The Malta Independent 5 March 2024, Tuesday
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No time to waste: we have the tools to end new HIV cases by 2030

Friday, 1 December 2023, 11:22 Last update: about 4 months ago

By Dr Mark Josef Rapa, Lecturer in Bioethics at the University of Manchester

On 1 December, on World AIDS Day, we come together to show support to those who are living with HIV and remember those who died from AIDS-related illnesses. We also celebrate the work of those who have come before us, who worked tirelessly to secure testing and effective treatment. Some still associate living with HIV with harrowing images of tombstones in health campaigns. Others may remember the viral photo of Lady Diana shaking hands with a patient living with HIV without gloves, a photo and event that challenged the misconceptions about HIV. 

HIV is a virus that can weaken the immune system and, if left untreated, can lead to AIDS. However, people living with HIV who are on treatment can expect to lead a normal, healthy life. Up until a few years ago, the treatment was a cocktail of pills with undesirable side effects. However, again, thanks to science, the treatment can entail a single pill a day with little to no side effects. 

While HIV can still not be cured today, the available treatment can suppress the virus to an undetectable level. Anyone with undetectable viral load has zero risk of HIV transmission during sex. Since 2016, this has become known as Undetectable = Untransmittable. Its message is backed by scientific data and supported by the international health community, including WHO and UNAIDS. In the latest development, even those with a suppressed (equal to or below 1000 copies/ml) but not undetectable have almost zero risk of transmitting HIV during sex.

It is unfortunate the advancements in treatment have not been met with a decrease in the stigma associated with the virus. This means that members of various communities in our societies feel marginalised because of a virus that they have acquired. The virus is not airborne. It can only spread from an HIV-positive person through the exchange of bodily fluids, most commonly during sex. It is not spread by sharing food, hugging or even kissing. Still, the stigma persists, and with it, the narrative that only some individuals are at high risk of acquiring the virus. 

In 2022, Malta reported an increase in HIV diagnoses (103 cases). However, 42% of the reported cases had already been diagnosed abroad. Similar to the region, sexual transmission between men remains one of the most common routes of HIV transmission. This does not mean that others are not at high risk of acquiring the virus. Globally, 53% of people living with HIV are women. HIV is a virus. It is not Santa. It doesn't care if you have been naughty or nice. 

There are currently 39 million people living with HIV globally. In 2022, there were 1.3 million new diagnoses, a dramatic global decrease from the 2.8 million in 2000.  Within the EU/EEA region, the ECDC reports 22,995 diagnoses of HIV in 2022 in the 30 EU/EEA countries, of which 3,824 cases were previously diagnosed. Even though this is an increase in cases compared to 2020 and 2021, the number of cases per 100,000 compared to 2019 has decreased. The ECDC contributes to the increase in cases to the restitution of testing and other sexual health services post-COVID and the increased population movement in the EU/EEA region. 

With UNAIDS's 2025 targets, 'putting greater emphasis on the removing societal and legal impediments to service delivery, and on linking or integrating the provision of HIV services with the other services needed by people living with HIV and communities at risk to stay healthy and build sustainable livelihoods', we all have a role to play. For many years, the primary ways one could prevent acquiring HIV were to either abstain from sex or use condoms. But we now have additional tools. Pre-Exposure Prophylaxis, better known as PrEP, is a pill that an HIV-negative individual takes to stay HIV-negative. Elsewhere, it has been compared to the contraceptive pills since it has to be taken daily for it to be effective. There are, however, alternative regimes such as on-demand or event-driven PrEP known as 2-1-1. An individual would take two pills two to 24 hours before sex, another pill 24 hours after the first dose and the last 48 hours after the first dose; cisgender women should not try to use this method. 

The efficacy of PrEP is undisputed. When taken as prescribed, it reduces the risk of getting HIV from sex by 99% and can also be taken by pregnant women. Where available, PrEP has contributed to a dramatic decrease in new HIV cases, particularly where it has been incorporated into the National Health or Private Health System. PrEP works, and we must ensure it reaches those who most benefit from it. 

In Malta, PrEP is available in pharmacies against a prescription from a GU or Infectious Disease specialist. It costs €58. We have long maintained that this price is prohibitive for most, particularly younger people who may not have an income or simply cannot afford it if they do. l. Some would argue that individuals engaging in high-risk activity should also be responsible for taking on the costs that come with them. Engaging in what tends to be a highly morally charged debate in this area is seldom helpful. While we can (and should) continue to have such discussions academically, we must prevent new HIV cases with all the tools we have available. 

The Maltese Government has been promising the introduction of PrEP on the NHS since before 2021. After a missed opportunity when leaving out PrEP from the tendering process for HIV medication back in 2019, the government is still unfathomably dragging its feet. The delay is unconscionable and does not follow either science or logic. The cost of providing PrEP would be far lower than providing treatment. Other than tablets used as PrEP, some countries have injectable PrEP available, a bimonthly injection that research has shown could prevent around 10% more new infections than tablets alone at similar levels of usage.

Similarly, Post-Exposure Prophylaxis (PEP), not to be confused with PrEP, is a combination of HIV drugs to be taken soon after one has potentially come in contact with HIV to reduce the chance of the virus taking hold costs upward of €600 for 28 days. Again, this is prohibitive and doesn't stand to any sound public health reasoning. 

A month ago, Health Minister Chris Fearne mentioned that a plan on how PrEP will be included in the government formulary would form part of the new sexual health policy. Fearne also said the new sexual health policy will be available for public consultation 'soon'. While incorporating access to preventative drugs should be part of the policy, those at high risk should not have to wait for it to come into place to benefit from such drugs. Furthermore, we know that attempts to update the 2010 Sexual Health Policy have been delayed before. 

The new Sexual Health Policy should be a relevant and ambitious document. Based on the latest scientific evidence, it should establish and secure sexual health and well-being as a priority. It should embrace this year's UNAIDS theme, 'Let Communities Build,' by working with local organisations such as Checkpoint Malta and HIV Malta, organisations that depend on volunteers who do a lot with little to no budget or support. 

These communities should be around the discussion table, leading and contributing to and leading the development of policies that affect their health and lives. They are the link to the communities most affected and who can change the narrative around sexual health and wellbeing. With better access to treatment for all people living with HIV,  PrEP and PEP, increased testing facilities including opt-out testing, and age-appropriate sexual health education, we can start seeing the number of new diagnoses go down. We can achieve all this and more, but not only through policy on paper but with communities leading the change.  

For more information about sexual health and HIV, visit www.hivmalta.com / https://www.facebook.com/checkpointmt/ www.prepingmalta.com www.sexualhealth.gov.mt. To book an appointment at the GU clinic, call: 25457494/1


Dr Mark Josef Rapa is a Lecturer in Bioethics at the University of Manchester. They are the founder of PrEPingMalta and member of the European AIDS Treatment Group

[email protected]

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