Ending HIV transmission in Scotland by 2030

Pillar interventions

This proposal adopts a population-based approach to ending HIV transmission. Taking the population of Scotland as a whole, people can be considered to be within four broad risk transmission categories (with some overlap and movement). These can be used to determine the appropriate strategic approach utilising a set of five pillar interventions spanning the high-level activities of prevention, detection and treatment.

Five pillar interventions to end HIV transmission in Scotland by 2030

• Testing
• Education including awareness raising and stigma reduction
• Combination prevention
• Entry into and retention in specialist HIV care
• Contact tracing

Population-based approach to broad transmission categories

1. Not at risk of HIV acquisition

Testing available + Education including awareness raising and stigma reduction

2. At risk but currently HIV-negative

Recommend testing + Education including awareness raising and stigma reduction + Combination prevention

3. Undiagnosed HIV

Testing + Education including awareness raising and stigma reduction + Entry into and retention in specialist HIV care + Contact tracing

4. Diagnosed HIV (in or out of current care)

Confirmatory testing + Education including awareness raising and stigma reduction + Entry into and retention in specialist HIV care + Completion of contact tracing

Overcoming key barriers that have so far prevented prevention, detection and treatment reaching all those who could and would benefit is central to the success of ending HIV transmission. Therefore the first pillar intervention focuses on the normalisation of routine HIV testing with high coverage in a range of settings, both where there is likely to be increased prevalence (sexual health services, prisons, drug services and selected emergency departments) and in all settings where clinical presentation could be linked to undiagnosed HIV. Community based initiatives also merit consideration, but in all circumstances, there have to be audited care pathways which support engagement, retention and re-engagement in care, all of which can be jeopardised by stigma. This is why the second pillar intervention spans workforce and public education to raise awareness of the many advances in progress that have been made in the understanding of HIV, underpinned by advances in treatment and care. In turn, this is a key tool in addressing stigma, both in relation to people already living with HIV, but also the effect it has on people who may defer testing or engagement in care. As previously highlighted [Ref 13], wider measures to tackle inequalities are also essential.

The third pillar intervention focuses on the extensive combination prevention toolkit now available to prevent HIV transmission, many of which also contribute to prevention of drug-related harms, other blood borne viruses, sexually transmitted infections and, in the instance of condoms, conception risk.

The fourth pillar intervention highlights the importance of entry into and retention in HIV care. The entire HIV transmission elimination proposal depends on continued high level of engagement and performance to meet the UNAIDS 95:95:95 goals. HIV services will be required to continue in future, even when the zero transmission target is met in Scotland. It is also essential that learning from Scotland is shared to support other nations make progress in transmission elimination to achieve the global goal.

Finally, contact tracing (also known as partner notification) providing high quality, person-centred support for people who have recently been diagnosed, is essential to assist identification and engagement of other people who may have been exposed to HIV and support testing, care and prevention. Working with people who have recently been found to have HIV can not only identify contacts, but also can reduce the "R number" (average number of people that one person passes the virus to) by offering combination prevention interventions and recognising clusters or linked cases of transmission.

The short life HIV Transmission Elimination Oversight Group (HiTEOG) recognises the complexity of the delivery landscape in Scotland. The recommendations for each pillar intervention are therefore shared across several key collaborators, including NHS service providers, NHS boards, local authorities, Health & Social Care Partnerships (HSCPs), Integrated Joint Boards (IJBs), Scottish Government, third sector and community providers. Where possible, a proposed lead agency for delivery of the recommendation (working with and co-ordinating other partners) is specified.

A total of 22 proposed actions are listed. Some are already in progress, others can be taken forward by collaborative working between key partners, whilst others will require design and oversight accompanied by release of resources.

