Four decades since the first reports of HIV and AIDS in Ireland, massive advances have been made in the field of HIV medicine such that in 2023 individuals newly diagnosed with HIV have the potential for life expectancy similar to that of the general population and new HIV infections could be prevented.
HIV surveillance and epidemiology in Ireland
Surveillance of HIV is vital for understanding and responding to the latest trends and features of the HIV epidemic. HIV became a notifiable disease in 2011, the Health Protection Surveillance Centre produces weekly and annual reports.
The most recent annual report demonstrates an increase in the number of new HIV diagnoses in 2022 compared to 2020 and 2021, which may be explained by a number of factors including: easing of restrictions associated with the COVID19 pandemic; resumption of normal testing services; increased migration to Ireland of people who are living with HIV and unmet need in HIV prevention services. The finalised report for 2022 is expected in quarter 2 2023.
Key features of the provisional surveillance data on 644 new diagnoses, corresponding to a rate of 13.5 per 100,000 population, from Q1-Q3 2022 include:
• The majority of HIV diagnoses (77%) are in people who were previously diagnosed positive outside Ireland (where history of previous diagnosis is known).
• The majority of HIV diagnoses are among males but a higher proportion of HIV diagnoses are in females, compared to recent years.
• The key population group affected by HIV continue to be gay, bisexual and men who have sex with men (gbMSM) accounting for 55% of HIV diagnoses (where route of transmission is known). The second most commonly affected group, heterosexual females, account for 29% of diagnoses (where route of transmission is known) which is higher than in previous years.
• Among those with known region of origin, the majority of HIV cases (88%) are among migrants, defined as originating outside the country in which they were diagnosed. This proportion is higher than in previous years.
Outcomes for people living with HIV (PLWH)
Without antiretroviral therapy (ART) the majority of PLWH will develop profound HIV related immunosuppression, HIV associated opportunistic infections and ultimately succumb to an AIDS related illness.
Early initiation of ART before there has been a decline in CD4 count (the current marker of HIV related immunosuppression) affords PLWH net benefits (both in terms of AIDS and non-AIDS serious events). The UK HIV cohort study found that successfully treated PLWH have a normal life expectancy and that those who started ART with a low CD4 cell count significantly improve their life expectancy if they have a good CD4 cell count response and undetectable viral load.
Given the benefits of early initiation ART, international guidelines recommend that ART is offered to all PLWH regardless of CD4 count. In Ireland, ART is available and recommended for all PLWH attending services. The first nationally, coordinated audit of PLWH attending all public HIV treatment services was conducted in 2018. This measured the number attending HIV services in 2017, the number on ART and the number who were virally suppressed. The audit found that 5,317 individuals attended a HIV treatment service in Ireland in 2017. Of these, 98.3% were on ART, of whom 95.4% were virally supressed to below the level of detection of the assay. A repeat audit is planned in 2023.
Availability and offer of HIV testing is essential to ensure that PLWH have the opportunity to benefit from early ART. HIV testing, and the role of Health Care Professionals in HIV testing is discussed later.
Global targets for eliminating HIV
Goal 3.3 of the United Nations Sustainable Development Goals is to end the AIDS epidemic by 2030. The global COVID19 pandemic has significantly affected the ability to reach this goal. Recognising this, UNAIDS has reset the 2020 HIV global targets from 90-90-90 to 9595-95, the aim being that by 2025; 95% of PLWH will be diagnosed; 95% of people diagnosed will be receiving ART; and 95% of PLWH on ART will be virally suppressed and unable to pass on infection. The repeat national audit planned for 2023 will contribute to our understanding of how Ireland is doing in terms of reaching global HIV targets.
Combination HIV prevention strategies to eliminate new infections
It is well accepted that the best approach to HIV prevention is through a combination approach of behavioural interventions, structural interventions and biomedical interventions. These have been defined by UNAIDS as:
“Behavioural interventions for HIV prevention are applied to promote change in sexual behaviour, and to increase HIV service utilization and adherence to HIV services and behaviours.”
“Structural interventions are activities designed to address the underlying environmental vulnerabilities of HIV infection, including political, legal, economic, physical, social and cultural barriers such as inequitable gender norms or HIV-related stigma and discrimination.”
Within structural interventions, it is important for us as Health Care Professionals to consider HIV-related stigma in healthcare settings where it remains a barrier to accessing testing, treatment and care for HIV. A study on the stigma experiences in healthcare settings of PLWH in Ireland found that experiences of enacted, anticipated and internalised stigma were common and that these experiences impacted participants’ engagement with care and affected health-seeking behaviours and treatment adherence.
