Ireland’s path to ending HIV

Paul Mulholland speaks to Consultant in HIV Medicine Prof Yvonne Gilleece about what Ireland can learn from the roll-out of England’s HIV action plan

The Programme for Government set out key targets for improving sexual health services in Ireland.

It included the promise to publish a new National Sexual Health Strategy for 2025-2030, which was launched in June.

The Programme also committed to delivering a national HIV action plan aimed at eliminating new HIV transmissions by 2030 – a target aligned with the international goal, endorsed by the United Nations, of ending AIDS as a public‑health threat by that year.

The value of such a plan was highlighted at a conference organised by HIV Ireland and Fast Track Cities UK and Ireland, held at the Aisling Hotel in Dublin on 29-30 September.

Among the speakers was Prof Yvonne Gilleece, Honorary Clinical Professor and Consultant in HIV Medicine and Sexual Health, Brighton and Sussex Medical School and University Hospitals Sussex NHS Foundation Trust, UK. As Chair of the British HIV Association, Prof Gilleece shared insights from England’s experience in tackling HIV.

In 2021, the UK government published Towards Zero – An action plan towards ending HIV transmission, AIDS and HIV-related deaths in England – 2022 to 2025. The plan set out priorities to reduce new HIV transmissions by 80 per cent by 2025 as a stepping stone to ending new transmissions entirely by 2030.

It was supported by £20 million in funding over three years to expand HIV opt-out testing in emergency departments (EDs), among other initiatives.

At the Dublin conference, Prof Gilleece spoke about how a similar, structured, evidence-based national plan can drive measurable improvements in HIV prevention and treatment outcomes in Ireland.

Speaking to the Medical Independent (MI) after the event, she stressed the importance of tailoring any plan to local needs.

“You can learn lessons about what worked in England, but Ireland needs its own action plan to define how it will work here,” Prof Gilleece, who studied medicine at University College Dublin, said.

English experience

Since April 2022, the opt-out blood-borne virus testing programme in EDs across England has been running under the action plan. In addition to HIV, the programme also screens for hepatitis C and hepatitis B viruses.

According to Prof Gilleece, to date, approximately four million HIV tests have been carried out in EDs, with over 1,400 new diagnoses.

Testing for HIV in EDs has also been extended over the last year.

“We now have taken stock of what has worked in the action plan and what needs improving,” she said.

Inequalities

Prof Gilleece said while the plan has helped reduce new HIV diagnoses in gay and bisexual men, the trend has not been the same for other groups.

“What we have seen is the detection of health inequalities,” she explained to MI.

“We have seen a continued increase of HIV transmissions in heterosexual men and heterosexual women and those individuals are arriving with late diagnoses. It means their immune system has already been quite affected by HIV.”

Prof Gilleece said this issue will be addressed in a new action plan, which is due to be launched later this year.

In the region where Prof Gilleece works, a scheme has already been established to offer women pre-exposure prophylaxis (PrEP).

“What we have noted is, if you look at people who receive PrEP versus people who are actually being diagnosed anew with HIV, the PrEP need in Brighton and Hove and West Sussex is in women. And so we are working on that to provide PrEP to women, in the context of existing health structures.”

Overall, Prof Gilleece said the action plan has served to “really focus the mind” on where efforts need to be concentrated.

“It has shown we can get HIV transmissions down,” she explained.

“But it’s not been effective in all groups, and therefore we need to now move on to the next part, where we’ve looked at what we’ve done. We’ve seen successes, but we’ve also seen areas where there needs to be improvement. So we’re not yet at zero transmissions, but we have definitely reduced the number of people living with undiagnosed HIV. We are getting people to maintain their HIV-negative status by providing PrEP and regular HIV testing. But we understand there’s more work to do, and that’s what we want to build on.”

Ireland

Prof Gilleece said she considers the goal of eliminating new HIV transmissions in Ireland within five years to be realistic.

Asked where the challenges here might differ from those in the UK, Prof Gilleece pointed to variation in prevalence and service access across regions.

She added that one of the key difficulties for the Irish health service is the lack of comprehensive data to map needs nationally.

“Ireland probably doesn’t have enough data yet to inform all of the needs for HIV care and treatment throughout the country.… So I think there needs to be a concerted effort to really understand where people with HIV, or who might be at risk for HIV, are living in Ireland, and then try and come up with that plan…. There needs to be a clear understanding of where to start, because you have to start somewhere.”

Prof Gilleece said the roll-out of testing and services should be a “dynamic process”.

Reaching areas of lower HIV prevalence has not been straightforward in England. 

“And I think Ireland will have that same issue, just because we know that it is harder to try and get people engaged in lower prevalence areas.”

Prof Gilleece emphasised that expanding access to testing will be central to achieving Ireland’s 2030 target for zero new HIV transmissions.

“To get to that goal, you need to diagnose people. So, whether that’s in clinics, in GP surgeries and emergency departments, and home sampling kits, you just need to get the testing out there. If someone tests positive, then it’s about linking them into care and getting them on treatment. Once the treatment is working, which is usually within three to six months, it’s about getting to a particular low level of viral load, so there’s a zero chance of them transmitting to anybody else. That’s really the key.”

Rolling out services for marginal or vulnerable groups is also vital.

“It’s reaching out to those who might have vulnerabilities, such as people who have difficulties with immigration status, homelessness, substance abuse, so they can all be brought into care and treated.”

Stigma

Prof Gilleece reflected on how far treatment has come since she began working in the field in the 1990s, pointing to the advent of modern antiretroviral therapy.

“Over time, we have reduced the number of tablets people have to take,” she explained. 

“We have improved the side-effect profile of the tablets.… We’ve seen a real sea change… where people now have a normal life expectancy.”

However, while testing and treatment have developed significantly, she warned that, unfortunately, prejudice still remains a barrier to progress.

“Stigma is still an issue,” Prof Gilleece admitted. “I think that is fair to say.”

Reducing stigma is a core component of the strategy in England.

“It’s probably been one of the hardest parts of the HIV action plan because we can’t control people’s thoughts,” she said, pointing out how social media can perpetuate misinformation and prejudice.

This is the reason she emphasised that “HIV testing should be a normal part of life”, and why education, funding and clear pathways into care must continue to be priorities.

On the Dublin meeting, she said it was “a very rich conference”.

“There was a lot of networking, a lot of information exchange. It felt like all the right people were in the room.”