WAD2014: Getting to Zero - is it possible?

December 2014


Against a dramatic backdrop of a stormy Melbourne sky and frequent rain showers, a defiant feeling of optimism prevailed at the Living Victoria/Burnet Institute World AIDS Day 2014 celebration.

For so many who attended, they have faced many challenges personally or through their love and support of partners and friends touched by HIV and AIDS. It was a fitting reminder that HIV can affect anyone. But the overwhelming message from speakers Sarah Feagan and Richard Keane who shared their personal stories, was that support of family and friends, and the elimination of stigma and discrimination is still a critical part of helping them deal each day with living with HIV. More than 35 million people are living with HIV globally and tragically more than 1000 people die each day from AIDS-related illnesses.

Burnet Institute’s Associate Professor Mark Stoové was proud to be this year’s keynote speaker at the event attended by the general public, members of Living Positive Victoria, Burnet Institute, JOY FM, Victorian Department of Health, community leaders, educators and parliamentarians.

Below is his keynote address:

First I would like to acknowledge the traditional owners of the land on which we meet, the Wurundjeri people, and pay my respects to their elders past and present. I’d also like to say that it is an absolute honour and privilege to be asked by Living Positive Victoria to help officially launch World AIDS Day 2014.

In Australia, we should be really proud of our HIV prevention efforts – not least because of the world-leading bipartisan government and community response that prevented the major HIV epidemic seen in many other parts of the world among people who inject drugs.

The galvanisation of the gay community in Australia in response to the devastating impact of HIV in the 1980s and 90s was also crucial in preventing many more infections. Community solidarity and advocacy was responsible for creating caring and supportive social and health environments that allowed those living with HIV and AIDS to do so with dignity, in an era where medicine had few answers.

The HIV world changed in the mid-1990s. New and effective therapies arrived that were able to suppress the virus and arrest HIV disease progression. Alongside this paradigm shift in the outlook of those living with HIV, we also saw continued declines in people being diagnosed in Australia. At this point HIV prevention in Australia was relatively black and white and revolved around condoms and lube.

Since then we have made cumulative and sometimes spectacular gains in our understanding of HIV prevention, which in turn has become more complex. World AIDS 2014 now coincides with the beginning of a new prevention era; one of true optimism. It now recognised that we have the prevention knowledge and tools capable of delivering a dramatic global reduction in the burden of HIV. ? Which brings us to the global theme of World AIDS Day 2014; a consistent theme over recent years – GETTING TO ZERO.

While GETTING TO ZERO includes zero AIDS-related deaths and zero discrimination, it is often the zero new infections that attracts most attention. Getting to zero new infections is an eye-catching and seductive statement – are we to take this goal literally? Is the goal realistic? Or is this goal essentially one of aspiration? ? Ambitious UNAIDS targets intended to propel us to zero were writ-large in metaphorical neon lights during the 2014 International AIDS Conference in Melbourne – the “90 90 90” targets by 2020:

  • 90 percent of people living with HIV knowing their status
  • 90 percent of people diagnosed with HIV on treatment
  • 90 percent of people on treatment with suppressed viral loads.

These targets were projected by UNAIDS to end the HIV epidemic by 2030 – meaning a reduction in annual HIV transmissions by 90 percent, to around 200,000 new annual infections globally.

In Australia, this would mean around 120 new diagnoses in 2030 – down from around 1,200 per year we see now. ? But how realistic is such a reduction in Australia if we were to hit those targets by 2020? Is it realistic to expect such a reduction in new HIV diagnoses when it is internationally recognised that Australia is as close as anywhere in the world to achieving the 90, 90, 90 targets now. Our best estimates suggest:

  • That about 86 percent of people living with HIV in Australia know their status
  • About 80 percent of people diagnosed are on ART
  • About 85 percent of people on ART are virally suppressed.

Over the past several years we have also seen gradual but important increases in all of these indicators; in particular we have reliable data showing substantial increases in overall HIV testing numbers among gay men in both Melbourne and Sydney.

But in parallel we have seen continued increases in annual HIV diagnoses that remain at post-HAART era highs.

