By Pam Pickering
World AIDS day on December 1, also launches the start of ABORIGINAL AIDS AWARENESS WEEK in Canada. It is a time for reflection: on what we have achieved with regards to the national and global responses to HIV, and what we still must achieve. This years World AIDS Day comes in the midst of another global pandemic, the coronavirus disease (Covid-19). The public health response to this is linked. Covid-19 is threatening access to HIV prevention, testing, treatment, and care. Without strategies to meet these needs, we may see a resurgence of HIV that would threaten our public health response to Covid-19.
The joint United Nations Program on HIV/AIDS (UNAIDS) and the World Health Organization have established a global strategy on HIV that includes a target of eliminating AIDS by 2030. Canada has adopted this strategy, including the specific targets of 90-90-90; which is 90% of all people with HIV know their status, 90% receive antiretroviral treatment, and 90% on treatment achieve viral suppression. Canada’s progress on meeting these targets as of the end of 2016; of the estimated 63,110 people living with diagnosed HIV has shown improvement. 86% are diagnosed with HIV, 81% are receiving antiretroviral treatment, and 91% have a suppressed viral load. Canada’s 90=90-90 estimates lie within the range reported by other developed countries such as the US, Australia, the UK, Denmark, and Germany.
Several factors play a role in achieving each of the 90-90-90 targets. There are more options for HIV testing in Canada than in previous years. There are 2 new tests awaiting approval and it is hopeful they will be available in early 2021. The first is the INSTI HIV self test which will be the first tool approved in Canada for people to test themselves for HIV. It is a test that is easy to perform and results are ready in a few minutes. ASK Wellness will be part of this role out by distributing these for free early 2021. In addition, several countries already have the OraQuick Oral HIV test that uses an oral swab rather than a finger pick to detect HIV, and Canada hopes to have approval in 2021 as well. Recent provincial testing initiatives such as “Know Your Status” have increased testing which have lead to new diagnoses.
There are still barriers to HIV testing. Particularly for those at high risk, facilitating early detection through the promotion and availability will help Canada reach the first target.
The second 90-90-90 target (proportion of those diagnosed who are on treatment) continues to be the lowest of the 3 targets. This is true in Canada and other Western countries and may in part be due to the recommendation to treat all HIV infected persons at diagnosis is relatively new. A variety of measure such as ensuring the availability of culturally and gender appropriate educational resources, eliminating barriers to treatment such as cost, developing new drugs and supporting health professionals with resources for appropriate and timely treatment will help in the achievement of the second 90 target. An exciting new drug is on the horizon that will only need to be injected once every 2 to 3 months to aid medication compliance.
After starting treatment many people remain engaged in ongoing care and support to monitor the effectiveness of therapy. These people are able to maintain a suppressed viral load if they take their medication as prescribed and have a drug combination that is effective against their strain of HIV. The effectiveness of such follow up may explain why the third 90-90-90 target is higher than the other two. Certain social, economic, and environmental factors such as the experience of stigma and discrimination, poverty, housing instability or social isolation may influence whether or not a person achieves a suppressed viral load.
The Public Health Agency estimates that 2165 new infections occurred in Canada in 2016 which is an increase from previous years. Among the new infections, approximately 1136 or 52.5% were attributed to gay, bisexual, and other men who have sex with men (gbMSM). There were 244 new infections attributed to people who inject drugs, representing 11.3%. Heterosexual contact remained constant at 33%, both endemic and non endemic.
The distribution of new infections continues to disproportionately affect certain populations including gbMSM, Indigenous people and people from countries where HIV is endemic. This highlights the need for evidence informed programs that are culturally and gender appropriate. In addition, 1 in 5 new infections is attributed to heterosexual contact among people born in Canada or in a country not on the endemic list, which emphasizes the need for ongoing, broad based prevention and education.
At the end of 2016, an estimated 9000 people or 14% of the 63,110 people living with HIV in Canada, were unaware of their infection. These people are hidden from the health care system so thus cannot take advantage of the appropriate prevention, treatment, and ongoing care and support until they are tested and diagnosed. Since HIV treatment has reduced mortality and new infections are occurring at a rate greater than deaths, the overall number of people living with HIV will continue to increase in the years to come. Strategies aimed at reaching the undiagnosed and increasing the number of people adhering to treatment, could help Canada achieve the first two 90-90-90 targets.
It is the strength within communities, inspired by shared responsibility to each other that has contributed in great part to our victories over HIV. We must continue to put people first. We must end the social injustices that put people at risk of contracting HIV. We must fight for their right to health. There is no excuse for governments to not invest fully for universal access to health. Barriers such as up-front user fees that lock people out must stop. All human rights must be respected, and the criminalization and marginalization of gay men, transgender people, sex workers, and people who use drugs must stop.
As we approach the end of 2020, the world is in very uncertain times and the months ahead will not be easy. Only global solidarity and shared responsibility will help find an affordable and accessible Covid-19 vaccine, end the AIDS epidemic, ,and guarantee the right to health for all.