Councils’ contribution to falling HIV rates should be acknowledged

Over the Christmas period I visited the grave of a good friend and fellow volunteer who died because of complications related to HIV infection in the late 1980s. We both volunteered as carers in the days when treatment was limited, outcomes poor, and loss commonplace. Less than two years later, I nursed him.

Had you told us 30 years ago that today we would have a decline in new HIV infections and folk with HIV would largely have the same life expectancy as those who don’t, we’d have dismissed you as fanciful. Today, friends and colleagues with HIV are mostly thriving. My address book now has more birthdays than death anniversaries.

Progressing towards improvement

This week Public Health England launched a report which showed HIV transmission has continued to fall “thanks to HIV testing” (commissioned by local authorities) – especially among gay and bisexual men. Fewer people are unaware of their HIV status, and fewer diagnosed late – a key risk factor for poor outcomes and avoidable early death. As outcomes have improved and treatment has improved the nature of social care has changed. So what’s not to celebrate?

Several things. First, the lack of fair recognition of who has done what. And second, there’s still considerable work to do. This is important if we are to achieve the government’s commitment of zero new transmissions by 2030.

At the risk of striking a sour note, I detect little acknowledgement of what local government has done. We commission most HIV testing. PrEP (pre-exposure prophylaxis) which prevents the transmission of HIV took a battle in the courts, and its delivery relies on council commissioned sexual health services even for the current trial. The Local Government Association argument was the one which won the day, if you read the court papers.

Improvement of HIV testing uptake has relied on our work with partners – drugs services with their pathways for testing and safe needle programmes, and sexual health clinics and charities. Areas (including Hertfordshire) that have worked hard to reduce late diagnosis of HIV saw the work led or co-led by local authorities.

Central government has relied on councils for 30 years as a delivery mechanism in the age of HIV. We would not be where we are without what councils and their partners and providers have done alongside community groups. It’s unacceptable that local government has not had fair acknowledgement for our part in this.

Today’s prevention challenge

Today’s prevention challenge is different, but it’s still there. Our toolbox includes condoms, PrEP, and treating people with HIV so their viral load is undetectable and therefore untransmissible.

But ensuring women, black and minority ethnic and trans populations get the same outcomes as men needs work. And as people live much longer with HIV, diseases of ageing, cardiovascular disease and HIV-related cognitive and neurological issues, including dementia can be more severe than in HIV negative people.

And there is more work still to do. Lots.

As people live much longer with HIV, diseases of ageing, cardiovascular disease and HIV-related cognitive and neurological issues, including dementia can be more severe than in HIV negative people

First, the fully planned and fully funded routine roll out of PrEP needs to happen so we continue to reduce new infections.

Second, we need to work on system issues: HIV commissioning is still split. Treatment is commissioned by NHS England and delivered by brilliant NHS services, which for outpatients are often the same providers that councils commission for sexual health.

Testing and sexually transmitted infection treatment are the domain of councils. Those areas that have worked on co-commissioning found significant benefits. If the sexual health commissioning review in 2019 showed us anything, it was that we should stop arguing about who commissions what and work together to commission jointly across the system.

For every 100 people with HIV thriving, there are small numbers in need of more complex care, not just from the NHS but from social care and housing too

Third, we need to look at the whole system of HIV and build a response. That needs continued voluntary sector work, not just statutory sector work.

Fourth, we need proper sustainable funding for sexual health and drug and alcohol services to address the needs of our populations.

Fifth, we have work to do on stigma.

And finally, we need to continue to develop treatment and care for those who are not thriving, are ageing or are unwell. For every 100 people with HIV thriving, there are small numbers in need of more complex care, not just from the NHS but from social care and housing too.

An independent HIV commission is currently deliberating on how and whether as a country we can get to zero HIV transmissions by 2030. One thing I will be telling them is blindingly apparent from history: we will simply not achieve this without proper recognition of, and funding for, the role of local authorities as a key part of the system.