HIV Update - MP Breifing 09

HIV Update MP Briefing

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HIV Update 2009 In the 24 years of the HIV epidemic in New Zealand, the landscape the New Zealand AIDS Foundation (NZAF) works in has changed. Homosexual Law Reform, the internet and most significantly, the advent of antiretroviral therapies are a few of the significant events that have changed the environment that the NZAF first confronted in 1985.

Antiretroviral drugs (ARVs) are medications for the treatment of HIV. While ARVs are an effective treatment, there is still no cure for HIV. Today, people living with HIV are healthier and live longer than previously however drug resistance to ARVs can develop and for some there are serious side effects such as kidney or liver failure.

Human Immunodeficiency Virus (HIV) is a virus. Once HIV is in the blood stream it slowly begins to attack the immune system, killing off healthy immune system cells. The deterioration and destruction of immune function leads to Acquired Immune Deficiency Syndrome (AIDS). AIDS is the final stage of the HIV infection. A person is said to have AIDS when their CD4 count (the number of T cells in the body) drops below two hundred and or a person has one or more opportunistic infections. Opportunistic infections are normal infections that a healthy person would be able to fight off.

Since 1996 when funded ARVs became widely used in New Zealand, the number of people whose HIV infection progressed to AIDS has decreased dramatically and the rate of mortality due to AIDS is the lowest ever recorded (two in 2008). Conversely, the number of people living with HIV, as opposed to dying of AIDS, has increased. Since the introduction of ARVs, many developed countries have seen a similar trend. New Zealand continues to have one of the lowest rates of HIV prevalence worldwide.

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The HIV Epidemic in New Zealand HIV is transmitted through blood, semen, rectal mucous, vaginal fluid and breast milk. New Zealand has low levels of injecting drug users and has had an effective needle exchange programme since the late 1980s so injecting drug use accounts for very few HIV infections in New Zealand. Similarly, condom use has been widely adopted among New Zealand sex workers therefore prostitution is not a significant vector for the transmission of HIV either.

Both are considered remarkable successes worldwide. In New Zealand the vast majority of HIV is transmitted sexually; the groups most at risk of HIV are primarily gay and bisexual men, followed by heterosexuals from African communities based in New Zealand.

Gay and Bisexual Men Most at Risk Gay and bisexual men are more at risk of HIV in New Zealand because gay and bisexual men have anal sex at much higher rates than any other section of the New Zealand population. This puts gay and bisexual men at risk because semen and rectal mucous carry more HIV than vaginal fluid, and because the prevalence of HIV is already higher among gay and bisexual men.

Table 1 comes from a study of people who attended a sexual health clinic in 2005-6. It shows that gay and bisexual men had rates of HIV that were approximately forty times higher (4.41%:0.12%) than their heterosexual counterparts.

Table 1 Unlinked anonymous HIV prevalence among sexual health clinic attendees 2005/6

Exposure category: Annual HIV diagnoses, 1985-2008 (Note: Does not distinguish between infections acquired in NZ and overseas)

Source: McAllister et al. Unlinked anonymous HIV prevalence among New Zealand sexual health clinic attendees: 2005-2006. IntJSTDAIDS 2008; 19:752-757.

Source: Graph produced by Research, Analysis and Information Unit, New Zealand AIDS Foundation 2009

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Place of Infection Most of the 91 gay and bisexual men newly diagnosed in New Zealand in 2008 were infected in New Zealand - 63 men, or 69% of these cases.

Place of infection: Annual heterosexual HIV diagnoses by Western blot antibody testing, 1996-2008

By contrast, in 2008 81% of heterosexual HIV transmissions occurred overseas, almost always in countries where there is a high prevalence of HIV. Heterosexual people from African communities have higher rates of HIV compared to non-African heterosexual communities.

Place of infection: Annual HIV diagnoses in homosexual/bisexual males 1996-2008

Source: Graph produced by Research, Analysis and Information Unit, New Zealand AIDS Foundation 2009

*Includes both homosexual/bisexual and homosexual/bisexual IDU Source: Data provided by AIDS Epidemiology Group, Department of Preventive and Social Medicine University of Otago Graph produced by Research, Analysis and Information Unit, New Zealand AIDS Foundation 2009

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This means that over the last five years, gay and bisexual men have accounted for 81% of the total HIV diagnoses by antibody testing in this country where infection has occurred here. The transmission of HIV within New Zealand overwhelmingly remains driven by unprotected anal sex between men.

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Ethnicity Over the ten year period 1999-2008, there was a total 85 new HIV diagnoses where infection occurred in New Zealand as a result of heterosexual transmission. Women of Ma-ori, Pacific, Asian and ‘Other’ ethnicities infected in New Zealand had two to four times higher infection rates than European women in this period. However, because the majority of heterosexual infection occurs overseas these numbers are very small and are not statistically significant, even when a ten year period is analysed1.

Ethnicity of men and women heterosexually infected in New Zealand during 1999-2008

Source: Adapted from a graph from AIDS Epidemiology Group. AIDS – New Zealand. Issue 63. Dunedin: AIDS Epidemiology Group, University of Otago, 2009.