“Biomedical interventions use a mix of clinical and medical approaches and tools to reduce HIV transmission. These include condoms, needle and syringe distribution, opioid substitution therapy, voluntary medical male circumcision (VMMC), antiretroviral therapy for prevention, STI testing and treatment and HIV testing.” Within biomedical interventions needle and syringe distribution and opioid substitution therapy are well established in Ireland. A national condom distribution service was established in 2015 with a steady increase in the number of free condoms and lubricants supplied per year through a range of health care, community and social settings. VMMC is not practiced within the Irish setting as a HIV prevention intervention.
Antiretroviral therapy for HIV prevention
In addition to the significant individual benefits associated with ART for PLWH, ART used in a range of circumstances is central to HIV prevention, specifically: Treatment as Prevention (TasP); PreExposure Prophylaxis (PrEP) and PostExposure Prophylaxis (PEP).
• Effective ART for people living with HIV has been shown in a large randomised controlled trial, conducted across a range of economic settings to avert HIV transmission. The real world protective effect of ART in preventing sexual transmission of HIV has been well established. These studies provide robust evidence in support of the statement “U=U”, undetectable equals untransmittable. Effective ART in pregnancy has similarly been shown to avert vertical transmission of HIV with vertical transmission rates of <0.4% since 2012 in England.
• ART can also be used following a potential HIV exposure, post exposure prophylaxis (PEP). PEP is a 28-day course of ART that must be started as soon as possible following a potential exposure and within 72 hours. PEP is available through most public STI clinics, some Emergency departments and sexual assault units. PEP is not available through community pharmacies. Irish PEP guidelines have been in place since 2012 with updates since then including 2022 updates which are currently out for consultation.
• Pre-exposure prophylaxis (PrEP) is the pre-emptive use of ART in HIV negative people to reduce the risk of HIV infection and has been shown to be highly effective in preventing infection when used correctly. A health technology assessment concluded the successful implementation of a national PrEP programme would be safe, effective and cost-saving over the medium to long term in Ireland. A national PrEP programme commenced in late 2019. The HSE Sexual Health and Crisis Pregnancy Programme provides information resources for PrEP users and providers. (sexualwellbeing.ie)
HIV testing is an integral part of combination HIV prevention given the clear benefits of effective ART in preventing onward transmission in addition to the significant individual health benefits with early initiation of ART for PLWH. At present there are no HIV testing guidelines in Ireland. However, the key principles and testing recommendations of the British HIV association guidelines published in 2020 are readily applicable to Ireland.
For healthcare professionals working outside the area of HIV and related fields some principles of the BHIVA guidelines are important to highlight, specifically: all healthcare workers should be able to offer an HIV test in their setting; people should be made aware that they are being tested for HIV and that testing is voluntary; and in general, lengthy pre-test discussion is not required.
Whilst there are no specific HIV testing guidelines in Ireland, HIV testing is routinely offered in a number of health care settings including opt-out antenatal screening which commenced in 1999; routine opt-out testing as part of STI screening and following a pilot study at St. James’s Hospital Dublin, routine opt-out HIV (hepatitis B and hepatitis C) testing for St. James’s Hospital Emergency Department attendees undergoing blood testing.
A number of medical conditions, referred to as HIV indicator conditions, are known to be associated with an undiagnosed HIV seroprevalence of at least 1 per 1000. These conditions include: malignant lymphoma; anal cancer/dysplasia; cervical dysplasia; community acquired pneumonia; seborrheic dermatitis; severe or atypical psoriasis; mononeuritis; candidemia; invasive pneumococcal disease; primary lung cancer and Guillain-Barre syndrome. Complete tables with the supporting references are available in the BHIVA guidelines. To assist non-HIV specialist healthcare professionals in providing HIV testing to people with HIV indicator conditions, OptTEST, has developed a training module, available at www.opttest.helmlms.com/login.
In 2023, there is a vast range of HIV treatment and prevention options available. It is critical that our health system and broader society is responsive and adaptable to ensure the best possible outcomes for people living with HIV (PLWH) and those at risk of acquiring HIV.
References available on request
Written by Professor Fiona Lyons, Medical Director/Clinical Lead in Sexual Health, HSE Sexual Health and Crisis Pregnancy Programme Consultant in Genitourinary Medicine, GUIDE Clinic, St. James’s Hospital, Dublin
Clinical Professor in Genitourinary Medicine, School of Medicine, Trinity College Dublin