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Consensus statement on comprehensive HIV prevention in Aotearoa/New Zealand

National HIV/AIDS Forum 31 May 2017

“The HIV epidemic can be reversed in Aotearoa/New Zealand by implementing effective HIV prevention actions urgently, to scale and in partnership. These include condoms, injecting equipment, prompt HIV treatment on diagnosis, ongoing retention in HIV care, HIV pre-exposure prophylaxis for those most-at-risk, more frequent HIV testing, and thorough STI screening. These actions need to be supported by a capable workforce, surveillance of infection and of behaviours, and the elimination of HIV stigma.”

Introduction

HIV poses a serious threat to public health. In Aotearoa/New Zealand HIV transmission has been relatively well controlled, particularly over the first 15 years of the epidemic. This was due to effective responses based on scientific evidence, timely action, progressive policy and law reform, and partnerships between communities, non-government organisations (NGOs), clinicians and the state.

However the current situation is worsening, with 2016 recording the highest annual HIV diagnoses on record.1 As the annual cost of treating HIV has doubled over 5 years to $32 million, this calls for urgent, focussed action utilising the latest scientific evidence and renewed partnerships. Members of the National HIV Forum which represents key stakeholders in HIV prevention and care in Aotearoa/New Zealand formally recommend that “comprehensive” HIV prevention be adopted as the national agenda for such responses.

Figure: New HIV diagnoses in New Zealand

Figure: New HIV diagnoses in New Zealand

Source: AIDS Epidemiology Group. Includes infections acquired in NZ and overseas.

“Comprehensive” HIV prevention

Comprehensive HIV prevention means:

  • using a combination of evidence-informed behavioural, biomedical and structural HIV prevention approaches strategically and simultaneously, as recommended by UNAIDS;2
  • initiating these approaches in multiple domains e.g. individual, relationship, community and society;
  • implementing strategies at a sufficient scale to reverse the epidemic.3

Comprehensive HIV prevention responds to two important developments in HIV prevention science:

  • evidence published since 2015 on the early use of HIV antiretroviral therapy (ART) to achieve and sustain viral suppression. This improves the health of people living with HIV4 and minimises HIV transmission risks.5,6 ART can also be used strategically as pre-exposure prophylaxis (PrEP) to dramatically reduce HIV acquisition among uninfected people;7
  • mathematical modelling of the large potential impact on HIV transmission at the population-level of increased HIV testing, prompt HIV treatment and PrEP for most-at-risk people.8 This includes epidemic reversal if scale-up targets are met.

Comprehensive HIV prevention therefore takes globally established best-practice and focusses national investment towards the realistic goal of reducing HIV incidence.

Actions

Reversing the HIV epidemic will require multiple simultaneous prevention strategies. To focus efforts and invest wisely for maximum impact, the following six priority actions are recommended:

Action Purpose
(1) Sophisticated promotion of condoms to protect against HIV and STIs during anal and vaginal intercourse, and continuation of needle and syringe exchange programmes To interrupt HIV and STI transmission
(2) Timely, more frequent and widespread HIV testing by improving access to testing services in clinical and community settings To reduce the number with undiagnosed HIV infection
(3) HIV antiretroviral treatment to be offered promptly following diagnosis, and ongoing retention in health care, to achieve and maintain an undetectable viral load To minimise transmission and maximise personal wellbeing of people with confirmed HIV infection
(4) Pre-exposure prophylaxis (PrEP) and quarterly STI screening made available to people without HIV at high risk and unable to sustain behavioural risk reduction To target the most vulnerable individuals who play a disproportionate role in onward HIV transmission
(5) Improved access to comprehensive STI vaccination, screening and treatment To control resurgent STI epidemics and synergistically enhance HIV control
(6) Ongoing surveillance and research into HIV and STI infection and risk behaviours To enable evidence-based decision making, evaluate progress and prompt agile responses

(Table adapted from [3])

Principles

The full spectrum of public health activity, skills and strategy will be needed to successfully implement these actions:

  • these range from individual interventions to policy reform, utilising approaches such as sexuality education, health education, community development, health promotion, harm reduction and social marketing;9
  • responses should be targeted to most-at-risk populations and their partners, especially men who have sex with men (MSM), migrant communities, people who inject drugs and sex workers;
  • services should be inclusive and respect diversity, and recognise the importance of peer-delivered services including Māori-led responses and the involvement of people living with HIV;
  • HIV stigma must be challenged to improve the lives of people living with HIV and to motivate engagement in HIV prevention and care;
  • health workforce capacity, training and guidelines need to keep pace with demand, especially in specialist sexual health services and primary care;
  • new prevention efforts should be carefully crafted and coordinated to minimise risk compensation and to ensure the effects are additive. For example, PrEP should not displace condoms and the outcome should be a net gain (i.e. it prevents more HIV infections).

Leadership

To achieve and sustain this goal, communities, NGOs, clinicians and the Government need to work in partnership. The proposed Sexual and Reproductive Health Action Plan provides an umbrella framework for partnership and this Comprehensive HIV Prevention Consensus Statement complements the Action Plan.

With a common understanding, a shared purpose, a clear roadmap of actions and a commitment to ending transmission the HIV epidemic can once again be reversed in Aotearoa/New Zealand.

National HIV/AIDS Forum members

This consensus statement was developed by the National HIV and AIDS Forum, a collective made up of parties working in HIV prevention, care, policy and research in Aotearoa/New Zealand. The objective of the Forum is to serve as a multi-disciplinary national HIV and AIDS body that provides leadership in cross-sector collaboration. It meets this objective by identifying and debating key issues, providing guidance to relevant government Ministries and agencies and supporting the co-ordination of HIV-related service delivery by public sector and civil society organisations.