1. Testing interventions

1.1 To increase HIV testing coverage in specialist sexual health services in Scotland from 2023 onwards.

Specialist sexual health services routinely assess HIV acquisition risk and offer HIV testing, but there may be scope to expand opt-out testing and detect undiagnosed HIV, particularly in women and non-GBMSM. This can be achieved by staff training, prioritisation and system redesign with the caveat that there is sufficient capacity for delivery given the other priorities that specialist services are required to implement. This setting is optimally placed to differentiate individuals who are in the category of not at risk of HIV acquisition from those who are HIV-negative but are at risk and would benefit from combination prevention. The number of HIV tests performed in Scottish specialist sexual health services prior to the COVID-19 pandemic was approximately 2,000 a month, but this fell by 90% from April 2020 [Ref 15]. There is currently limited national data on new positivity rate and entry into specialist care in Scotland. Surveillance of HIV prevalence in specific populations (such as women attending specialist sexual health services specifically for contraception) would be helpful in targeting future testing strategies in this setting. Further analysis of testing offer and uptake is required to quantify optimal reach of HIV testing in people attending with a range of presentations.

Lead agency: specialist integrated sexual health services within NHS boards.

1.2 To provide sufficient laboratory capacity to support expanded BBV testing and confirmation activity from all providers in Scotland.

Laboratory based tests for blood borne viruses (including HIV and hepatitis C) are undertaken by NHS boards, but work has been displaced owing to COVID-19. In addition, extra capacity will be required if more BBV tests are received. Beyond diagnosis and confirmation, the proposed targets require avidity tests and algorithms to differentiate recency of HIV acquisition plus delivery of phylogenetic analysis to determine HIV transmission dynamics [Ref 30].

Lead agency: NHS boards.

1.3 To increase BBV testing coverage to people in custody including those already in Scottish prisons reaching 90% uptake within the previous 12 months by December 2024.

This builds upon the previously issued guidance to support opt-out BBV testing in prisons that was issued in July 2019 [Ref 31] but implementation was delayed owing to COVID-19. This setting will include individuals straddling the categories of not at HIV risk, at risk but negative and HIV-positive but unaware. HIV tests should be recommended to everyone in custody unless already known to be HIV-positive or been tested within the previous year and not been at risk of transmission. Initial work is required confirm BBV testing rates during 2021/22. Previous 2019 guidance on hepatitis C case-finding [Ref 32] recommended HCV opt-out testing at services used by people at highest risk, including prisons. This intervention could also be combined with hepatitis B sampling and to offer testing for sexually transmitted infections.

Lead agency: Scottish Prison Health Service, supported by NHS boards.

1.4 To offer universal opt-out BBV testing in Scottish drug services by December 2024.

This recommendation stems from the HIV outbreak in people who inject drugs in Glasgow from 2015 despite wide provision of harm reduction interventions. This includes a population who may be at increased risk of HIV acquisition and also include some people who have not yet been diagnosed. Learning suggested that there was reduced client and service awareness of HIV. Access to drug treatment services (and not just injection equipment provision) remains an important primary prevention intervention in itself. Therefore, this recommendation is closely aligned with the wider Scottish Government policy to address drug-related harms [Ref 33]. National data on BBV testing rates in 2021 and 2022 is required to establish the baseline. This intervention could be combined with hepatitis B and C sampling.

Lead agency: Drug & alcohol service providers within Health & Social Care Partnerships (HSCPs).

1.5 To pilot HIV opt-out testing programmes in urban emergency departments where the diagnosed population HIV prevalence exceeds 1 in 500 people.

The aim is to identify people who have HIV and are either unaware or not currently engaged with specialist care and treatment. Evaluation will require cross-system working to establish numerators and denominators and to guide future outcomes relating to cost per diagnosis found in areas with the highest HIV prevalence in Scotland. This intervention could be combined with hepatitis B and C testing. There is a role for third sector support for testing in this setting (supporting and informing patients and staff with peer support for individuals who test positive). Delivery of this pilot will require identified leadership and funding for implementation, monitoring and evaluation.

Lead agency: public health teams within NHS boards with increased HIV prevalence.

