Speech to Body Positive 'HIV Treatments Update Seminar 2021'
E ngā mana
E ngā reo
E ngā iwi
Tēnā koutou katoa
Ka huri ki ngā mana whenua o te rohe nei. Tēnā koutou.
He mihi hoki ki a tatou kua tau mai nei I raro I te kaupapa o te rā.
Nō reira tēnā koutou katoa
It’s a pleasure to join you today, albeit online, something we’re becoming very accustomed to in these challenging times.
I would like to first acknowledge Mark Fisher and Body Positive for hosting this conference, and for the work they do to support people living with HIV.
I’d also like to acknowledge the organisations, researchers, clinicians and individuals working hard to reduce the transmission of HIV, and support people living with HIV. This includes Positive Women, NZ AIDS Foundation and the AIDS epidemiology group who work alongside sexual health, infectious disease clinicians, and the wider health sector in responding to HIV/AIDS in New Zealand.
There’s an impressive line up of speakers today, and this is a really valuable opportunity to share and learn from each other.
As many of you know, I was an infectious diseases physician, with a small but rewarding part of my practice was caring for people living with HIV. Today I want to talk about where I think we are at with HIV in NZ, and the ambition I want to drive in the new sexually transmitted and blood borne infections strategy - and the HIV action plan which sits underneath the strategy.
Where are we at with HIV in NZ?
Currently, 2,828 adults and 11 children in New Zealand are living with HIV and receiving anti-retroviral treatment.
In 2020, the number of notified HIV infections in New Zealand was the lowest it has been in the past five years, but we still have a lot of work to do. There are significant inequities in HIV that we must address. Men who have sex with men are 873 times more likely to be diagnosed with locally-acquired HIV than the rest of the population. While Māori and Pacific men who have sex with men are slightly less likely to have HIV, they are more than twice as likely to be diagnosed late and present with advanced HIV.
That said, there is a lot which New Zealand does well in this field. We do have access to effective medicines, and a hard-fought-for human rights approach to health care.
But we face challenges in addressing stigma and discrimination in healthcare, especially outside of HIV specific support. We are also not meeting the needs of some groups, including Māori and refugees.
Some of the most fulfilling clinical experiences I’ve had, have been caring for women with HIV during their pregnancies. In a wider sense, we could do more to support the specific social needs of women with HIV.
Impact of HIV on public health
HIV is an example of community activism leading to a better health response.
The traditional assumption that the bureaucracy and experts would decide what communities needed was turned on its head with the emergence of HIV/AIDS, and the subsequent activism to ensure access to healthcare and support.
It was the communities … the gay community, sex workers, people who inject drugs … who knew what was happening and what had to be done. It was these communities who led the way, who challenged what were often quite dangerous beliefs about morality and legality and medical authority. And it was these communities who spearheaded the establishment of those organisations in Aotearoa which led - and continue to lead - disease control and prevention efforts.
Body Positive is an example of this. Set up in 1994 as a peer-led NGO to support people living with HIV, it’s been funded by the Ministry of Health since 2011 to provide free testing and screening, peer-led HIV prevention and outreach, and to provide networks and support for people living with HIV.
Body Positive has been a strong advocate for access to PrEP and HIV treatment, and the U=U message: that undetectable viral load means HIV is untransmissable. This message is important to counter the stigma that positive people experience.
Over the years Body Positive has piloted and supported innovative ways to ensure access to screening, prevention and treatment for everyone who needs it, and was a key contributor to the 2020 Stigma Index Report detailing the experiences of people living with HIV in New Zealand.
It was also activism that led to New Zealand having the world’s first national publicly-funded needle and syringe programme to assist with the prevention of HIV, and we now have one of the lowest rates in the world of HIV among people who inject drugs.
And activism remains crucial going forward, to tackle the stigma and discrimination that people affected by HIV experience.
I’m determined to ensure there is a greater focus on the voice of communities in public health programmes. For public health in general, there needs to be more emphasis on community engagement and the lived experience of those in our most vulnerable communities.
The COVID-19 experience, like the HIV/AIDS experience before it, has shown what can be achieved with nationally consistent and decisive strategies, and we know what we can achieve with ambitious elimination goals.
Alongside addressing stigma and discrimination, we need to be more responsive to Māori and other groups who disproportionately experience the impact of HIV - as well as a lack of responsiveness within healthcare.