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Additional Signatories

Dr Edward Coughlan
Christchurch Sexual Health Service
Dr Rupert Handy
Auckland District Health Board Adult Infectious Diseases Service
Jane Bruning
Mark Fisher
Dr Graham Mills
Waikato District Health Board
Dr Jane Morgan
Waikato District Health Board
Dr Anne Robertson
MidCentral District Health Board
Alison Green
Dr Alan Pithie
Canterbury District Health Board
Dr Massimo Giola
Bay of Plenty District Health Board
Dr Jane Kennedy
Compass Health
Suzanne Werder
Auckland Regional Sexual Health Service
Dr Nigel Raymond
Capital & Coast District Health Board
Dr Mark Thomas
Auckland City Hospital
Dr Paul Bohmer
PHP Consulting
Dr Mark Hobbs
Auckland City Hospital
Annabelle Donaldson
Auckland District Health Board
Eamon Duffy
Auckland District Health Board
New Zealand Sexual Health Society
Dr Rick Franklin
Auckland Regional Sexual Health Service
Dr Sunita Azariah
Auckland Regional Sexual Health Service
Dr Christine Foley
Auckland Regional Sexual Health Service
Dr Mitzi Nisbet
Auckland City Hospital
Dr Stephen Ritchie
Auckland City Hospital
Elspeth Fougere
Auckland Regional Sexual Health Service
Eileen Brown
Auckland Regional Sexual Health Service
Alex Anderson
Auckland Regional Sexual Health Service
Dr Simon Briggs
Infectious Disease Unit, Auckland City Hospital
Dr Joan Ingram
Infectious Diseases Unit, Auckland City Hospital
Michele Lowe
Community HIV Team, Auckland City Hospital
Dr Charon Lessing
Auckland University of Technology
Dr Pani Farvid
Auckland University of Technology
Dr Lorna Claydon
Bay of Plenty District Health Board
Carmel Vyas
Auckland District Health Board
Aaron
 
James McCarthy
 
Andrew Sweet
Firecone NZ
Philip Patston
Anthony Fallon
 
Grace Falwasser
Te Rakei whakaehu
Brian Gilberthorpe
 
Jay Tuwhakaararo Hohaia Portelli
Ruapotaka Marae Auckland
Rev'd Stephen Donald
Holy Trinity Anglican Church, Gisborne
Sandie Halligan Nurse Practitioner
Sarah Gerritsen
School of Population Health, University of Auckland
Dr Teena Mathew
Lakes DHB and Wellington Sexual Health Service
Michael Browne
University of Auckland
Kent Teague
 
Anna Booth
Auckland UniServices
Ally Wakeham
Compass Health
Kate Grimwade
Bay of Plenty District Health Board
Debbie Hager
School of Population Health, University of Auckland
Jason Lindsay
 
Shannon Anahera White
 
Tim Melville
 
Dan Coomey
Life Member NZ AIDS Foundation
Yehuala Aboye
New Zealand AIDS Foundation
Craig Waterworth
Richard Nind
New Zealand AIDS Foundation
Graeme Boag
 
Guy Alexander
 
Jan Arnold
Nelson-Marlborough DHB
Vaughan Meneses
 
Karen Ritchie
Cartier Bereavement Charitable Trust
Dr Pam Stone
 
Diane Ryan
 
Karen Hicks
University of Auckland
Judith Mukakayange
NZAF-African community coordinator & Positive Women Inc
Victoria Riddiford
New Zealand AIDS Foundation
Hilary Gerrard
New Zealand AIDS Foundation
Dr Torrance Merkle
Kudakwashe Tuwe
 
Evelyn Mann
Public Health South, Southern DHB
Ari Lewis
 
Caroline Wharry
Waikato District Health Board
Loren Mooney
WDHB SHC
Jill Wolfgang
SDHB
Jason Cooper
 
Virginia Braun
School of Psychology, The University of Auckland
Dr Nicky Perkins
ADHB Sexual Health Service
Ashley Barratt
 
Gertrude M. Agbozo
 
 

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  1. AIDS Epidemiology Group. AIDS – New Zealand. Issue 76. Dunedin: University of Otago, 2017.  Link >
  2. UNAIDS. Combination HIV Prevention: Tailoring and Coordinating Biomedical, Behavioural and Structural Strategies to Reduce New HIV Infections. Joint United Nations Programme on HIV/AIDS (UNAIDS), 2010.
  3. Saxton P, Hughes A, Giola M. HIV prevention today: with coordinated action, we can end transmission. New Zealand Medical Journal, 2015; 128 (1426): 8-15.
  4. The INSIGHT START Study Group. Initiation of antiretroviral therapy in early asymptomatic HIV infection. New England Journal of Medicine. 2015; 373:795-807.
  5. Cohen MS, et al. Antiretroviral therapy for the prevention of HIV-1 transmission. New England Journal of Medicine. 2016;375:830-9.
  6. Rodger A, et al. Sexual activity without condoms and risk of HIV transmission in serodifferent couples when the HIV-positive partner is using suppressive antiretroviral therapy. JAMA. 2016;316:171-81.
  7. McCormack S, 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. The Lancet. 2016 8;387:53-60.
  8. Punyacharoensin N, et al. Effect of pre-exposure prophylaxis and combination HIV prevention for men who have sex with men in the UK: a mathematical modelling study. The Lancet HIV. 2016; 3:e94-104.
  9. Hughes A, Saxton P. Thirty years of condom-based HIV prevention among gay men in New Zealand. New Zealand Medical Journal, 2015; 128 (1426): 19-30.