Immigration Most heterosexual people diagnosed with HIV in New Zealand were infected overseas. Heterosexual HIV diagnoses increased in New Zealand from 1996 to 2006 and then began to decrease from 2007. In late 2005 Immigration New Zealand introduced mandatory HIV testing for residency applicants and people applying for a visa for longer than 12 months. Since 2006 the numbers of new HIV diagnosis have also included people diagnosed through the mandatory immigration HIV screening in New Zealand.

In 2008, 36 of the 184 people diagnosed with HIV were tested at an immigration medical. It is not known, but likely that many of the 36 people who were diagnosed during their immigration medical did not remain in New Zealand.

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AIDS and HIV: the 2008 figures In 2008, 48 people were diagnosed with AIDS.2 There were two notifications of AIDS deaths in 20083, the lowest in the history of the epidemic.

However, 184 people were newly diagnosed with HIV, the highest number ever recorded. The number of people living with HIV is increasing every year in New Zealand primarily because very few people are dying. Each new infection adds to the number of people living with HIV.

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The Future Until 2000 the numbers of new HIV diagnoses had been decreasing, however a few years after ARVs were introduced the number of people living with HIV began to rise. The growing pool of people with HIV infection means that if the annual rate of secondary transmission from HIV positive individuals remains stable, we would expect to see a higher number of new infections every year. In order to reduce the annual number of new infections, it will therefore be necessary to considerably reduce the annual transmission rate – maintaining it is not enough. This can be achieved by increasing condom use among the most-at-risk population groups, and by diagnosing new infections early and treating HIV to reduce infectiousness.

Research has shown that gay and bisexual men in New Zealand are maintaining their current rates of condom use. While this is a considerable achievement given changes in the epidemic such as the impact of effective HIV treatments and internet dating, these levels must be increased if we are to limit new infections.

It is a serious concern that international research has predicted that if the incidence of HIV infection continues at current levels, the prevalence of HIV among gay and bisexual men who are currently aged twenty could be as high as 50% by the time they are 50 years of age4.

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Stall R, Mills TC, Marshal M. Re-Emerging HIV Epidemics among MSM in the United States and Other Industrialized Nations. Paper presented at: 16th International AIDS Conference, 2006 Aug 13-18, Toronto, Canada.

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HIV Related Costs in New Zealand In 2008 1,145 people living with HIV received funded ARV treatment in New Zealand. The average cost of ARVs per person was $13,148 per annum. The current total cost of ARVs is approximately $15 million per annum.

If we assume the numbers of new diagnosis per year continue at current levels (184 per year), the cost of ARVs alone will increase by $1.77 million per annum (with 75% of those diagnosed immediately commencing ARVs).

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HIV Treatment

HIV Prevention

Until recently New Zealanders living with HIV could access the same range of publicly funded clinical treatments as those in Australia. At present there is one medication that is not funded.

The NZAF in collaboration with the University of Otago conducts behavioural surveillance of gay and bisexual men every two years (the Gay Auckland Periodic Sex Survey, GAPSS, and Gay Online Sex Survey, GOSS). International research has established that condoms and lubricant are the most effective prevention measure against sexual transmission of HIV. GAPSS and GOSS research in 2002, 2004 and 2006 showed that condom use is not reducing among gay and bisexual men in New Zealand.

Research shows that the long term prognosis for a person living with HIV is improved the earlier ARV treatment begins. Access to HIV testing is key to enabling the early commencement of treatment. The NZAF introduced rapid HIV testing in 2007 which provides a result in 20 minutes and there has been a 600% increase in HIV testing at the NZAF. The tests are World Health Organisation (WHO) recommended, FDA approved and cost $7 per test.

By contrast the HIV antibody test used for primary care and sexual health services costs $16 per unit, requires transportation of blood samples and a wait of several days.

HIV testing saves lives and money. People who know they are HIV positive are more likely to take precautions against transmitting HIV, and once on ARV treatment their viral load is lowered which also reduces the risk of transmitting HIV.

While this is reassuring, it is now clear that the rates of consistent condom use that were effective in reducing the HIV infections in the period up to 2001, have to be raised to higher levels to counteract the impact of a larger population of people living with HIV. The NZAF has undergone a comprehensive review of our HIV prevention response during 2009 and has developed a new approach based on the most up to date evidence and knowledge available. This new approach has integrated health promotion models with behaviour change strategies, and focuses on four behaviour change goals that will have the greatest impact on the HIV epidemic in New Zealand.

The four behaviour change goals are: 1. increased rates of condom use for anal sex for gay and bisexual men 2. increased Sexually Transmitted Infection (STI) and HIV testing rates for gay and bisexual men 3. increased rates of condom use for first anal sex for gay and bisexual men 4. increased condom use within New Zealand-based African communities.

The range of health outcomes that will contribute to these goals will include activities and projects that recognise the effective influences of wha-nau, peers, community and social support for safe sex practices, and will make significant use of online technologies to build virtual safe sex cultures and increase rates of condom use.

