In a time when biomedical HIV prevention strategies are dominating the social dialogue, we look at the increasingly broad selection of sexual health strategies available without losing sight of traditional methods that have undoubtedly helped reduce the impact of the HIV epidemic.
The unprecedented impact of new HIV prevention tools like PrEP reducing new HIV transmissions in Australia is popular in media and health promotion messaging right now. At the same time, we’re also experiencing a time of awakening to scientific, evidence-based confirmation that people living with HIV who maintain an undetectable viral load for more than six months do not transmit the virus.
But today, not everybody across Australia is aware, ready, or willing and able to embrace biomedical choices as highly effective HIV prevention strategies. Most importantly, everyone should feel confident in choosing option(s) that work for them. Because ultimately, taking action and choosing one or a combination of sexual health strategies is far better than choosing none.
And let’s be clear. Debating the effectiveness of different strategies is absolutely important. But talk is cheap, and choosing to actively protect yourself and other people is what really prevents new HIV transmissions from occurring. So here’s some information to help you decide how you can be part of the solution.
Type: Biomedical HIV prevention strategy
Description: PrEP stands for Pre Exposure Prophylaxis. It is the use of prescription only medication to prevent HIV. Using PrEP is highly effective in reducing transmission of HIV. An introduction to PrEP is available here.
Introduced: VicPrEP was the first demonstration project to offer PrEP to more than 100 Melbourne residents in 2014. The Australian Therapeutic Goods Administration (TGA) approved PrEP for preventing HIV-1 infection in May 2016. Even prior to TGA approval, some GP’s were prescribing PrEP to patients who could benefit from it. Clinical studies in Victoria, New South Wales and Queensland began enrolling participants, with staggered start dates from around March 2016 onward.
Can be used by: Only people who are HIV negative.
Combination approach: PrEP can be safely used in conjunction with condoms to maximise protection against HIV and reduce the chance of acquiring STIs – this is an important consideration as PrEP offers no protection against other STIs.
Sexual health tests: Part of a managed PrEP program includes sexual health testing every three months at least once every three months.
Frequency and duration of use: One pill every day. PrEP must continue to be used daily for 28 days after the last possible exposure to HIV. PrEP can be used as an ongoing strategy for as long as someone chooses.
Usage trends and population uptake: Based on current clinical studies, there are an estimated 10,000+ people already using PrEP in Australia. According to recent data from the Gay Community Periodic Survey: Melbourne 2017, the proportion of people using PrEP increased from 5 per cent in 2016 to 16 per cent in 2017. Although 2017 data is not yet available, data from the 2016 surveys for Sydney and Queensland showed 4 per cent and 6.8 per cent of usage respectively.
“Taking action and choosing one or a combination of sexual health strategies is far better than choosing none”
Accessibility: Prescriptions are available from participating GPs across Australia. Although any GP can prescribe PrEP as part of a managed sexual health program, not all GPs may be aware of it. Some states have clinical studies which are providing free or subsidised PrEP to eligible participants.
Personal cost: Free or subsidised PrEP is available through clinical studies in some states. Community organisations PrEP’D For Change and PAN (PrEPaccessNOW) provide more information on how to access PrEP across the country. Even if not taking part in a clinical study, personal importation options to purchase PrEP online with a prescription from a GP start from around $35 per month. PrEP is not yet available on the Pharmaceutical Benefits Scheme (PBS) – the list of federal government subsidised medicines – although this is currently being considered by the Pharmaceutical Benefits Advisory Board (PBAC). For anyone in financial hardship, PAN offer a community assistance coupon scheme.
Considerations: PrEP offers extremely high levels of protection against HIV. It has been reported that PrEP can reduce the transmission of HIV by up to 99 per cent. PrEP does not protect against other viruses or bacterial infections, such as STIs. Most common STIs are easy to detect and straightforward to cure. PrEP can only offer protection against HIV when used as advised. Although becoming increasingly popular since its arrival, PrEP may not be suitable or desirable for everyone. This is another reason why three monthly testing and treatment of other STIs is so important when someone chooses to use PrEP as an HIV prevention strategy.