  • If we take diagnoses alone should we consider our efforts at HIV prevention a failure because they are not consistent with getting to zero?
  • If we take numbers testing, the amount of undiagnosed HIV, and the numbers on treatment, should we consider our efforts at HIV prevention a success because they are approaching the ambitious UNAIDS targets?

Unfortunately it is often bold declarations about disease outcomes that dominate prevention success or failure; ones that are sometimes more politically driven than evidence-informed.

The most prominent recent example for HIV prevention in Australia is the target in our current national strategy of reducing sexually transmitted HIV by 50 percent by 2015.

Unfortunately, taking on such ambitious disease outcome targets as literal, rather than aspirational, risks worthy and otherwise successful programs being discarded or inappropriately revised if new diagnosis targets are not met.
? We must ensure we focus on the right measures success. Not simply the number of people diagnosed with HIV:

  • but the number of people considered at risk who are testing frequently
  • the number who are diagnosed and aware of their status
  • the number who are accessing and being retained in care or treatment
  • the number who have an undetectable viral load
  • the number of people reporting protecting themselves or their partners – whether through condoms, negotiated safety, not sharing needle and syringes or other means.

To some extent if we focus on these targets, the rest takes care of itself. But we also have to acknowledge that there will always be a certain number of people unaware of their status, there will always be a certain number of people who, for whatever reason, engage in risk, and thankfully, there is also In Australia a growing number of healthy, socially engaged and sexually active people living with HIV.

We must therefore acknowledge that, as with any transmissible disease, there will, for the foreseeable future, always be HIV risk – all the more so when risk intersects with pleasure, relationships, social connectedness and identify. In this context Getting to Zero new infections must be viewed as a laudable aspirational goal rather than an absolutist yard stick measuring prevention success or failure.

  • One that inspires us and drives our prevention efforts
  • One that provokes a sustained commitment and investment from government
  • One that encourages innovative services, like peer-delivered and community-based HIV testing at PRONTO!
  • One that drives health systems to offer people choice such as allowing home-based testing for those who want it, or providing opportunities to access PrEP for people feel this is the best way to protect themselves.
  • One that drives the effective collaborations we see between community organisations like the Victorian AIDS Council and Living Positive Victoria and research organisations like Burnet Institute.

And also ones that ensure we continue to be vigilant in areas that sometimes receive less attention because of our previous successes:

  • Ensuring accessible, culturally acceptable and effective harm reduction services for Aboriginal communities, including Aboriginal people who inject drugs.
  • Reducing barriers and providing supportive environments for people who inject drugs or those with injecting histories to access opioid substitution therapies or other drug treatment programs.
  • Implementing strategies that are evidence based rather than politically palatable, such as supervised injecting facilities and prison-based needle and syringe programs that have provided strong prevention evidence in other countries.

But ours are also first-world problems. On World AIDS Day it’s important to reflect on how privileged we are to be living in a country with high quality health care and low levels of stigma and intolerance towards those at risk or living with HIV compared to many other parts of the world.

I’ve only just returned from Myanmar where I spent time at Burnet Institute’s drop-in centres for people who inject drugs and men-who-have sex with men. This is a country where:

  • the average income is less than $100 per month
  • A country where only half of those eligible for HIV treatment are receiving it. And eligibility in Myanmar is still based on having a CD4 count less than 350!
  • This is also a country where sex work, sex between men and injecting drug use remain illegal and vulnerable people who engage in these practices continue to be harassed and arrested.

I spent nights with our peer outreach workers in the cruising sites of Mandalay and Yangon, and watched how their HIV education work and their distribution of condoms and lube were disrupted by police harassment.

So, while we enjoy our freedoms in Australia, we must also remember that our aspirations of Getting to Zero also mean ZERO discrimination. The end of intolerance and legislative sanctions towards risk populations or people living with HIV must end if we are to have any chance of ending the global HIV epidemic.

Remember those we love and loved, and keep up all the great work. Thanks.

Written by Tracy Parish. Keynote address by Associate Professor Mark Stoové.

In Australia, we should be really proud of our HIV prevention efforts – not least because of the world-leading bipartisan government and community response that prevented the major HIV epidemic seen in many other parts of the world among people who inject drugs.

Mark Stoové