HIV/AIDS: A Shifting Epidemic

June 1981 – the first recorded case of a disease that would go on to kill an estimated 36.3 million people worldwide. Over the past 41 years, HIV/AIDS has typically been viewed as a problem most prevalent in gay and bisexual men; however, for the first time in a decade, heterosexual HIV diagnoses in the UK have overtaken those in LGBTQ+ groups (1).

Relative to population size, gay and bisexual men are still impacted more by HIV than heterosexuals – but the fall in diagnostic rates over the past eight years makes it clear that targeted interventions have been hugely successful. At the Terrence Higgins Trust, testing is a crucial component of HIV prevention. “Testing access has expanded with the introduction of online testing (self-sampling and self-testing) and, in turn, the number of people with undiagnosed HIV has gradually been decreasing,” says Marianne Holt, the sexual health charity’s Media Manager. “Testing is the only way to know your status. The sooner you know it, the sooner you can get treatment and avoid passing the virus on to anyone else.”

Reducing viral load is crucial to halting HIV transmission. “People with undetectable virus levels cannot pass HIV on. This is known as U=U (undetectable=untransmissible),” says Kate Folkard, Interim Deputy Director of Blood Safety, Hepatitis, STIs and HIV Division, UK Health Security Agency.

“Test, test, test” has always been an underlying message of prevention campaigns but, in the era of social media, dating apps, and the metaverse, the approach to outreach and advocacy has changed. At the Terrence Higgins Trust, teams use social targeting to tailor posts to specific audiences who need to engage with the message most. “This is particularly helpful for health promotion or campaigning for policy change,” says Holt. “When we launched ‘Their Story, Your Choice,’ a series of interactive films that targeted men who have sex with men from Black African and Asian communities, we were able to promote the films to individuals from these groups.”

She continues, “The rise of influencer culture has also affected how we promote HIV testing. Influencer work is integral to HIV Testing Week – a campaign coordinated by HIV Prevention England to promote regular testing to groups most affected by HIV in the UK. During the campaign, we work with individuals whose audience consists of at-risk groups and send them self-testing kits to educate their followers and encourage them to get tested.”

For those who aren’t social media-savvy or don’t subscribe to influencer culture, there are other modern forms of spreading the message – ways that showcase how far our understanding of HIV/AIDS has come since 1981 and what it’s like to live with the disease. “TV shows like Russell T. Davies’ It’s A Sin are fundamental to HIV awareness – they are a springboard to discussions about the facts on HIV, which can challenge misinformation about the virus,” says Holt. “Talking about the reality of HIV today is important for raising awareness. Public perceptions haven’t caught up with medical advancements; therefore, many still mistakenly perceive HIV as a death sentence.”

Is the stigma around HIV/AIDS preventing people from being tested? Though diagnosis rates have increased in the heterosexual population, they are still less likely to be tested for the virus than gay and bisexual men. Folkard notes that this issue is still being investigated and aims to increase testing in A&E settings in high-prevalence areas. “More work needs to be done to reduce the stigma of HIV and reinforce the message that, with the right treatment and care, people with HIV can live long and healthy lives.”

It should be noted that the UK has free and universal access to healthcare – a privilege that residents in other countries may not have. “It is vital in all settings that access to HIV testing and treatment remains free at the point of access,” Folkard says. “The key to our success has been the provision of PrEP, combined with frequent HIV testing and rapid referral upon diagnosis to treatment and care.”

However, despite increased access to testing and treatment, the fight is far from over. “PrEP has been a game-changer for gay and bisexual men, but we’re currently working to increase awareness of PrEP in all communities impacted by HIV in the UK,” says Holt. “Almost half of new HIV diagnoses among heterosexuals in the UK are Black African men and women – despite making up less than two percent of the British population. PrEP among Black African people shows worryingly low uptake – with just four percent of those accessing the drug from groups other than gay and bisexual men.”

To replicate the reduction in diagnostic rate seen in gay and bisexual men, targeted interventions that lead to increased testing for other groups are needed. “HIV can affect anyone – regardless of sexuality, gender, ethnicity, or age – and everyone needs to know how to protect themselves,” says Holt. “We need to see an increase in regular testing in at-risk groups to prevent anyone from living with undiagnosed HIV for a long time. This is important for their own health as well as for efforts to stop HIV transmission, given that the vast majority of people get HIV from someone who is unaware they have it.”

^{Hero and Teaser image credit: Scanning electromicrograph of an HIV-infected H9 T cell. Credit: NIAID (CC BY 2.0).}