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A critical aspect of the NZAF HIV prevention response is community-based rapid testing. All NZAF HIV and STI screening services include therapeutic interventions from professionally qualified staff, to improve an individual’s safe sex practices.

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Policy Issues Public Health Bill Data about new HIV diagnoses has been voluntarily collected alongside data about AIDS diagnoses since 1985. This data on HIV and AIDS uses anonymous coding for the protection of the privacy of people living with HIV. However AIDS is a notifiable ‘disease’ and HIV is not. The anonymous data on HIV has been crucial in monitoring the trends and state of the HIV epidemic in New Zealand. The NZAF supports HIV and STIs becoming notifiable under the proposals within the draft Public Health Bill. This will not change any aspect of a person’s current experience of the data collection, but will ensure the anonymous collection of the crucial data is protected in the future as well. Individuals will not be able to be identified through this proposed change.

Blood Donation Deferral The NZAF has welcomed the evidence based reduction of the deferral period for blood donation from ten years to five years for any man who has had anal or oral sex with another man. The NZAF understands that this ‘blanket’ deferral approach in addition to effective laboratory protocols and the testing of donated blood ensures that the New Zealand Blood Service can guarantee one of the safest blood supplies in the world. It is essential there is no risk of HIV entering the donated blood service from the population with the highest prevalence of HIV in New Zealand (gay and bisexual men). The blanket ban is comparable with other population group deferrals including those who have lived in high prevalence countries such as African nations.

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HIV and Criminal Prosecutions In 2005, an important precedent was established that using a condom and lubricant was a reasonable precaution to discharge the duty of care in a criminal nuisance prosecution under Section 145 of the Crimes Act 1961.

The NZAF considers this ruling to be an excellent match of the criminal law supporting a public health approach aligned with the prevention of HIV transmission.

A case before the courts at present concerns an individual who is alleged to have transmitted, or attempted to transmit HIV with the intent to do so.

This case is unusual as the majority of people living with HIV take appropriate precautions to take care of their sexual health and their partners.

The NZAF has been chairing a working group of the National HIV and AIDS Forum in drafting a set of guidelines for use in the rare situation of a person living with HIV being unable or unwilling to take appropriate precautions to protect others from HIV transmission.

New Zealand’s Sexual and Reproductive Health Strategy The NZAF and Family Planning have expressed increasing concern that the Sexual and Reproductive Health Strategy has not progressed since its development in 2001. The 2001 strategy was based on data from the late 1990s. The impact on New Zealanders from the increase in STIs including HIV alone is reason enough to urgently update the strategy, with measurable milestones and appropriate government leadership.

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The role of the New Zealand AIDS Foundation The NZAF is New Zealand’s leading HIV prevention and professional support organisation. The NZAF provides positive health services and HIV prevention programmes to the communities most at risk of HIV, as well as research, analysis, policy and leadership.

Issues for the Pacific The ongoing danger of an HIV epidemic in the South Pacific is a serious concern. Human rights are essential to enable an effective HIV prevention response for the groups most at risk of HIV. Poor health systems including limited infrastructure for HIV testing and surveillance limit the efficacy of HIV treatment. In 2009, the NZAF received funding from the Pacific Islands HIV and STI Response Fund to develop a programme with its Pacific partners that combines activities and interventions such as the promotion of condoms and lubricant for men who have sex with other men. These initiatives aim to reduce the prevalence of undiagnosed HIV and STIs, prevent the transmission of HIV, reduce health inequalities, and reduce discrimination for Pacific gay men, bisexual men, non-identifying Pacific Island men who have sex with men, Fa’afafine; Akava’ine, Fakaleiti and other Pacific Transgender People.

The NZAF National Office is in Auckland, and there are four regional centres in Christchurch, Wellington, Hamilton and Auckland. The NZAF is a registered charity that grew out of gay community initiatives in the 1980s.

Today, the NZAF brings history, commitment, knowledge, expertise and diversity to meet the emerging trends of the HIV epidemic and the changing needs of the communities we serve.

AIDS Epidemiology Group. 2009. AIDS New Zealand - Issue 63 - March 2009. Department of Preventive and Social Medicine, University of Otago Medical School: Dunedin.

AIDS Epidemiology Group. 2009. AIDS New Zealand - Issue 63 - March 2009. Department of Preventive and Social Medicine, University of Otago Medical School: Dunedin.

3 AIDS Epidemiology Group. 2009. Eighteenth Quarterly Report of the AIDS Epidemiology Group to the Ministry of Health. Department of Preventive and Social Medicine, University of Otago Medical School: Dunedin.

4 Stall, R. 2009. “Running in Place: Implications of HIV Incidence Estimates among Urban Men Who have Sex with Men in the United States and Other Industrialized Countries” in AIDS Behaviour, 10 February 2009.

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Mission

The New Zealand AIDS Foundation’s mission is to prevent the transmission of HIV and to support people affected by HIV and AIDS to maximise their health and wellbeing.

Koromakinga Ki te a¯rai i te tuku o te HIV me te whakapai ake i hauora me te oranga o nga¯ ta¯ngata e ora ana me te HIV me te AIDS.

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