Special mention: Places around the world that have introduced large scale access to PrEP among gay and bisexual men have observed significant reductions of new HIV diagnoses. The state of New South Wales recently announced a 39 per cent decrease in new HIV transmissions. ACON announced that PrEP is considered one of the contributing factors for this unprecedented drop. The volume of new HIV transmissions reported for the period in NSW is the lowest since 1985 when HIV surveillance first began.
Type: Physical barrier device used as an HIV and STI prevention strategy.
Description: A condom is a physical sheath-shaped device used to cover the penis during sex. Using a condom can help reduce the transmission of HIV and other STIs.
Introduced: Condoms were first acknowledged to prevent the transmission of HIV close to the start of the HIV epidemic in the early 1980s. It took a few years to discover that the virus was passed on via bodily fluids. As a result, gay and bisexual men quickly adopted them and were pioneering community activists in promoting condom use as the only known means of protecting against HIV at the time. Throughout most of the 1980s, before treatments became available, acquiring HIV was likely to result in premature death, so using a condom was directly associated with staying safe and alive. Despite the prevalence of other STIs long before the HIV epidemic, condoms were not typically used for sex between men as they were predominantly considered a means to prevent pregnancy.
Can be used by: People who are HIV negative or people who are HIV positive. As condoms are only used to cover the penis, they are only worn by the insertive partner – the top.
Combination approach: Condoms can be safely used in conjunction with PrEP to maximise protection against HIV and other STIs. Although using HIV treatment medication to maintain an undetectable viral load for more than six months means there is no risk of transmitting the HIV virus, condoms can still be safely used to further reduce any concerns of transmitting HIV. Using condoms can also reduce the chance of acquiring or transmitting STIs.
Sexual health tests: A sexual health test every three months at a minimum is important because condoms may not be used consistently every time. Condoms are not typically used for oral sex and they do not always fully cover affected areas. Testing between at least four times a year is part of an effective safe sex strategy.
Frequency and duration of use: One condom for every occurrence of sex. A fresh condom should be used with every sexual partner. Condoms can be used as an ongoing strategy to reduce transmission HIV or other STIs.
Usage trends and population uptake: According to the Centre for Social Research in Health (CSRH) Annual Report of Trends in Behaviour 2016, condom use continues to play an important role in gay men’s sexual risk reduction practices. However, while consistent condom use remains the most common behavioural risk reduction strategy among HIV-negative men, the proportion of HIV negative men reporting consistent condom use has decreased significantly, from 34 per cent in 2006 to 26 per cent in 2015.
“Choosing to actively protect yourself and other people is what really prevents new HIV transmissions from occurring”
Accessibility: Condoms can be purchased in some supermarkets, service stations, pharmacies, restroom vending machines, or online. Some LGBTI venues, sexual health clinics and HIV/AIDS organisations provide condoms and lube for free or at low cost.
Personal cost: Condoms vary in price between free to upwards from around $5 for a pack of 10. Some non-latex condoms, or custom-made condoms may cost more.
Considerations: When used correctly, condoms offer protection against HIV and some STIs. However, condoms do not always cover affected areas of skin, there is the possibility of slipping or breaking and they are not typically used for oral sex. If a condom is not being worn, it cannot offer any protection. Condoms can only be effective when used correctly every time. Although condoms are a useful tool, they might not always be to hand and not everyone enjoys using them.
Special mention: Use of condoms by gay and bisexual men has prevented millions of HIV transmissions and saved countless lives since the beginning of the HIV epidemic in the early 1980s.
