Dramatic cuts to HIV Prevention England funding

The government has announced that funding for HIV Prevention England, the national HIV prevention programme in England, will be cut by 50% from April 2015. This will have a significant impact on local prevention and testing services and on the dozens of organisations that act as local delivery partners.

NAT (National AIDS Trust) has described the decision as “outrageous, given the ongoing high rates of HIV transmission in England and significant gaps in public understanding about HIV”.

Central government funding for national HIV prevention programmes has been progressively reduced in recent years. HIV Prevention England began in 2012 with an annual budget of £2.4 million (less than the combined budgets of the previous prevention programmes, NAHIP and CHAPS).

The Government will now only allocate £1.2 million for the year beginning in April – and has made no commitment to continuing this in 2016.

Even in areas of high HIV prevalence, many local authorities’ spending on HIV prevention is inadequate. In some areas, the only prevention activity taking place is commissioned through the national programme.

The estimated lifetime cost of treating someone with HIV is £360,777. This means that even if the £2.4 million programme only prevented seven new transmissions a year, it would save the NHS money.

However, there is a total of around 1.2 million men who have sex with men and black African adults living in England. A budget of £1.2 million means that the national programme only has £1 to spend a year for each person in its target audience.

NAT is urging people living in England to write to the Public Health Minister, Jane Ellison, and ask for funding to be continued at least at current levels for the next three years.

NHS urgently needs to make PrEP available

Following the highly encouraging results of two studies of pre-exposure prophylaxis (PrEP) in the UK and France, a coalition of community organisations working on HIV prevention has come together to call for the NHS to speed up its processes and make PrEP available to those at the highest risk of acquiring HIV. The organisations point to the continued high rate of new infections and say there is an urgent need to improve HIV prevention.

Although an NHS England process to evaluate PrEP is underway, any decision to provide PrEP will probably not be implemented until early 2017, which the statement says is too long to wait: “We are calling for earlier access to PrEP. The NHS must speed up its evaluation process and make PrEP available as soon as possible. Furthermore, we call for interim arrangements to be agreed now for provision of PrEP to those at the highest risk of acquiring HIV.”

Over 1000 organisations and individuals have already signed the statement. Among those supporting earlier access to PrEP are HIV Prevention England, NAM, Terrence Higgins Trust, Yorkshire MESMAC, National AIDS Trust, GMFA, the Lesbian and Gay Foundation, Positively UK, Metro Centre, UK-CAB, HIV i-Base, HIV Justice Network, Naz Project and Act Up.

Which gay men are passing on HIV?

A modelling study based on the UK’s HIV epidemic in gay men suggests that the majority of HIV transmissions come from men who are not taking treatment and are not aware of their HIV status. They tend to be younger, have relatively high levels of sexual activity and are often in a relationship.

The model aimed to estimate the contribution of various behavioural and biological factors to HIV transmission between men who have sex with men. This could help with the design and targeting of HIV prevention and testing interventions.

  • Although only one in five gay men living with HIV are undiagnosed, around 63% of transmissions come from undiagnosed men.
  • Although only a third of gay men living with HIV are not taking HIV treatment (and most of them are undiagnosed), around 85% of HIV transmissions come from men who are not on treatment.
  • Although the majority of men living with HIV are somewhat older, around 62% of HIV transmissions originate in men aged 15 to 34.
  • While many gay men have less sex than this, around 80% of HIV transmissions originate in men who have at least two new sexual partners each year.
  • Around 90% of HIV infections occur in repeat sexual partnerships – this includes both ongoing romantic relationships and ‘fuck buddies’.
  • Around 10% of HIV transmissions come from men who have primary HIV infection (i.e. acquired HIV very recently). This is considerably lower than some other estimates.

The findings should be used to improve the design and targeting of HIV prevention and testing interventions. In particular, they show that younger gay men with high levels of sexual activity are a priority for HIV testing services, especially services which facilitate regular testing. The large number of transmissions occurring within some sort of ongoing relationship suggest the value of interventions for men in relationships.

