and they are cheap. We definitely want people to test more and want to diagnose as many of those who have HIV as early as we can, to get them on treatment and achieving undetectable viral load. For guys who won’t use condoms, yes we want PrEP to be available through sexual health services. Number one, we want to keep condoms at the forefront of prevention and push condom use even higher. We can get all of these things working in the right combination with the emphasis in the right places and that will have an impact on the epidemic. - Shaun Robinson, Executive Director, NZ AIDS Foundation. Shaun Robinson - 5th June 2015