Australia's Seventh National HIV Strategy and the AIDS 2014 Legacy Statement

A commitment to virtual elimination of HIV transmission by 2020 and the role for clinicians

At the 20th International AIDS Conference in Melbourne in July, Australia presented its Seventh National HIV Strategy,1 along with the AIDS 2014 Legacy Statement, which commits health ministers to working towards the virtual elimination of new HIV transmission in Australia by the end of 2020.2

Unlike its predecessors, the Seventh National HIV Strategy contains numeric targets, which reflect the United Nations Political Declaration on HIV/AIDS3 and have been adopted in other jurisdictional HIV strategies.4,5 These strategies place Australia well on its way to reaching the UNAIDS targets by 2020 of 90% of people living with HIV being diagnosed, 90% of people living with HIV receiving antiretroviral therapy (ART), and 90% of people receiving ART having an undetectable viral load. When an HIV-positive individual is receiving effective ART and his or her plasma viral load is undetectable, the risk of transmission becomes negligible, making HIV treatment a highly effective means of prevention.6 These approaches require targeting efforts to communities that are most at risk and where most transmission occurs.

Many will recall Australia's “grim reaper” television advertising of the late 1980s, designed to galvanise the general community's fight against HIV and spur people to action. Today it would be viewed as targeting the wrong audience, as we now recognise that HIV affects different communities differently. In Australia, HIV remains highly associated with men who have sex with men (MSM). In other countries, HIV epidemics are more closely associated with sex workers or people who inject drugs. In many countries, the epidemic is generalised, also affecting heterosexual people and young women. As a consequence, Australians who come from or travel to these countries can be at elevated risk of HIV.

Clinicians play a significant role in meeting the key targets of increasing the number of people receiving effective ART and reducing transmission. Modelling suggests that a significant increase in identification of HIV in the community is needed to drive down new infections. Infections largely fall into two groups: those that are established and undiagnosed (prevalent infections) and those that are new (incident infections). Different approaches are required to reach these groups. The AIDS 2014 conference and domestic initiatives provide insights into how to do this.

• Opportunistic HIV testing initiated by clinicians can be tailored to individual patients' needs. Sexually active MSM should be encouraged to test regularly,7 up to four times annually and after any risk events. HIV testing is easier now and should be considered as part of routine care for MSM. Clinicians can reinforce this message through statements such as “We like to test all new patients for HIV, are you OK with that?” and “We do an HIV test as part of any screen for sexually transmissible infections”. Clinicians can also provide negative test results over the phone.8 Sexually active MSM who have not been tested recently should be encouraged to do so.
• Point-of-care tests are common internationally and are being increasingly used in Australia. Recent changes will also allow the Therapeutic Goods Administration to evaluate HIV tests for self-use.9 These tests can also reach those MSM and other at-risk people who have not been accessing testing through traditional avenues.10
• Identifying seroconversion illness and recent HIV infection is also important and may not be considered outside clinics with considerable experience in HIV management. Many people (about 80% of patients) have a febrile illness soon after exposure to HIV,11 and this is particularly important to identify among people returning from overseas.

In Australia, achieving treatment uptake and HIV virological suppression should be more achievable than it is globally, as we have access to subsidised drugs and no institutional barriers to treatment commencement. Newer ART drugs are more potent at suppressing viral replication, less susceptible to development of resistance and more tolerable than older drugs. All general practitioners can initiate HIV testing and be involved in shared care for their patients living with HIV, and accredited GPs can initiate ART.

Australia has always practised a partnership approach to HIV. Clinicians, researchers and affected communities worked together to initiate epidemiological and behavioural research12 before the causal agent was identified. Australia also initiated a national discussion on how to respond to HIV/AIDS13 and from this developed the first National HIV/AIDS Strategy in 1989. Australia has since maintained a strategy-led response to HIV and has expanded this approach to hepatitis B and C and other sexually transmissible infections, and blood-borne viruses and sexually transmissible infections among Aboriginal and Torres Strait Islander peoples.14 Twenty-five years later, the Seventh National HIV Strategy has been launched as part of this suite of national strategies, endorsed by all state, territory and federal governments. Underpinned by the Seventh National HIV Strategy, the AIDS 2014 Legacy Statement renews Australia's commitment to its partnership approach to HIV.