As World AIDS Day, December 1st, approaches it is becoming clear there is growing disquiet in HIV circles and the gay men's community regarding how committed our government is to powering up the fight against the resurgent HIV epidemic. Perhaps the most concerning aspects of HIV prevention work recently are that last year New Zealand had the highest annual number of newly-detected HIV infections amongst men who have sex with men since what are considered the horror years of the late 1980s. (See red portion of bars in graph of annual new diagnoses above.) And there has been a spending freeze on funding for the NZAF for several years, with inflation meaning the Foundation is caught between rising costs and static funding. Then there is drug funding agency Pharmac's refusal so far to fund putting the newly-diagnosed, most of whom are gay and bi men, on effective HIV-suppressing medications as soon as they are diagnosed, thus improving their health prospects and dramatically lessening the likelihood they will pass on HIV if they have unprotected sex. The murmur of discontent has been growing steadily for a year or more in HIV-prevention circles but, perhaps fearful of biting the hand that feeds them, little is being said publicly. That's perhaps understandable when almost all HIV/AIDS prevention and support work done in New Zealand is reliant on what little government funding reaches them. However, Shaun Robinson, Executive Director of the the NZAF, the biggest force in the HIV prevention field, is now pulling no punches when asked if he believes that government agencies have simply lost their focus on, and commitment to, HIV and particularly HIV prevention. “Yes I do,” he says emphatically. Let's take the government's drug funding agency, Pharmac, as an example. Pharmac thinking still seems to be predicated too much on patient health and not prevention, namely only how much improvement in their health management a person with HIV will experience if they get treated up front compared to waiting until their immune system – CD4 test – indicator drops to a certain threshold level. Everyone from the World Health Organisation to its own advisory committee is telling Pharmac there are health benefits to immediate treatment access, though the committee has only given it a medium priority level recommendation. But there are also huge epidemic prevention benefits to immediate treatment too. The early stage of their infection is freqently when people are most infectious but the properly medicated person with HIV is way less likely to transmit HIV, even through unprotected sex. So, month after month, year after year, Pharmac is still just considering the recommended removal of the CD4 Threshold. Its Director of Operations, Sarah Fitt, says “recommendations from clinical committees are important inputs to Pharmac’s decision-making process. Pharmac’s role is to make funding choices from within the available budget... To date, other funding options have taken higher priority over this option.” “At this stage,” Fitt says, “widening access to HIV [treatments] remains a funding option that Pharmac could pursue.” That's regarding immediate access to drugs after infection, but wider than 'special case' funded access to pre-exposure prophylaxis (PrEP), in essence making medications available as a matter of course to individuals at high risk of contracting HIV before they get infected as a preventative measure, is also a strategy that remains stubbornly below the government's radar. So, as new prevention and treatment techniques become available, and the HIV infection rate amongst gay and bi men inexorably rises, the government seems to be asleep on the sideline. For a government-funded health bureaucrat Robinson is refreshingly frank. “The official New Zealand government HIV strategy for New Zealand is a decade out of date, which says it all,” he says. “There have always been really good people in the Ministry of Health and Pharmac who have done their very best for the communities affected by HIV, but there has not been much political support from governments of various colours for a long time.” In a perverse way the until-recently highly successful gay and bisexual men's response to HIV in this country, of which the NZAF's prevention work is a major part, has brought about the current malaise. “I think it’s the same reason why the general public has lost awareness of HIV and AIDS and the gay community has lost some focus on it... condom use reduced HIV transmissions to relatively low levels and medications meant that there were very few AIDS deaths. Politicians turned their attention and money to other things.” Robinson is on a roll. “Quite frankly, with a hundred or more people each year getting an incurable disease that still has the potential to be fatal, this is just not good enough!” New Zealand, he says, is in a position to get “right on top of the HIV epidemic and demonstrate to the world how this can be done. In a small country with a low-level epidemic we have a real chance to bring HIV close to zero transmissions. With what we have achieved so far and the new tools now