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HIV Prevention Success in Australia
Learning From Success: How Australia Is Excelling at HIV Prevention

Released: November 14, 2023

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Key Takeaways
  • New South Wales, Australia, is seeing incredible drops in HIV transmission among men who have sex with men. 
  • The combination of treatment as prevention, PrEP uptake, and a background of condom use has contributed to this success and can serve as a road map for others in addressing the global HIV epidemic.

New South Wales is a state in Australia comprising approximately 8 million people, with approximately 5 million of those individuals living in the city of Sydney. The HIV epidemic here exists predominantly among men who have sex with men, accounting for more than 70% of newly diagnosed cases in recent years. Therefore, my team focused our analysis on this group, and at IAS 2023 we presented data from 2008-2022 on progress toward the UNAIDS 95-95-95 targets: having 95% of Australians living in New South Wales know their HIV status, 95% of these individuals being treated with antiretroviral therapy, and 95% of these individuals being virally suppressed. We also looked at data on the impact of pre-exposure prophylaxis (PrEP) on prevention of new HIV diagnoses, and I think there is a lot to learn from what we found. 

Statewide, HIV diagnoses in New South Wales have fallen by 50% in the past 10 years. In addition, there was a 56% decline among men who have sex with men, which is terrific. These data represent similar trends across the rest of Australia.

But my team was interested in looking more closely within Sydney because we noticed a pattern in the notification data: Far fewer notifications of new HIV infections were received over time from the central Sydney doctors who traditionally had notified most cases. When we looked at data from 2010-2022, the team noted an 88% decline in new HIV diagnoses in central districts in Sydney where more men who have sex with men reside, but only a 33% decline in outer Sydney suburbs. 

How Australia Reached This Success
It certainly has been a long road, and it is worth noting that New South Wales has had high-level and coordinated government support in addressing HIV since the beginning of the epidemic. It implemented needle and syringe exchange very early on, and the state saw the decriminalization of sex work between adults in 1995. These actions prevented a more generalized epidemic.

More modern changes since have heavily focused on HIV prevention, which is how we made great progress toward the 95-95-95 targets with treatment as prevention—and we had enormous PrEP uptake over that period. Although New South Wales was not the first place in the world to roll out PrEP, when we did in 2016, we did so with a big bang—quickly, targeted, and at a large scale. By 2022, approximately 80% of men who have sex with men in New South Wales who reported risk behaviors that traditionally would have placed them at risk for HIV were taking PrEP. This allowed us to excel in this effort with extraordinarily high PrEP uptake.

I believe our success is not from one silver bullet. Rather, it stems from several things coming together and, since 2016, 2 things in particular: treatment as prevention and PrEP, both with a background of condom use.

HIV Prevention Lessons Learned in Sydney
PrEP has been promoted enormously and broadly to men who have sex with men in New South Wales. We were successful with this because of the strong government-funded LGBTQ organizations that developed the demand creation. These community organizations developed simple, direct promotion online and posted in highly visible parts of Sydney, such as at train stations and the sides of buses. In fact, it is hard for a gay man in inner Sydney to not be aware of PrEP and U=U and their effectiveness in stopping HIV transmission. For those who are HIV negative, we promote the message that they should be taking PrEP or using condoms. For people living with HIV, we heavily promote the benefits of U=U. This high level of promotion has been key to getting men who have sex men living in Sydney to take PrEP. 

In addition, Australia took a partnership approach to addressing the HIV epidemic. This was a real partnership between multiple players, with the leaders being government action guided by formally adopted HIV strategies. We have been blessed by the fact that HIV has never been a political issue. The Government and Opposition parties decided in the crisis of the 1980s that this was too important an issue to politicize—to leave up to politicians—but should be guided by experts. Ever since, Australian HIV policy has been evidence based.

Other factors also are critical to HIV treatment and prevention. For example, Australia has a good public healthcare system where most everybody can afford to see a doctor, access free pathology testing, and receive highly subsidized prescriptions. These steps are all covered through our national healthcare system.  

The Challenges That Remain
Despite the good news, we are certainly experiencing some major challenges. For example, we are not seeing large declines in HIV transmission outside the center of big cities like Sydney. What is happening there is that HIV seems to be concentrated among recently arrived overseas migrants. This is a common pattern around the world—migrant populations are at high risk for HIV—so we need to promote PrEP and HIV testing to communities in which HIV is highly stigmatized and link people to HIV prevention and care services soon after arrival, which is a real challenge. 

In Australia, researchers have found that the gay and bisexual men living in areas of our cities that voted against gay marriage in our 2018 national same-sex referendum have lower rates of HIV testing and PrEP use. This is likely related to stigma in these socially conservative areas. So, we must work with those communities to address the existing HIV stigma and increase education among gay and bisexual men. My team is making moves to try to replicate the success we are seeing in inner Sydney on a national scale, but it is going to be a challenge. 

The Role of PrEP Among Other Groups 
I think it will be challenging to implement PrEP in places globally where heterosexual transmission is the predominant mode of transmission but does not occur at high levels. In settings where HIV transmission is predominantly among heterosexual people but is uncommon, the trick will be determining how to best target those at risk, which will not be simple. PrEP does work in men and women no matter their sexual orientation. Although there is some evidence that oral PrEP can prevent HIV infection for persons who inject drugs, we have had such extraordinary success in preventing HIV through needle and syringe programs that those will remain the predominant prevention approach in Australia.

Eliminating HIV Completely
It is critical that we all work toward the UNAIDS 2030 goals. But reaching these goals, including a 90% reduction in new HIV infections, is not going to be the end of HIV. Until we have both a cure and vaccine, we cannot completely eliminate HIV. Only a cure will ensure the elimination of new transmissions without the need for adherence to ongoing medication. Although current treatment does make HIV untransmittable, this requires lifelong adherence to HIV treatment, and some people will not be able to consistently achieve that goal. 

Without a vaccine, any hope of complete elimination is just not possible. For example, the one disease in human history that has been eradicated is smallpox, and a big part of that was because we had an extremely effective vaccine. So, we are still a long way away from eliminating HIV.

When we present encouraging data, as I did in Brisbane, it is also important that they not be interpreted as meaning that HIV elimination is a reality that can be achieved quickly or easily. The HIV epidemic is absolutely not going to be over anytime soon—much more work is needed. Australia can act as a road map for the rest of the world to move us closer to HIV transmission elimination.

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