As we get closer to eliminating transmission of HIV we need to do things differently to reach people who currently we are not. This is not always about bringing more people into services or the current system, but also about pushing into communities and being by led what their needs are. This is particularly important if we want to increase the uptake of PrEP.
Privacy is also crucial to ensure people at risk of HIV transmission feel confident to access testing and services. The significant stigma and discrimination still attached to HIV contributes to this. The few patients who I couldn’t engage in care, felt unable to accept their diagnosis because of the stigma that surrounds HIV. I’m proud to be a member of the Labour Government’s rainbow caucus, and part of a government that is tackling the wider context of homophobia and transphobia, through work such as our efforts to ban conversion therapy.
Prevention and treatment
HIV medicine also taught me important lessons in public health. In HIV medicine it is so obvious that treatment is prevention. It is a lesson that we need to apply across communicable disease control – as we have for a long time in tuberculosis and more recently in Hepatitis C.
Caring for people with HIV using modern treatments and truly patient-centred services leads to undetectable viral loads, and better personal and public health outcomes. HIV is a manageable chronic illness in New Zealand, and support for the U=U message is an important way to support people living with HIV to enjoy full, meaningful lives free of stigma.
Healthcare providers will continue to play a key role in ensuring widespread screening and testing for HIV where relevant, supporting people to access PrEP, and ensuring access for treatment for people living with HIV.
Since 2018, PrEP has been publicly funded and around 2,500 people are currently prescribed it. We have also seen greater options for how to take PrEP, with daily pills or event based 2-1-1 for people who have clearly defined times when they would be at risk of HIV exposure.
While PrEP is still a special authority medication, we are seeing more GPs trained in how to prescribe PrEP, greater uptake in primary care, and continued increase in number of people accessing.
More than 100 PrEP-friendly providers are listed on the EndingHIV website, but I continue to advocate for more clinicians to take up this important role.
Unfortunately, people who are living with HIV still experience stigma within healthcare settings. Only one third of people inform non-HIV healthcare providers of their status.
Gaps in NZ prevention and treatment
In June this year New Zealand signed up to the UN political declaration on HIV and AIDS to end AIDS as a public health threat by 2030. This includes pursuing the 95/95/95 cascade of care targets by 2025.
Let’s go through each of these targets.
The first target, is that 95 percent of individuals living with HIV will know their HIV status. Currently, that figure is just 80 percent, based on a 2011 community seroprevalence study. Dr Peter Saxton is about to undertake an update to the study, which will show how we’re tracking and help identify what we need to do.
The second goal, is that 95 percent of people diagnosed with an HIV infection will receive anti-retroviral therapy. A recently published 2021 study by Dr Sue McAllister and her colleagues, based on 2017-2019 records, showed we are just at this target with 94.5 percent on therapy.
And finally, the target is for 95 percent of those taking anti-retroviral therapy to have achieved suppression of the virus. Based on the same 2021 study, we are not yet achieving this goal - at just 82.1 percent. Maintaining access to medicines in a way that supports adherence will help us reach these targets. We also need to understand the characteristics of those who don’t achieve viral suppression and ensure our clinical and community services better meet their needs.
By developing a sexually transmitted and blood borne infection strategy we can start to build consensus around where the gaps are, what we need to prioritise, and how to get there.
By bringing sexually transmitted infections and blood borne viruses together in a single strategy we can build on opportunities to enhance surveillance, screening, prevention and treatment, with shared modes of transmissions and priority populations.
We have to think strategically about the data we need in order to improve treatment and prevention, and work with experts and the community to get it.
Combining these areas also reflects recent bio medical advances where elimination of transmission for many of these infections - some with vaccinations and cures - becomes a real possibility.
A key component of the strategy is an HIV action plan which sets a path for elimination of HIV transmission within New Zealand, and for ensuring people living with HIV have healthy lives free from stigma and discrimination.
We will be guided by the targets set at the international level by UNAIDS and WHO, and aim to exceed them where we can - to take advantage of the new opportunities in treatment and prevention.
This strategy is being informed by a working group made up of clinical, sector, lived experience and research perspectives. I would like to take this opportunity to thank everyone who has been involved in the strategy and action plan to date, and those who will be involved in the future. I’m looking forward to seeing the results of your work, and the better future we can create together.
Thanks to the incredible work of dedicated organisations, researchers, and individuals, we’ve seen progress in the rates of transmission and the experiences of those with HIV in Aotearoa. But as I’ve said, we still have a lot to do.
I’m committed to maintaining the momentum in this area, and would again like to thank you all for your continued efforts - they really are making a difference.