Ending HIV transmission in Scotland by 2030

Background

By the end of 2021, there were 6,415* people known to be diagnosed and living with HIV in Scotland [Ref 3], compared with 5,617 in 2019 [Ref 4]. Of the 6,415, 46% were gay, bisexual, and other men who have sex with men, 38% were people who were thought to have acquired HIV by heterosexual contact, 9% were people who inject drugs and 7% who acquired HIV through other or unknown routes.* Access to HIV specialist treatment and care is relatively high in Scotland; based on 2019 data, 90% of people diagnosed were attending specialist HIV services, 98% of those attending were receiving antiretroviral therapy, and 95% of people treated had achieved an undetectable blood level of HIV (undetectable viral load) [Ref 4].

Over the last decade, the annual number of people diagnosed with HIV for the first time – referred to as first ever HIV diagnoses – in Scotland has declined, reducing by 37% between 2010 (266 people) and 2019 (167 people), and by a further 54% to 2021 (77 people) * [Ref 3]. National HIV data from 2020 and 2021 should be interpreted with caution as COVID-19 measures impacted service delivery resulting in a large reduction in HIV testing. Therefore, data to the end of 2019 were used to inform the actions and targets in this proposal.

* Owing to active follow-up, data on the Scottish National HIV database are constantly changing. Figures presented in this document may differ from those previously or not yet published.

* Total (all exposure categories) includes diagnoses with other or unknown routes of exposure under investigation.

Between 2010 and 2019, most marked reductions in the annual number of first ever HIV diagnoses in Scotland were observed among gay, bisexual, and other men who have sex with men, (51%) and people who acquired infection heterosexually (48%). These reductions likely reflect a decline in the incidence (and transmission) of HIV infection in Scotland associated with a range of public health measures over this period. The key interventions and milestones which contributed to this progress were:

• Updated UK adult treatment guidelines from 2015 which recognised the individual clinical benefits of earlier initiation of therapy plus the importance of HIV treatment as prevention (TasP) in that undetectable plasma HIV viral load means that the virus cannot be transmitted (undetectable = untransmittable or "U=U"). [Ref 1], [Ref 4]
• Attainment across Scotland in 2018 of the UNAIDS 90:90:90 goals (90% of people living with HIV know their HIV status: 90% of people with diagnosed HIV receive sustained antiretroviral therapy; 90% of people receiving antiretroviral therapy have viral suppression) [Ref 5].
• Implementation of an NHS-delivered national HIV pre-prophylaxis (PrEP) programme from 2017 [Ref 6], making Scotland one of the first countries worldwide to provide this intervention in routine care. Within two years the incidence of HIV in gay, bisexual and other men who have sex with men attending sexual health clinics in Scotland reduced by 75% among those prescribed PrEP, compared to those attending in the two years prior to the introduction of PrEP [Ref 7].
• Universal blood donor and ante-natal HIV screening with pilot opt-out testing in other settings.
• Rapid access to HIV post-exposure prophylaxis (PEP) provision after sexual or occupational exposure.
• Behavioural interventions and campaigns underpinned by condom distribution schemes and specialist sexual health services.
• Comprehensive contact tracing (also referred to as partner notification) in people with newly diagnosed HIV to trace individuals with undiagnosed virus and to inform prevention interventions.

Over the same period from 2010 to 2019, a 50% increase in the annual number of first ever HIV diagnoses was observed among people who inject drugs (PWID), associated with an outbreak predominantly in Glasgow city [Ref 8]. Prior to 2015, the HIV prevalence in PWID was 1% in Scotland [Ref 8]. Since then, over 180 people have been diagnosed (representing the largest outbreak among PWID for over 30 years in the UK) and the prevalence of infection in this population rose three-fold across Scotland and ten-fold in Glasgow [Ref 8]. This occurred despite relatively high coverage of harm reduction measures to prevent drug-related transmission of blood borne viruses (particularly opioid agonist therapy and injecting equipment provision). The public health response to the outbreak has been considerable, including a range of novel approaches to increase access to injecting equipment, to scale-up HIV testing in services engaged with people who inject drugs, and to achieve high adherence to antiretroviral therapy of those diagnosed through an enhanced model of HIV care involving outreach nursing and community prescribing. [Ref 9] [Ref 10] An outreach PrEP service, the first to demonstrate that a tailored intervention can reach people who inject drugs effectively and achieve a high level of adherence, has also been piloted [Ref 11].

Apart from a comparatively high level of drug-related harm and death [Ref 12], Scotland has additional challenges linked to alcohol and tobacco use, obesity, safety in communities, poor early years outcomes, mental health impact, high poverty levels and existing inequalities leading to lowered life expectancy [Ref 13]. Furthermore, prior to 2010, asylum seekers and refugees originally housed in other parts of the UK were dispersed to Scotland. This included people from sub-Saharan Africa and parts of the world with higher HIV prevalence than the UK.

There were estimated to be around 500 people with undiagnosed HIV living in Scotland in 2019 [Ref 14]. Approximately a third were thought to be in the NHS Greater Glasgow & Clyde health board area, a further third in NHS Lothian, and the remaining third in other health board areas, in keeping with the geographical population of Scotland. The absolute number of people with undiagnosed HIV in Scotland is thought to be larger in heterosexual individuals, emphasising the importance of considering HIV in people without identified current risk behaviours and the potential for greater impact of HIV-related stigma.

When the UNAIDS 90:90:90 target was achieved, attention turned to whether it might be possible to end HIV transmission, recognising that a tailored approach would be required given the specific set of circumstances affecting Scotland. However, this work was delayed because of the COVID-19 pandemic and new variables which could impact HIV incidence, including lockdown measures, changes in behaviours, access to prevention and specialist services, community testing and the interruption of epidemiological data monitoring. This proposal therefore re-visits the Scottish landscape two years later and makes recommendations to reinstate and achieve the goal of ending HIV transmission by the end of the decade.