As the world marks World AIDS Day on December 1, Scotland stands at a crossroads in its efforts to end the HIV epidemic by 2030. The country has made significant progress in reducing new infections, improving access to treatment and care, and eliminating stigma and discrimination. However, challenges remain, especially in reaching key populations, addressing health inequalities, and ensuring sustainability of the response.
Scotland’s achievements and challenges in the HIV response
Scotland has been a global leader in the HIV response, being the first country in the world to provide universal access to pre-exposure prophylaxis (PrEP), a daily pill that prevents HIV infection. PrEP has been shown to be highly effective and cost-effective, and has contributed to a 37% decline in new HIV diagnoses among men who have sex with men (MSM) in Scotland between 2016 and 2020.
Scotland has also achieved the UNAIDS 90-90-90 targets, which aim to ensure that 90% of people living with HIV know their status, 90% of those diagnosed are on antiretroviral therapy (ART), and 90% of those on treatment have suppressed viral load. According to the latest data from Health Protection Scotland, 94% of people living with HIV in Scotland were diagnosed, 98% of those diagnosed were on ART, and 97% of those on treatment had suppressed viral load in 2020. This means that Scotland has virtually eliminated the risk of onward transmission of HIV among people who are aware of their status and on effective treatment.
However, despite these achievements, Scotland still faces some challenges in the HIV response. One of them is the persistent gap in testing and diagnosis among some key populations, such as people who inject drugs, migrants, and heterosexuals. According to Health Protection Scotland, 43% of people diagnosed with HIV in 2020 were diagnosed late, meaning that they had a CD4 count below 350 cells/mm3, which indicates a weakened immune system and increased risk of illness and death. Late diagnosis also increases the risk of transmitting HIV to others, as people may not be aware of their status and may not be on treatment.
Another challenge is the impact of the COVID-19 pandemic on the HIV response. The pandemic has disrupted the delivery of HIV prevention, testing, treatment, and care services, as well as the access and adherence of people living with HIV to their medication. The pandemic has also exacerbated the social and economic vulnerabilities of people living with or at risk of HIV, such as poverty, unemployment, homelessness, mental health issues, and substance use. Moreover, the pandemic has highlighted the need for a more integrated and resilient health system that can respond to multiple health threats and address the underlying determinants of health.
The role of communities in the HIV response
The theme of World AIDS Day 2023 is ‘Let communities lead’, which recognizes the vital role that communities have played and continue to play in the HIV response. Communities are not only beneficiaries of HIV services, but also providers, advocates, and innovators. Communities of people living with HIV, key populations, and civil society organizations have been at the forefront of demanding and delivering HIV services, challenging stigma and discrimination, and influencing policies and programmes.
In Scotland, communities have been instrumental in shaping the HIV response, from campaigning for the introduction of PrEP, to providing peer support and education, to conducting research and evaluation. For example, the PrEP4Scotland Consortium, which consists of HIV Scotland, Terrence Higgins Trust Scotland, Waverley Care, and the National Health Service (NHS), has been involved in the design, implementation, and monitoring of the PrEP programme in Scotland. The consortium has also produced resources and tools to raise awareness and increase uptake of PrEP among eligible populations.
Another example is the Fast-Track Cities initiative, which is a global partnership of cities and municipalities that are committed to ending the HIV epidemic by 2030. Glasgow and Edinburgh are among the 300 cities that have joined the initiative, and have developed action plans that are informed by the needs and priorities of local communities. The initiative also aims to foster collaboration and coordination among different stakeholders, including people living with HIV, key populations, civil society, health care providers, and local authorities.
The way forward for Scotland in the HIV response
As Scotland approaches World AIDS Day 2023, it is important to reflect on the achievements and challenges of the HIV response, and to renew the commitment and action to end the HIV epidemic by 2030. This requires a comprehensive and multisectoral approach that addresses the prevention, testing, treatment, and care needs of all people living with or at risk of HIV, as well as the social and structural factors that affect their health and well-being.
It also requires a strong and sustained involvement of communities in the HIV response, as they are the ones who know best the realities and challenges of living with or at risk of HIV, and who can provide innovative and effective solutions. By letting communities lead, Scotland can ensure that no one is left behind in the HIV response, and that everyone can enjoy their right to health and dignity.