Quick facts: female condoms

These figures come from 753 heterosexual African men and women living in England who took part in the recent African Health and Sex Survey.

“Female condoms are an effective means of preventing HIV transmission which could be an alternative if people have trouble using male condoms,” says Adam Bourne of Sigma Research. Given the very low rates of awareness and usage, “future interventions may wish to emphasise the benefits of Femidom use and explain where they can be obtained.”

“It’s about taking them out, raising awareness and getting women to try them out and be comfortable using them,” says Celia Fisher of LASS. The first time a woman tries a female condom, this should not be for sex – it often works better if she can try it on her own, to get used to the fit and feel. While the appearance of a female condom out of the packet may be discouraging, many women say that they feel different when it’s inserted. “When people have the confidence to try them out, they find out that actually it’s nothing like the bag that it seems on the outside,” says Celia.

While LASS continues to distribute far more male condoms (36,000) than female condoms (1000) each year, the demand is growing with women coming back for more at venues such as hair salons, African nightclubs and the British Red Cross.

Drugs work should focus on pleasure and practicalities

Harm reduction interventions often fail to engage people who inject drugs because they over-emphasise infection and risk, according to UK research. While people who inject drugs frequently adopt safer injecting practices, they tend to be motivated by a desire to have a quick, pleasurable hit – not by concerns about blood-borne viruses.

The researchers made particular efforts to talk to people who had used drugs for many years but had managed to remain free of hepatitis C. Maybe health programmes can learn from these individuals.

Several avoided re-using needles because a blunt needle would be painful, take a long time to use, damage veins (making future injections harder) and risked leaving ‘track marks’ that publicly identified the person as a drug user. Others insisted on preparing their own drugs, rather than allowing a friend to do it. This reduced the risk of shared equipment but was mostly motivated by a desire to avoid badly prepared mixtures. 

Harm reduction programmes may be more effective if they focus on the issues that matter to people who inject drugs – having a pleasurable hit and maintaining usable veins – rather than the risk of blood-borne viruses.

The researchers noted that whereas some HIV prevention materials for gay men acknowledge the pleasure of sex (for example, slogans like ‘have fun safely’), materials for drug users tend to be much more negative. The themes identified in the research could be reflected in harm reduction messaging, perhaps with slogans like ‘Don’t use used works, it hurts’ or ‘New kit – better hit’.

Case study: mentor mothers

Women living with HIV who wish to have a child face a complex set of choices at each stage, from conception to delivery and infant feeding. Positively UK’s ‘mentor mothers’ programme aims to empower women to navigate these complexities and to challenge the stigma that women living with HIV face. As with the rest of Positively UK’s work, peer support is at the heart of the project – all the volunteers providing one-to-one emotional and practical support have had children since their own diagnosis. “Someone who has lived that life and has walked that journey can better anticipate what the person needs,” says Angelina Namiba of Positively UK. A careful selection process and training programme ensures that the mentors have the skills needed to provide peer support.

Moreover, the mentor mothers provide living proof that it is possible to have HIV and give birth to an HIV-negative child. They demonstrate that the challenges of HIV and pregnancy are not insurmountable and normalise the idea of living with HIV.

Women are referred to the project by midwives, clinicians and voluntary organisations. The women who receive support tend to be recently diagnosed (often during pregnancy), have disclosed their HIV status to very few people and are socially isolated. The volunteer mentor mothers have often had similar experiences in the past and want to help other women avoid having as tough a time as they had themselves. Kay Francis, lead HIV midwife at the North Middlesex University Hospital is involved in training the mentors. She emphasises the “motherly aspect” of the volunteer role and the strong bonds that the mentors and mentees forge. Peer support complements that provided by clinicians, midwives and other professionals, she says.

The mentor mothers also help deliver workshops to people living with HIV, have produced a booklet based on the questions they are most often asked, and have taken part in videos on HIV and pregnancy. (These resources are available on Positively UK’s website).

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