Ending HIV transmission in Scotland by 2030

The How

To achieve the HIV transmission elimination goal in Scotland, a whole-system and whole-society approach will be required. The high-level activities required are primary prevention, detection and treatment. However these will need to be provided across a range of health settings, including (but not limited to) sexual health & HIV services, primary care, prison health, drug and alcohol services, and secondary care. There is also a role for wider participants including local authorities, employers and the third sector, who will need to be engaged in development and implementation of the elimination goal, in order to engage with people that are not currently being reached by existing interventions.

1. Primary prevention

stopping the virus from passing from one person to another. The main route of HIV transmission within Scotland is sexual contact in gay, bisexual and men who have sex with men and in heterosexual people. Condom use and safer sex practices have been established prevention interventions since the 1980s. Although numbers have decreased after identification of the 2015 outbreak, people who inject drugs may acquire HIV from injecting equipment, and/or from sexual partners with higher HIV prevalence than the general population. Examples of universal interventions for primary prevention that can continue to be utilised include behavioural change, condom use, pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP). For people who inject drugs, the provision of drug treatment services is, in itself, a key intervention in addition to injecting equipment exchange provision, as discontinuation of drug use or transitioning to lower risk pathways reduces the possibility of drug-related BBV transmission substantially. Equitable access to and uptake of prevention is required to avoid amplifying existing inequalities.

2. Detection

Finding undiagnosed people by the offer and acceptance of an HIV test. This identifies people with recently acquired infection as well as others who may have acquired HIV some time previously. HIV diagnosis provides an opportunity to carry out detailed contact tracing to identify transmission networks, to notify and offer treatment to others who may not be aware of their HIV status (secondary prevention) and, if needed, to provide prevention support to partners found to be HIV-negative. Examples of such interventions include offering remote self-sampling with linkage to care and opt-out HIV testing in settings such as ante-natal care, sexual health services and prisons. Community and outreach testing initiatives supported by the third sector are effective in terms of acceptance of a test and also increasing public knowledge and awareness of HIV. As population prevalence declines in the population, testing of all people with HIV indicator conditions, in accordance with UK adult testing guidelines [Ref 29] increases in importance.

3. Treatment

HIV therapy lowers levels of virus in body fluids to a level below detectability, meaning it cannot be passed on to others. This is sometimes called Treatment as Prevention ("TasP"). Adherence to medication and monitoring is required to maintain and confirm viral suppression. Retention in HIV care and high uptake of well-tolerated antiretroviral therapy is needed to support reduction of HIV transmission. Individuals in care in Scotland are also linked to peer support, both within services and also directly to third sector and community organisations if funded to do so.

Several of these activities can be applied widely, but there are specific elements tailored towards target populations depending on local circumstances, priorities and resources.

Examples include:

Gay, bisexual and other men who have sex with men

• Prevention: Behavioural change (safer sex). Condom use. PrEP.
• Detection: Community outreach testing e.g. LGBTQ+ venues, self-sampling/testing for HIV.
• Treatment: HIV treatment as prevention. Testing for STIs (such as syphilis) which can facilitate HIV transmission.

People who inject drugs

• Prevention: Drug treatment services. Provision of injecting equipment. PrEP.
• Detection: Regular BBV testing in drug & alcohol services, prisons and pharmacies.
• Treatment: HIV treatment as prevention. Co-administration with opioid agonist therapy.

Heterosexual and high prevalence populations

• Prevention: Information for travellers. Free condoms. Free formula feeding for women living with HIV.
• Detection: Access HIV test on arrival in UK. Opt-out testing. Community HIV self-sampling or testing. HIV testing in the presence of an HIV indicator condition.
• Treatment: HIV treatment as prevention and during pregnancy to prevent mother to baby transmission.