The fight is not yet won, the experts caution, and the last stretch of disease eradication efforts is often the toughest. But in the past five years, the number of new infections with the virus has dropped by almost a quarter in Australia, with higher declines among gay and bisexual men, according to a report released last week by the Kirby Institute, an infectious disease research center in the state of New South Wales.
In 2018, just 835 HIV diagnoses were recorded nationally. At their peak, in 1987, there were 2,412.
The most recent advance in Australia’s battle against the virus, which is seen as a model around the world, is the rapid adoption of a drug regimen known as PrEP. Under the regimen, patients typically take a daily pill, which — even without the use of condoms — is close to 100 per cent effective at preventing contraction of HIV, experts say.
In Australia, more than 40 per cent of gay men considered to be most at risk of infection are on PrEP, according to the Kirby Institute. Adoption rates are significantly lower in the United States: While the Centers for Disease Control and Prevention say that more than 1.1 million Americans need PrEP, one group that tracks data on the regimen says that only about 270,000 are on it, and other estimates are lower.
“Provided we don’t take our foot off the pedal, we stand a chance of eliminating HIV by 2030” in Australia, said Andrew Grulich, an author of the Kirby Institute report and a professor of epidemiology at the University of New South Wales.
Truvada, which is used for HIV treatment and PrEP — the abbreviation stands for pre-exposure prophylaxis — was formally added as a preventive medication to the list of pharmaceuticals available at subsidized rates under Australia’s universal health care program in April 2018.
Since then, any permanent resident or citizen of Australia has been able to get the pill, or its generic alternative, by obtaining a prescription from a doctor and purchasing it from a pharmacy. For these people, it usually costs about 40 Australian dollars, or $28, per month.
“If you have a universal health care system like Australia does, then getting yourself on PrEP is easy, whether you are unemployed or a millionaire,” Grulich said.
Truvada was developed in the United States and first approved for use in HIV prevention there in 2012. But the medication has been slow to gain a foothold in the country because of a variety of obstacles, including what Dr. Robert Grant, a professor of medicine at the University of California, San Francisco, called a “byzantine system” that many patients find impossible to navigate.
Some cities, including New York and San Francisco, have made strides toward providing free or subsidized access to PrEP, with corresponding declines in HIV diagnoses. Gilead Sciences, the maker of Truvada, also recently promised to supply 200,000 uninsured patients with the pill.
And as of last month, most private health insurers are now required to offer the medication — which has a list price of about $2,100 per month — at no out-of-pocket cost to their policyholders.
But in poorer and more rural areas, patients and even doctors may not have heard of Truvada, said Grant, who led the development of PrEP. Costs for doctor’s appointments themselves might be prohibitive, or patients may be unaware of the assistance available to them, he said. In addition, Truvada has been stigmatized in some parts of the United States as promoting promiscuity, creating barriers to access and use.
Bill Bowtell, a strategic health policy consultant who helped lead Australia’s response to the AIDS crisis and continues to advise governments on HIV policy, said the system in the United States “could not be set up better to maintain a continuing HIV and AIDS pandemic.”
Rates of HIV have remained largely unchanged in the United States in recent years: They continue to rise among gay and bisexual Hispanic and Latino men, and have not improved among gay and bisexual African-American men, according to figures from the Centers for Disease Control and Prevention.
Among these minority communities, PrEP adoption is minimal: They account for two-thirds of the at-risk population, but only a small fraction of prescriptions, a study last year showed.
Australia is also not immune to disparities in HIV prevention and treatment.
While there has been rapid progress among Australian-born urban gay men, the rates of the virus among Aboriginal and Torres Strait Islander Australians have remained stable. These groups, along with overseas-born gay men and those who live in rural areas, are less likely to make use of PrEP or HIV testing, researchers say.
Despite these challenges, Australia has among the lowest HIV prevalence rates in the world: About 0.1 per cent of the population carries the virus, according to a separate 2018 report from the Kirby Institute. The figure in the United States is four times as high.
