HIV Treatment and Care Cascade in Australia

Time to commencement of cART
In Australia in 2019, 92% of people diagnosed with HIV were receiving cART and, of these, 97% had a suppressed HIV plasma viral load, preventing disease progression and onward HIV transmission.¹⁴ Between 2004 and 2015, the proportion of newly diagnosed PLHIV who commenced cART within six months increased from 17% to 53%, attributed to an increase in the recommended CD4+ cell threshold at which to start treatment.¹⁵ More recently, the time from HIV diagnosis to commencement of cART was evaluated in NSW; in 2019, the median time from diagnosis to cART commencement was 16 days, and 91% of people newly diagnosed with HIV had commenced cART within six weeks.¹⁶

The treatment of care cascades observed in some other countries are more advanced than in Australia. The Fast-Track Cities initiative17 reports on Treatment and Care Cascades in major international cities. In 2019, in London, an estimated 95% of PLHIV were diagnosed; of these, 98% were on cART and, of those on cART, 97% were virologically suppressed.¹⁷ In 2018, in Manchester, an estimated 92% were diagnosed, 98% were on cART, and 97% were virologically suppressed. Although comparing treatment uptake in selected cities in the UK to all of Australia is not straightforward, there are more PLHIV in London accessing HIV care than the total number of PLHIV in Australia, so on a volume basis, the UK’s performance is very strong. It is important to note HIV testing, clinical care and cART are free in the UK, irrespective of immigration or residency status, unlike in Australia.¹⁸

Delayed commencement of HIV cART in sub-populations in Australia
There is heterogeneity in time to cART commencement across HIV-positive populations in Australia. For example, culturally and linguistically diverse (CALD) populations were significantly less likely to commence cART within six months of HIV diagnosis than people born in Australia.¹⁹ Migrants to Australia from Southeast Asia, Eastern Asia and Europe had larger gaps in their HIV treatment and care cascades than non-migrants: 85% of migrants were diagnosed, 85% of those diagnosed were on treatment, and 93% on treatment were virologically suppressed (85-85-93) versus 94-90-96 in Australian-born people.²⁰ The HIV treatment and care cascade for Aboriginal and Torres Strait Islander people in 2016 was not as good as in other Australians, with 80% diagnosed, 90% on treatment and 76% of those on treatment being virologically suppressed.²¹ Comprehensive HIV cascade of care data are not available for people who inject drugs (PWID), but in sexual health clinics in Australia in 2017, HIV virological suppression was observed in 79% of PWID, compared to 92% of gay and bisexual men (GBM) and 89% of CALD patients.²²

Clinical care and HIV cART costs in Australia
In Australia, clinical care and cART is subsidised by Medicare and the PBS, respectively. In NSW, cART is free for PLHIV. Medicare-ineligible international students and workers living in Australia receive only partial reimbursement for HIV treatment and care services through their private insurance; free clinical care and cART is available via public sexual health services. However, the Australian Government recently committed to providing free cART to all Medicare-ineligible people living in Australia.

HIV cART adherence in Australia
Adherence is crucial to achieving the benefits of cART. Recently, adherence to cART was evaluated in over 2,000 PLHIV in Australia; adherence was defined as the proportion of a patient’s treatment coverage days being ≥80% during the first 12 months of treatment.23 Overall, 83% of participants met the definition of “adherent”. Using modelling to characterise adherence patterns, a third of participants were identified as having moderate to low adherence.23 Factors associated with suboptimal cART adherence include younger age, poverty, poor mental health, substance use and stigma, which is likelier to be experienced by people of colour, people who are homeless, PWID, sex workers and people from some ethnic and cultural backgrounds.

HIV cART dosing options
In Australia, daily dosing of cART medication is the only treatment modality currently available. However, advances in pharmacotherapy have led to the recent approval in Europe, Canada and the United States of long-acting injectable antiretrovirals, given every two months. Soon, six-monthly antiretroviral injections and long-lasting implants will become available, and it is anticipated these options will enhance adherence in sub-groups with currently sub-optimal adherence.

• To eliminate HIV transmission by 2025, 98% of all people diagnosed with HIV must be taking cART, and 98% of people on cART must be virologically suppressed.
• To eliminate HIV transmission, Australia must provide free clinical care, laboratory monitoring and cART to all PLHIV in Australia, irrespective of their visa or residency status.
• To optimise health, quality of life, retention in care and prevention of HIV transmission, national programs involving clinicians, pharmacists, community-based organisations and peers must be funded so 90% of all people diagnosed with HIV can commence cART, ideally on the same day as diagnosis, but no later than 14 days after diagnosis.
• Upcoming novel antiretroviral treatments must receive priority evaluation for TGA registration and PBS subsidisation to enhance treatment uptake and sustained use by PLHIV.

The relationship between the metrics of the HIV Care Cascade and the elimination of HIV transmission is complex and will vary between countries and within jurisdictions of individual countries.

Proposed treatment targets required to achieve the elimination of HIV transmission in Australia by 2025

1. 98% of all people diagnosed with HIV will be on cART.
2. 98% of people on cART will be virologically suppressed.
3. 90% of all people diagnosed with HIV will commence cART, ideally on the day of diagnosis, but no later than 14 days from diagnosis.

Priorities with respect to HIV treatment and the achievement of elimination of HIB transmission

• Obtain federal and jurisdictional funding commitments to provide free clinical care, laboratory monitoring and cART for all people diagnosed with HIV in Australia, irrespective of their visa or residency status.
• Create national programs enabling people newly diagnosed with HIV to commence rapid cART.
• Double the number of S100 prescribers in Australia from 500 to 1,000 by 2025, and increase reimbursements for all MBS items related to the treatment and care of people diagnosed with HIV in Australia.
• Remove all barriers preventing the TGA and the Pharmaceutical Benefits Advisory Committee from calling for submissions for priority evaluation of novel HIV treatments for registration and subsidisation.
• Increase funding for surveillance and research into cART uptake, ongoing cART use and HIV virological suppression in all HIV priority populations in Australia, irrespective of visa or residency status.