Maintaining an undetectable viral load (UVL) with an HIV treatment program
Type: Biomedical HIV treatment program with additional benefits as an HIV prevention strategy
Description: Use of prescription only medication to manage HIV in people living with the virus. Using an effective HIV treatment program is important for people living with HIV to remain healthy. When an HIV positive person is taking treatment, the amount of HIV in their body, also known as viral load, can effectively be reduced to a level that is undetectable. This doesn’t mean they are cured or free of HIV; it simply means that their treatment has suppressed the virus. People living with HIV who maintain an undetectable viral load for more than six months do not transmit the virus to sexual partners.
Introduced: Zidovudine (AZT) was the first effective antiretroviral medicine introduced in 1987. From around March 1996, HAART (highly active antiretroviral therapy) became the new standard for treating HIV using a combination of different classes of HIV medicines. In 2017 there are well over a dozen HIV treatment medicines available for use in Australia, with new and improved medicines in ongoing development and production.
Can be used by: Only used by people who are HIV positive.
Combination approach: Although using HIV treatment medication to maintain an undetectable viral load for more than six months means there is no risk of transmitting the HIV virus, condoms can still be safely used to further reduce any concerns of transmitting HIV. Using condoms can also reduce the chance of acquiring or transmitting STIs.
Sexual health tests: Part of a managed HIV treatment program includes sexual health testing at least every three months.
Frequency and duration of use: Treatment regimes may vary between taking one and multiple pills every day. HIV treatment must be used on an ongoing basis to ensure someone’s health and wellbeing is best maintained. Regular monitoring of viral load from a clinician will help ensure the treatment continues to be effective at suppressing the virus to undetectable levels with no risk of onward transmission.
Usage trends and population uptake: According to data from the Kirby Institute, it is estimated that there were 25,313 people living with HIV in Australia in 2015. Of these, 75 per cent (19,051) were receiving antiretroviral therapy, and 69 per cent (17,544) had a suppressed viral load. The percentage of people receiving antiretroviral therapy in Australia has gradually increased over a period of three years: 70 per cent in 2013, 73 per cent in 2014 and 75 per cent in 2015. The percentage of people with a suppressed viral load has also gradually increased over the same period: 63 per cent in 2013, 66 per cent in 2014 and 69 per cent in 2015. Over the past few years in New South Wales, treatment uptake has continued to increase with 95 per cent of people living with HIV now on treatment, many of whom started their treatment within six weeks of being diagnosed.
“People living with HIV who maintain an undetectable viral load for more than six months do not transmit the virus”
Accessibility: Only GPs trained as specialist S100 prescribers under the Australian Government’s Highly Specialised Drugs program may prescribe HIV treatment medication. A list and map of S100 prescribers for all states and territories is available from the Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM).
Personal cost: For people with Medicare, HIV Treatment medications are available on the Pharmaceutical Benefits Scheme (PBS) – the list of federal government subsidised medicines. The current maximum charge for a PBS listed medication is $38.80, or $6.30 for people with a concession. Residents of New South Wales are able to access HIV treatment medications for free.
Considerations: Although various highly effective treatment options exist, there is currently no cure for HIV. Most people living with HIV who are on treatments which suppress the virus will reach an undetectable viral load; however, a very small number will not achieve this. Even in this small number of cases, the virus may still be suppressed to very low levels which will result in a greatly reduced risk of onward transmission of HIV to sexual partners compared to not being on treatment.
Special mention: HIV treatment is proven to extend and improve quality of life for people diagnosed with HIV. Furthermore, after following 358 couples over four years in Australia, the Kirby Institute’s Opposites Attract study recently concluded that condomless sex with a person living with HIV who has sustained an undetectable viral load for six months or more is a form of safe sex. Another study, PARTNER, is ongoing in Europe and the UK. In July 2016, it reported its phase one results showing there were no HIV transmissions following an estimated 58,500 acts of condomless sex between mixed HIV status couples where the HIV positive partner had an undetectable viral load.
More information: Contact your GP, local HIV/AIDS organisation, or community groups like The Institute of Many for support and further information. Information on how to access HIV care and treatment is available from the National Association of people with HIV Australia (NAPWHA).