Ending HIV transmission in Scotland by 2030

Defining HIV transmission elimination

Our vision is to end HIV transmission. This means achieving the ambitious target of zero people contracting HIV within Scotland by 2030. This aligns with wider global strategic aims. The World Health Organization (WHO) refers to a goal "to end the AIDS epidemic as a public health threat by 2030" [Ref 19]. Similar visions have been articulated by other nations [Ref 20], [Ref 21], [Ref 22], [Ref 23].

HiTEOG defines HIV transmission elimination as the point when there are zero individuals acquiring HIV within Scotland, regardless of age, sex, gender identity, sexual orientation, race, ethnicity, religion, deprivation or disability status.

Definitions used in this proposal

• Incident infection: infection in people who have acquired HIV in the 12 months prior to the date of first diagnosis.
• Recently acquired infection: infection in people who have acquired HIV in the 3-4 months prior to the date of first diagnosis.
• Established infection: infection in people who have acquired HIV over 12 months prior to the date of first diagnosis.

Individual HIV transmission events cannot easily be quantified directly at a population level, and instead have to be estimated through statistical modelling of a range of data. The number of first ever HIV diagnoses has been used elsewhere as an indicator for new infections and can be directly monitored over time according to population group and setting. This indicator however encompasses people who have established HIV (acquired more than 12 months ago) as well as people with incident infection (acquired within the previous 12 months). Thus, to provide a more accurate proxy measure of transmission, additional data, particularly those which inform the timing of infection such as HIV antibody avidity testing [Ref 24] and dates of previous negative tests, need to be used in combination to determine the extent of incident infection events.

In addition to monitoring the number of first ever new HIV diagnoses in Scotland per year, HiTEOG recommends that estimation of (people who have acquired HIV in the 12 months prior to their diagnosis) is developed and used as a future key outcome measure to track progress on HIV elimination.

As an interim outcome measure, HiTEOG also recommends that (people who have acquired infection in the 3-4 months prior to diagnosis) is used to track progress on HIV elimination.

As far as we are aware, to date no other settings have adopted such a monitoring approach differentiating between first ever HIV diagnoses arising from established and incident infection. HiTEOG believes that this unique approach is appropriate to Scotland's specific circumstances and given relatively small numbers of newly diagnosed people. By tracking first ever diagnoses according to incident and recently acquired infection in the interim, the aim is to differentiate between people who have lived with undiagnosed HIV for some while, rather than people who have acquired the virus more recently.

The focus is on transmission occurring within Scotland, so people previously known to be diagnosed with HIV at the time of entry into NHS Scotland are not included in the indicator. The goal is not to create a "zero HIV nation" as there will continue to be a cohort of people who are already in Scotland and living with HIV [Ref 3]. We recognise that language and terms can contribute to stereotypes, stigma and discrimination, and that there are inherent biases around using the term "elimination" in relation to HIV transmission. It is also recognised there is further work to be done on better reporting data regarding transgender and non-binary people. We therefore affirm the people-first approach adopted in this proposal [Ref 25] and also a wider recognition that Scotland will continue to welcome people living with HIV to visit, study, work and settle in the country.