Features

HIV Scotland:
Lessons learnt and the way forward

World AIDS Day will be marked in Scotland this year against the backdrop of the highest ever infection rates, with implications for prevention and health care.

Highest levels

In the third quarter of 2007, 145 new infections were reported, the highest for a single quarter. Explained only in part by extraordinary reporting delays of up to 40 cases from the previous quarter, it is difficult to foresee any slowing down.

Of the 145 cases, 59 are through sex between men, and 52 through sex between men and women, while 28 are not yet categorised. The majority (78 or 54%) are presumed to have been infected outwith Scotland. Only four infections are through intra-venous drug use.
It is clear that the final total for 2007 exceed 400.

Features of the epidemic over the past few years are, firstly, that 60% of cases are among those infected abroad. Secondly, of those infected within Scotland, 75% are among men who have sex with men.

What does this mean for HIV in Scotland?

Early lessons

First of all, the new figures are a signal that HIV, and particularly HIV prevention, should be ranked again among our health priorities. Given Scotland’s proud record on HIV prevention in the early days of the epidemic, we can learn from the early success of focus, urgency and concerted national effort in relation to IV drug users. By the time that the individuals who are represented in the figures have become HIV positive, prevention has failed to meet their needs.
And yet, it seems unfair to speak of failure in the context of what are some excellent initiatives, such as outreach and capacity building, health promotion, support, excellent partnership working, and often good levels of involvement of those most affected. ‘Connected’, ‘Scottish Netreach Network’ and the ‘Comeback’ and ‘Equal’ campaigns in Edinburgh and Glasgow respectively, have evaluated well so far. Remoteness and rurality, cultural and religious barriers, or Scotland’s rapidly changing demography with long-standing Scottish Government policies to attract and keep those who wish to come and live in Scotland, are real challenges but also at times considerable national strengths.

National priority

It seems an appropriate time to pause to ask of ourselves if our core message that condom use demands 100% commitment is being communicated clearly and consistently. Some questions can be answered only with provision of more research and evaluation opportunities to assist in the effective use of prevention resources.

By World AIDS Day, Scotland’s Comprehensive Spending Review will have shown the level of priority give by the Scottish Government to HIV, sexual health and prevention. One hopes that it will demonstrate the leadership the above figures warrant, a commitment to no less than a doubling of funding for HIV prevention over the next five years, to match and hopefully limit the projected rise in new infections. Used properly this investment must make sense, with 400 new cases in a single year costing over £200 million over the lifetime of those individuals, to say nothing of the personal impact and effects.

Way forward

Earlier prevention efforts saw HIV either controlled or massively reduced as in the case of intravenous drug use, prevention needs to be higher on the priority ladder. Increasingly, the response to HIV is focused on the provision of medication, and staffing levels and their deployment will need careful planning. HIV testing efforts need to concentrate on those who either repeat test with negative results until it comes back positive, as well as on those who attend for sexual health check-ups but decline an HIV test. Among gay men, these represent significant levels of undiagnosed infection.

We need to ensure that every Health Board in Scotland is tackling this problem; that it is of a scale and intensity that will make a difference; and that the people who are affected directly are not blamed and shamed, but included as part of the solution. If there is high-level leadership to change the social circumstances in which people find it hard to have safer sex, if we build relationships with the people and communities most affected, and gain their trust through supporting them in the difficult times, then we know that prevention will work.