In May 2021, Health Equity Matters convened an expert panel of Australia’s most senior scientists, clinicians, and community leaders to review the evidence and set new targets and priorities to see Australia achieve the virtual elimination of HIV transmission by 2025. This technical paper provides the evidence assembled by the panel and priorities and targets they have endorsed to achieve virtual elimination.

• Advances in HIV prevention bring the virtual elimination of HIV transmission in Australia within reach.
• People living with HIV (PLHIV) on treatment, with an undetectable viral load, cannot transmit HIV sexually (known as Undetectable = Untransmissible, or U=U).
• People who are adherent to pre-exposure prophylaxis (PrEP) reduce their risk of HIV to almost zero.
• A rapid scale-up of HIV testing, treatment and PrEP use is needed, plus continued support for condom use.
• Australia is not using existing HIV prevention, testing and treatment technology optimally because of restrictive conditions or costs to the consumer; these must be overcome on public health grounds.
• Reducing stigma related to HIV and homosexuality is vital to ensure the rapid uptake of prevention methods, as well as improving individual health, well-being and quality of life for people living with HIV (PLHIV).
• Investing in prevention, testing, treatment and care, and stigma reduction today will have long-term personal, societal and economic benefits.
• The Commonwealth and States and Territories must renew their partnership and their respective investments.
• Sustaining the HIV partnership of community, clinicians and researchers is essential to achieving virtual elimination of HIV transmission.
• Australia has a health sector which is capable of the implementation of urgent and rapid reforms that will allow us to eliminate HIV transmission in all priority populations by 2025.

Inequalities in overall health outcomes for Aboriginal and Torres Strait Islander people compared to the general Australian population are also reflected in HIV indicators. To achieve the overarching elimination goal, we must set and meet targets for Aboriginal and Torres Strait Islander people, including GBM and other subgroups. Scale up of prevention programs is needed for Aboriginal and Torres Strait Islander GBM. Innovative approaches which make testing more convenient, culturally safe and discreet will mean more Aboriginal and Torres Strait Islander GBM will access testing. More effort is required to improve the HIV treatment and care cascade for Aboriginal and Torres Strait Islander people and to increase those on treatment being virologically suppressed. This includes peer support. Layered stigma is particularly relevant for GBM and women living with (or at risk of) HIV who are Aboriginal or Torres Strait Islander, requiring increased investment in research and stigma reduction programs to improve health outcomes. Initiatives should be designed and led by Aboriginal and Torres Strait Islander people.

The expert panel has, for the first time, endorsed a measurable target for the achievement of virtual elimination of HIV transmission in Australia. This target is a 90% reduction in HIV diagnoses in Australia (compared to a 2010 baseline). The expert panel therefore confirms that Australia will have achieved virtual elimination when less than 91 local cases are reported each year.

If the number of HIV diagnoses in Australia continues to 2030 at 2019 levels, 9,010 people will acquire HIV. The cost of the status quo in lifetime HIV treatment and care alone is $2.1b. By implementing the priorities set out in this paper and achieving virtual elimination by 2025, Australia will prevent over 6,000 people from acquiring HIV by 2030. By this time, Australia will have avoided $1.4b in HIV treatment and care costs.

Overarching goal: Achieve the virtual elimination of HIV transmission in Australia by 2025

To achieve this goal, we must meet the following targets by 2025. They apply to all people at heightened risk of HIV and to subgroups of GBM defined by age group, geographical area of residence and country of birth, and in Aboriginal and Torres Strait Islander GBM.

Overarching targets

1. A 90% reduction in preventable HIV diagnoses in Australia (compared to a 2010 baseline)
2. A reduction in preventable new HIV infections in GBM to less than one per 1,000 GBM per year

HIV prevention targets

1. 95% of people at risk of HIV infection use one or more forms of effective HIV prevention (e.g. condoms, PrEP, U=U)
2. 95% of people for whom PrEP is beneficial to use it

HIV testing targets

1. 95% of PLHIV are diagnosed
2. 90% of all people at heightened risk of acquiring HIV have a yearly HIV test
3. 80% of all GBM at risk of HIV have a test every three months

HIV treatment targets

1. 98% of PLHIV diagnosed with HIV are on treatment
2. 98% of PLHIV on treatment have an undetectable viral load
3. 90% of newly diagnosed PLHIV commence treatment within two weeks of diagnosis

Stigma

1. >95% of PLHIV report no stigma in the last 12 months
2. >95% of GBM report no stigma in the last 12 months
3. >95% of the general public indicate they would not behave negatively towards a person because of their perceived or actual HIV status or sexuality
4. >75% of PLHIV report good quality of life

HIV prevention

• Make subsidised PrEP available to all people residing in Australia, regardless of visa status.
• Scale up prevention programs for GBM who have had less prevention success, including those residing outside the inner cities, men recently arrived from overseas, culturally and linguistically diverse men, Aboriginal and Torres Strait Islander men, young men and non-gay-identified men who have sex with men (MSM), while sustaining efforts in inner-city and Australian-born GBM.
• Invest in health promotion of appropriate forms of PrEP, including daily oral PrEP, event-driven PrEP and periodic PrEP and rapid assessment and approval of new PrEP technologies such as long-acting injectable PrEP.
• Investigate and (if feasible) implement the provision of PrEP in non-medical settings.
• Sustain investment in prevention initiatives in sex workers and people who inject drugs

HIV testing

• Make subsidised HIV and other sexually transmissible infection (STI) testing available to all people residing in Australia, regardless of visa status.
• Remove visa conditions that inhibit temporary visa holders from accessing HIV testing contrary to public health outcomes.
• Increase access to and promotion of HIV point-of-care testing (POCT) and HIV self-testing.
• Investigate and implement opt-out HIV testing in settings of higher HIV prevalence.
• Investigate and implement molecular epidemiology to inform the public health response to HIV clusters.

HIV treatment

• Make free HIV care and treatment available to all people residing in Australia, regardless of visa status.
• Enable all people newly diagnosed with HIV to commence treatment within 14 days of their diagnosis.
• Double the number of S100 cART prescribers in Australia by 2025 and increase reimbursements for all Medicare Benefits Scheme (MBS) items related to the treatment and care of PLHIV.

Stigma

• Working with PLHIV and at-risk communities, investigate and implement multi-level interventions designed to reduce stigma at individual, interpersonal, organisational/institutional and policy/governmental levels.
• Conduct research to increase the evidence base for effective stigma-reducing interventions and improved design of stigma monitoring and evaluation systems.
• Repeal stigmatising non-evidence-based laws which criminalise HIV exposure and transmission.

Enablers

• Implementation research is required to ensure new technologies and interventions have maximum impact.
• New forms of surveillance are needed to measure progress towards the HIV targets and overarching goal.
• A renewed Commonwealth and State and Territory partnership is required, bringing together public health leadership, governance, cooperation and effective coordination of efforts.
• Existing investments in HIV, including for community action, must be maintained and new investments made to bring to scale the initiatives needed to complement Commonwealth action.
• Wrap-around care is needed for people who experience complex social or co-morbid health issues at diagnosis and throughout their life.
• New, more sensitive and effective models of contact tracing are required, including peer-led models.
• A rapid, pro-active regulatory approach is required to consider the registration and funding requirements of new technologies to virtually eliminate HIV transmission.
• The continued cooperation of PLHIV and those at risk must be sustained. These populations remain mobilised to achieve Australia’s goals. The investment and tools needed must be placed in their hands to bring HIV transmission to an end.