1.6 To support health care workers to test people for HIV in the presence of an HIV indicator condition

This action is underpinned by the British HIV Association/British Association for Sexual Health and HIV/British Infection Association Adult HIV Testing Guidelines [Ref 29] and builds on previous training on the recognition and diagnosis of HIV led by NHS Education Scotland (NES) which targeted healthcare practitioners in non-HIV specialist roles [Ref 16]. This targeting includes health care workers in surgical specialties to support recognition of undiagnosed people, reduction in stigma and to ensure appropriate pre- and post-operative infection control procedures (see 2.2). In addition, the British HIV Association is working to update UK-level non-specialist clinical guidelines to incorporate HIV testing. Changes to postgraduate specialist medical training since 2022 are increasing the presence and visibility of HIV-experienced clinicians in hospital settings.

Lead agency: NHS Education for Scotland (NES) supported by HIV third sector organisations and health improvement teams within NHS Boards.

1.7 To evaluate existing community HIV testing interventions led by the third sector.

Supported by Scottish Government funding, there are community-led programmes already in progress in Scotland utilising home HIV self-testing and self-sampling. Key metrics include reach (accessing individuals and populations who are not already taking up HIV tests from NHS providers), and the number of people confirmed to be positive for the first time using standard laboratory testing and who can be confirmed as entering specialist care. These are more meaningful outcomes than simply the number of kits provided, or tests returned. Co-ordination with HIV testing initiatives elsewhere in the UK would be an advantage (see 2.3).

Lead agency: third sector.

2. Education including awareness raising and stigma reduction interventions

2.1 To routinely prompt consideration of HIV on laboratory result reports where the condition is a possible differential diagnosis by the end of 2023.

A "once for Scotland" approach is needed to raise awareness in instances when HIV should be considered as a differential diagnosis of a laboratory result. Examples include negative glandular fever serology or a low total lymphocyte count [Ref 29].

Lead agency: NHS boards laboratory services supported by Public Health Scotland.

2.2 Provision of training (with support from HIV third sector organisations) to highlight HIV risk reduction for primary and secondary care clinicians.

The objective is to support multidisciplinary team clinicians outside specialist settings with knowledge, skills and attitudes to assess and discuss individual HIV risk and to facilitate interventions to reduce future risk. Clinicians may not be in a position to directly initiate some prevention interventions but will be supported in signposting people to partners who can progress options tailored to individual circumstances.

Lead agency: NHS Education for Scotland (NES) supported by HIV third sector organisations.

2.3 To support health and social care worker knowledge about the realities of HIV in the era of effective therapy and prevention.

Some non-specialist health and social care professionals have gaps in knowledge despite the large amount progress made in treating and preventing HIV since the 1980s. Lack of up-to-date knowledge may exacerbate stigma and lead to inappropriate infection control measures. There is an opportunity for NHS/local authorities to support or mandate training for employees (including the impact of stigma), linking to wider partnerships such as the Fast Track Cities initiative [Ref 34].

Lead agency: NHS Education for Scotland (NES) supported by HIV third sector organisations and health improvement teams within NHS Boards.

2.4 To support public facing information to increase understanding and knowledge of HIV and to reduce stigma given the impact of effective treatment and prevention.

A Fast Track Cities [Ref 34] 2018 Europe-wide survey including 500 respondents from Scotland [Ref 35] found that 69% of Scottish respondents would not feel comfortable dating someone with HIV and that 22% would not feel comfortable working with a person with HIV. 42% believed that people living with HIV should not be permitted to work as healthcare professionals. There was also poor knowledge of HIV transmission with only 28% are that women living with HIV could have children without passing on the virus. Work to update the public and reduce stigma could build upon existing campaigns and materials (such as HIV testing week) and ideally in collaboration with the other UK nations. A Scottish HIV testing week has not so far been delivered but should be considered and resource appropriately. Scottish organisations including those in health, local authorities, justice and employers should be encouraged to review practice and policies in their role as anchor institutions. However, HIV third sector organisations are uniquely placed to play a pivotal role in engaging people who are not currently being reached by existing initiatives, plus progressing wider anti-stigma initiatives. In recent years, there have been notable successful outcomes in relation to prosecution policy linked to sexual exposure, occupational supervision of people living with HIV and wider understanding of the U=U message.

