Ending HIV transmission: Does this Pride Month signify the biggest leap towards the golden age of HIV prevention so far?

It would be remiss to discuss HIV and the recent progress that has been made without first acknowledging the disproportionate effect that this devastating, and often highly stigmatised, disease has had on the LGBTQ+ community. Since the first case was discovered in the US in 1981, which sparked a global epidemic, approximately 88 million people have been infected, with roughly 40 million currently living with the disease. If left untreated, HIV attacks and destroys CD4 T lymphocytes, gradually destroying the immune system and leading to the onset of AIDS. In the early 1980s, prior to the isolation of HIV, AIDs was believed to only affect specific groups, particularly gay men in developed countries due to a high disease prevalence at the time. The lack of effective treatment meant that those diagnosed with HIV faced debilitating illness, social isolation and, in most cases, death within a number of years. Contaminated blood used for transfusions, such as the prominent UK case where over 30,000 people were infected with HIV and hepatitis C, proved that the disease could also affect heterosexuals. Currently, approximately two-thirds all people living with HIV reside in Sub-Saharan Africa posing different but equally unfair challenges in obtaining suitable disease control to those experienced in the past.

Advances in HIV treatment and prevention leave a lot to be optimistic about regarding the both the quality of life of those living with the disease, and the hope for its eventual eradication. When researching the disease whilst at university (circa 2016-2019), I recall the statistic at the time comparing a HIV positive patient on effective medication to having the same life expectancy to someone with diabetes. Although I can’t find the reference now, the statistic is somewhat obsolete as, in the UK, those living with HIV supported by the right medication and care are expected to have a ‘completely normal’ lifespan. This is clearly a massive improvement from the early years of the disease and shows what can be achieved with appropriate funding for both research and healthcare. Unfortunately, despite the availability of effective treatment options, 600,000 people globally die from the virus, either due to a lack of either diagnosis or access to these treatments.

As with many infectious diseases, it is a widely accepted fact that prevention is better than cure. For HIV, the development of PrEP (pre-exposure prophylaxis for HIV) in the early 2010s was gamechanger in the control of the disease. Approved by the FDA in 2012 and the EMA in 2016, PrEP is an oral therapy that, when taken once daily following a loading period, prevents the spread of HIV through two active substances, emtricitabine and tenofovir disoproxil. The treatment works by stopping the HIV lifecycle meaning that, if infected with the disease while on stable treatment, the virus is unable to replicate. This can reduce the transmission of HIV by more than 99%. Nowadays, the UK NHS offers this routinely to groups of people at higher risk of HIV infection. However, again thinking back to circa 2019, and as a ‘young and healthy individual’ (i.e., not affected by a chronic/rare disease), availability of PrEP in the UK was my first (and still to this point only) personal experience of restriction in patient access to a medicine which dumfounded me.

As mentioned, by 2016 both the treatment was approved in Europe, yet PrEP did not become available on NHS England until 2020, almost 4 whole years post-EMA approval. Therefore, between 2016 and 2020, ‘higher risk’ individuals in England became increasingly aware of a preventative treatment becoming offered in Europe while access here remained stunted. Anecdotally, this led to a significant number of individuals acquiring the treatment privately from European pharmacies, creating disparity between those who were able to pay and those who could not. An editorial published in the Lancet following the 2020 decision titled “Building on the PrEP victory” acknowledges the long hard fight of HIV activists and healthcare providers to make the drug widely accessible. Ultimately, this begs the question of why it took so long to be made available and whether some prejudices still cloud decision-making, regardless of an effective and safe data package.

As anyone that requires regular daily treatment, whether to treat a chronic illness or as a preventative measure for those at high risk, sometimes just remembering to take a daily treatment can lead to increased stress and feeling of reduced freedom. Recent advancements in long-acting medication options outside of HIV have had major impacts on both patients QoL and improved efficacy through more convenient treatment reducing non-adherence. For HIV, and somewhat fitting for Pride Month, a very recent victory was announced in the battle to end HIV transmission. On the 18th of June, the FDA approved Yeztugo® (lenacapavir) as the first HIV prevention option offering a whopping 6 months of protection per injectable dose. Supported by two Phase 3 trials, the injectable HIV-1 capsid inhibitor was shown to maintain 99.9% of trial participants as HIV negative. For high-risk individuals in England where daily oral PrEP remains the only routinely offered preventative treatment option, the idea of a twice-yearly injection is immense. Therefore, it will be extremely interesting to see if the same 8-year delay from FDA approval to availability in England, as was the case for PrEP, will occur again.

How the HIV prevention landscape develops over the next few years will strongly dictate the current aims of many developed countries to end HIV transmission by their respective given dates. However, it is also important to acknowledge our collective responsibility to reduce global inequity to effective treatment options, particularly when considering the tumultuous history this disease has already had. Everyone is deserving of access regardless of sexual orientation but also regardless of socio-economic or geographical disparity.

Sources:

1. https://www.kff.org/global-health-policy/fact-sheet/the-global-hiv-aids-epidemic/#footnote-629201-1
2. https://hivinfo.nih.gov/understanding-hiv/fact-sheets/hiv-and-aids-basics#:~:text=HIV%20attacks%20and%20destroys%20the,and%20the%20onset%20of%20AIDS.
3. https://www.who.int/news-room/spotlight/why-the-hiv-epidemic-is-not-over
4. https://www.bbc.co.uk/news/health-48596605
5. https://www.gilead.com/news/news-details/2012/us-food-and-drug-administration-approves-gileads-truvada-for-reducing-the-risk-of-acquiring-hiv#:~:text=FOSTER%20CITY%2C%20Calif.,product%20in%20the%20United%20States%20.
6. https://www.ema.europa.eu/en/news/first-medicine-hiv-pre-exposure-prophylaxis-recommended-approval-eu
7. https://www.nhs.uk/medicines/pre-exposure-prophylaxis-prep/about-pre-exposure-prophylaxis-prep/
8. https://www.gov.uk/government/news/hiv-drug-prep-to-be-available-across-england#:~:text=Updates%20to%20this%20page,Published%2015%20March%202020
9. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30688-7/fulltext#:~:text=This%20decision%20will%20be%20met,WHO%20recommended%20their%20use%20for
10. https://www.gilead.com/news/news-details/2025/yeztugo-lenacapavir-is-now-the-first-and-only-fda-approved-hiv-prevention-option-offering-6-months-of-protection

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