available it is truly possible. But to achieve this the health sector and the community need to be empowered to use the full range of prevention tools.” He runs through those prevention tools. Firstly, condoms and lube. “Condom promotion must be funded adequately. Condoms have prevented fifty million infections across the world and it is condom use that has put New Zealand in reach of the ultimate goal. Lube must be provided free via Pharmac and the number of condoms distributed must be funded to increase. Condom use must remain high and the new prevention tools must be added to the effect of condoms." Yes, you heard right... to ensure condoms do not break during anal sex and to counter tissue damage, which could facilitate HIV transmission, through dry fucking lube is almost as important as the condom itself. Thirty years into the HIV/AIDS epidemic Pharmac funds some condoms but no lube. Next up is treatment using drugs as outlined above. “We need to maximise the benefits of treatment and undetectable viral load. The science is clear that this creates a major reduction in infectiousness. Government has a responsibility to adopt the UN AIDS targets of 90 90 90 for New Zealand: 90% of people with HIV to be diagnosed, 90% of those diagnosed to be on medication and 90% of those on medication with undetectable viral load.” HIV testing. “This needs a major boost across the whole health system and rapid testing needs to be available everywhere you can test. We can get the level of undiagnosed HIV to very low levels, it is totally achievable if we have the support and commitment of government. It must be done for the health of those individuals who have the virus and don’t know it and so that their viral load can be suppressed to undetectable level.” Funding. “Pharmac must be funded to remove the CD4 Threshold so that people can access treatment as soon as they are diagnosed – the science is clear that this improves their health and helps prevent the spread of HIV. This is what the World Health Organisation has called for and as a first world health system New Zealand should meet this standard.” Support for people with HIV. “Support organisations such as Body Positive and Positive Women should be funded to fight HIV stigma and to support people who are diagnosed to get onto treatment and to be adherent. Stigma, discrimination and fear about HIV are just wrong and stop people testing and accessing treatment. In a small country like New Zealand we can turn this around and accelerate the drive to end HIV transmissions.” Pre-exposure access to anti-HIV drugs. “PrEP should be funded by Pharmac and made available via sexual health services. PrEP is not as good as condoms in terms of sexual health and is too expensive for wide-spread use, but if targeted to motivated, high-risk people, it works and is cost effective. The World Health Organisation has also recommended that PrEP be made available in all countries and the evidence is clear that for a targeted group of gay men it works very well at preventing HIV. We must have it in New Zealand.” Research. “Research into HIV, the health of gay men and general sexual health are all very neglected in New Zealand. Research and monitoring must be funded so that we can track the effects of the different tools, getting frequent feedback on progress towards the targets.” “This comprehensive package would make New Zealand world leaders in responding to HIV,” Robinson says. “This is not only the right thing to do in human terms but the smart thing to do financially. Every new HIV infection costs the country $800,000 to $1 million over the life of the person. With 100 to 150 people a year contracting HIV the growing cost to the country is astronomical. Investment that would really drop this persistent level of infections over five years would be highly cost effective. The final push to get HIV transmissions to zero is good for everyone.” But it's not just the government Robinson is gunning for. "It is time for government, the health system and also the community to reinvigorate New Zealand’s efforts to get to the UN goals of zero HIV and AIDS. We cannot accept a continuing low level epidemic with a hundred or more lives affected each year - most of whom are gay men. To do so courts the disaster of transmissions rising as prevalence creeps up. Now is the time act, we have all the tools and all the scientific evidence, we just need the backing and political will." Despite all this Robinson somehow remains determinedly optimistic that progress will occur, and that funding for other aspects of HIV prevention will sooner rather than later. “There is work on a Sexual and Reproductive Health Action Plan that will include HIV, the World Health Organisation has recommended that PrEP be made available and we have asked for more funding to ramp up HIV testing and condom promotion. If government supports these things we are back on track.” “I think the next six months will tell us if government will get back in the game and help New Zealand take advantage of the new opportunities to really get on top of HIV in this country.” Jay Bennie - 23rd November 2015