Lead agency: HIV third sector organisations supported by health improvement teams within NHS Boards.

2.5 To align teaching content in Scottish educational settings and in the Curriculum for Excellence to reflect updated HIV transmission risk and the reality of living with HIV in current times.

This recommendation is primarily in relation to secondary education, but there is also scope to widen it in future to consider tertiary education providers; notably training medical and allied health profession undergraduates.

Lead agency: Local authorities supported by health improvement teams within NHS Boards and HIV third sector organisations.

3. Combination prevention interventions

3.1 To create an implementation group to disseminate updated HIV pre-exposure prophylaxis (PrEP) prescribing guidance, provide training to prescribers, roll-out awareness resources and deliver PrEP preparedness.

This early action was agreed by the PrEP delivery group to extend reach to anyone who would benefit. Updated UK specialty guidelines on PrEP suitability and risk assessment are expected in Q4 2022. The implementation group will be jointly led by community sector and clinical representatives who will develop training and support for PrEP initiation and monitoring. Increasing confidence and consistency of approach of prescribers is a core action to widen use. Dedicated awareness resources tailored for women, trans-people, and people from minoritised communities will be supported by community mobilisation of third sector organisations. Apart from information and awareness, there is scope for supporting access to and engagement with PrEP ("community navigators") to increase preparedness.

Lead agency: PrEP clinicians in partnership with HIV third sector organisations supported by health improvement teams within NHS Boards.

3.2 To estimate the characteristics and number of additional individuals likely to initiate PrEP in primary care settings (such as community pharmacies and general practice).

This is required to enhance PrEP provision and broader HIV prevention to individuals who would benefit but are not currently accessing specialist sexual health services for a variety of reasons, including stigma relating to the use of such services. There is some evidence that PrEP awareness raising, initiation and maintenance in community settings would be acceptable, and also help address inequalities from specialist service delivery only [Ref 36]. However, there are considerable capacity pressures in primary care and also practical aspects to work through before this can be more widely implemented. Like opt-out HIV testing pilots in Emergency Departments, delivery will require identified leadership and funding for implementation, monitoring and evaluation. Work to be progressed in 2023.

Lead agency: Scottish Government, supported by Public Health Scotland with academic institution collaboration.

3.3 To explore the acceptability and feasibility of alternative community-based PrEP access and delivery models for people whose needs are not being met by existing arrangements in specialist sexual health settings.

Development of integrated care pathways to deliver PrEP medication and remote testing to individuals without the need to regularly physically attend specialist sexual health services. These models should include development of online PrEP services ("e-PrEP") [Ref 37]. This will include systems development of governance systems for electronic remote prescribing, along with exploration of general practice and pharmacy-based care pathways. Perspectives to be evaluated from community, current PrEP users, potential PrEP users and health care providers. HIV third sector organisations are well-placed to support such community-based models.

Lead agency: specialist integrated sexual health services within NHS boards, supported by HIV third sector organisations with academic institution collaboration.

3.4 Enhanced sexual health specialist service capacity to support clinical governance for HIV transmission elimination.

Specialist sexual health service capacity is required as a frontline partner to implement HIV transmission elimination. Apart from supporting a wide range of partners, direct clinical care and prevention is also provided in this setting. There is medically supported expertise for complex PrEP delivery in the presence of underlying medical conditions which is not provided elsewhere. Sexual health advisers are integral to delivering comprehensive contact tracing after newly diagnosed HIV. As part of wider clinical governance, there is responsibility for failsafe systems to ensure that positive results are acted upon and people with HIV are linked to and attend specialist care.

Lead agency: specialist integrated sexual health services within NHS boards.

