We have come a long way since the first cases of HIV were identified forty years ago. We went from no treatment to a cocktail of drugs with undesirable side effects to a daily pill with little to no side effects. Two weeks ago, the first injectable medication was approved in England. This is a dual combination therapy that comes in the shape of two injections (one with each drug) to be administered every two months and should be available in England and Wales come April. There are 36.7million living with HIV globally. 53% are women and girls. 1.5million were diagnosed in 2020.
We have at our disposal brilliant preventative medication and strategies but which unfortunately, we are failing to use effectively and maximally. PrEP is a combination of two drugs in one pill that reduces the risk of acquiring HIV by over 99%. This medication is recommended for people who engage in sexual activity that puts them at high risk of getting infected by the virus. It is recommended for both men and women and can be taken daily. Men can also take PrEP on-demand (when they need it).
If you are HIV negative and you think that you are engaging in high-risk sex, then PrEP might be for you. You can get a consultation and risk assessment at the GU clinic for free. But there is a catch. You will need to buy the medication privately. If taken daily, this would set you back around €57 per month. This is a price barrier for many, especially younger people who are possibly more risk-averse than adults. If the government were to fund PrEP we would see more people coming forward for testing and consultations at the GU clinic, reducing the risk of onward transmission of HIV and other sexually transmitted diseases. Dramatic falls in HIV have been reported in England and Scotland were PrEP has been made available on the national health services.
However, we must not disregard the importance of condoms. When used correctly, condoms offer strong protection against HIV and reduce the risk of exposure and transmission to other sexually transmissted infections which have, in recent years, also gone up. Combined with PrEP, condom use offers the ultimate protection against both HIV and other STIs. It’s the combination and promotion of various preventative strategies that will encourage people to come into the clinic and to make informed choices about what works for them.
Malta has one of the highest rates of HIV transmission in the EU/EEA region (45 case in 2017, 70 in 2018, 72 in 2019, 81 in 2020 and 66 between January and October 2021*), and for someone who has been in the field for several years, it baffles me how our response to the HIV pandemic is so inefficient. Last December Malta didn’t have some of the life-saving treatment people living with HIV take in stock. There was no plan how to remedy this, other than a multitude of excuses and blame shifting. NGOs had to step in and organise getting medication from other patients and distributing it to those who were left with none.
This year, access to treatment has improved and patients living with HIV, after years taking toxic medication, can get gold-standard treatment from a community pharmacy of their choice. If you are a patient living in Gozo, you have to get your medication from the Gozo General Hospital. In Gozo there is also a GU clinic operating every fortnight.
Since 2016, we have known that a person living with HIV who is on treatment and has an undetectable viral load cannot transmit HIV when engaging in high-risk sexual activities. This has become known as Undetectable = Untransmittable. To date there hasn’t been a single publicly funded campaign about U=U in Malta. This is outrageous. U=U is revolutionary in terms of scientific achievements and a powerful tool to fight stigma and discrimination which is rife in Malta and globally. This is evident from the very few people who engage with the HIV community; there are over 500 people living with HIV in Malta.
We have been promised an updated sexual health strategy for a long time. The one in place was published 2010 and was outdated the day it came out. In 2020, the deputy prime minister and minister for health, Chris Fearne, told us that we would have a new policy in 2021. Last October we learnt that the policy he was presented with had to go back to the drawing board because it was based on data from 12 years ago.
With Malta’s size and demography, we should be the leading country in Europe on managing infectious diseases. Look at our response to COVID19. There, the strategies proposed before political interference and lack of enforcement took over were splendid. They were science and data driven. We invested in contact tracing that stopped the spread of the virus and invested in other tools that could and will take us out of this pandemic.
HIV demands the same attention. More testing facilities - installed after extensive consultation with patient advocates, NGOs and clinicians – would improve access and end inequality. Ending inequality and improving engagement with health care services can only improve the quality of those who engage with the services. The current infrastructure is simply not enough! If presenting no symptoms, one must wait at least three months for an appointment at the GU clinic. The workload of Infectious diseases and HIV clinicians has increased and will continue to increase as people living with HIV grow older and are affected by other comorbidities.
NGOs and the media are doing their part. The series Sex Education on Netflix has taken the lead on educating the general population on LGBT issues, sexual health and, in the latest season, HIV and HIV prevention. Two other series that deal with HIV include ‘Pose’ and ‘It’s a sin’. The latter depicts the life of a group of gay men and their friends during the HIV pandemic in the UK. It’s an extraordinary series that well describes and navigates several key issues around HIV prevalent then and now. Locally, last May Teatru Manoel staged ‘il-Pozittivi’, a play tackling the stigma and surrounds people living with HIV in Malta.
Today, on World AIDS DAY 2021, Checkpoint Malta, MGRM, Movement Graffiti, and Udjenza are organising a free event where they will screen a short film on the experiences of trans persons living with HIV followed by a panel discussion exploring issues around HIV as lived in Malta and globally. You can read more about the event here https://www.facebook.com/events/478458456917173
We can do more, and we can do better, but this demands a proactive approach from our government to introduce an updated sexual health policy, make PrEP available for free and increase resources to our clinicians. There is no need to reinvent the wheel and take even longer to do all this. We have all the scientific evidence we need and enough examples of other countries how to go about all this. It’s a matter of sense and sensibility, knowing where we are failing and how we can excel and end HIV transmission for good.
*The data comes from the Health Promotion and Disease Prevention Department and may be different from data in the ECDC HIV/AIDS Annual Surveillance report.