3.5 To update local HIV post-exposure prophylaxis (PEP) care pathways to be consistent with current guidance.

The current BASHH-BHIVA UK guideline for the use of HIV post-exposure prophylaxis (PEP) was published in 2021 [Ref 38]. The purpose of PEP is to prevent HIV transmission after community sexual, occupational and non-occupational exposures. To achieve this, PEP needs to be delivered as soon as possible after the exposure. This is usually in a variety of settings including emergency departments, sexual assault services and other specialist services. Requires staff training.

Lead agency: public health teams within NHS boards.

3.6 NHS Boards to annually review local actions to prevent BBV transmission including condom distribution, behavioural and biomedical interventions, provision of injecting equipment, testing in the presence of HIV indicator conditions and routine opt-out testing in relevant settings.

Many NHS boards already formally co-ordinate and deliver prevention interventions in partnership with key partners to meet local needs, usually led by a dedicated committee. These contribute to wider positive outcomes, beyond HIV alone (e.g. prevention of pregnancy, sexually transmitted infections, drug-related harms, detection of hepatitis, and stigma reduction).

Lead agency: public health teams within NHS boards.

4. Entry into and retention in specialist HIV care interventions

4.1 Episodes of late HIV diagnosis or death to be investigated using existing local clinical governance pathways for serious adverse events, with supportive feedback and training offered if required.

Late HIV diagnosis (first presentation linked to underlying immune deficiency and/or a CD4 cell count below 350) or death are serious adverse events which are potentially preventable and should be managed using the same clinical governance pathways/escalation as other adverse events (for example, surgical adverse events and deaths). This is to support learning and prevent further instances from happening. Avoiding HIV-exceptionalism will also help to reduce HIV-related stigma.

Lead agency: public health teams within NHS boards.

4.2 To document defined care local pathways to support rapid entry into specialist HIV care after a positive test or access to primary combination prevention (if increased transmission risk identified) after a negative HIV test result.

People living with HIV may engage with different partners in health & social care and the third sector in Scotland. If newly diagnosed or not currently attending a clinic, rapid entry to specialist HIV care (within 2 working days) is important to provide advice, support, assessment and treatment. Care pathways should be documented and shared with key collaborators. Individuals who would benefit from combination prevention (including but not limited to PrEP) need to have prompt access to specialist advice and services.

Lead agency: public health teams within NHS boards supported by specialist HIV service providers and the third sector.

4.3 To provide feedback to HIV care and treatment services when individuals relocate and enter care elsewhere (notably in another UK nation).

On most occasions, when a person living with HIV changes clinic or service provider, consent is provided to contact the previous service to handover care. However, this does not always happen, especially if a person moves from one UK nation to another. This leads to uncertainty when a person is regarded as "lost to follow up". This action is to encourage confirmation of care transfer between providers, supported by third sector organisations supporting people living with HIV to let service providers know if they do not plan to return to the original clinic.

Lead agency: specialist HIV services, supported by HIV third sector organisations.

5. Contact tracing interventions

5.1 To monitor and evaluate comprehensive contact tracing with partner support for people with newly diagnosed HIV in Scotland.

Contact tracing aims to identify and contact all people who might have been/are at risk of acquiring HIV from the person who has been newly diagnosed (index patient) and to provide person-centred testing, care and support with linkage to HIV treatment services or HIV prevention services as appropriate (ideally within a short time of the index patient's first positive result). This will be led by sexual health specialist services working with key collaborators in HIV and other relevant services and underpinned by failsafe systems linked to clinical governance reporting mechanisms. National non-aggregated data (not currently available) would help target future prevention initiatives taking account of geographical locations or behaviours, plus share learning and best practice more effectively. Phylogenetic analysis of HIV (which provides "a fingerprint") to link chains of transmission is a further tool which is already commonly utilised. UK guidelines on HIV contact tracing are being updated in 2022/23.

Lead agency: specialist integrated sexual health services within NHS boards.