Let down by a now decimated HIV prevention budget, a record number of gay men were diagnosed with HIV in 2013. Chris Godfrey speaks to the National Aids Trust, GMFA and ACT UP London to find out how current HIV prevention strategies are failing and what is needed to curb the worrying increase in transmissions. 

3,250 gay men were diagnosed with HIV in 2013. It’s the highest number recorded since the start of the epidemic. Increased testing testing will have contributed, but the harsh reality is that rising transmission rates are primarily responsible for this surge. And the problem is set to worsen.

The rising levels of STI diagnoses like gonorrhoea (up 32% between 2013 and 2014) and syphilis (up 46%) among gay men are strong indicators that future HIV transmission rates will continue rising. If it isn’t already, the situation is on the verge of once again becoming a public health crisis.

“In one year those are massive spikes in STIs amongst gay men,” says Yusef Azad, director of policy & campaigns at the National Aids Trust (NAT). “They suggest very significant increases in unsafe sex. Gonorrhoea especially is considered to be an indicator of HIV transmission rates and future diagnoses of HIV.”

Though more people than ever are getting tested, hook-up apps have increased partner turnover, unsafe sex and access to ‘chillouts’ for many gay men. The persistent rise of transmission rates suggests the current prevention strategies are failing to adapt to these changing behaviours, leaving a huge demographic unmoved or unreached by dated campaigns.

“Gay men especially…need intensive targeted interventions that make sense to them. It is, in the end, a question of money,” says Azad. “Money doesn’t necessarily equal impact and effectiveness, you need to prove that money works, but on the other hand no money can’t work.

“I don’t think there is, as of yet, a coherent London wide strategy for HIV that includes: schools and young people strategies, the roles of sexual health clinics where many gay men attend regularly, engaging with social media apps and gay venues, which is advocating for PrEP and which significantly increases the amount of HIV testing.”

Compared to a lifetime of treatment (estimated between £280,000 and £340,000) the cost of prevention is fractional. Treating the 3,250 gay men diagnosed in 2013 would cost at least £910 million – and that’s a conservative estimate.

But according to NAT, the NHS is spending 55 times more on treatment for people living with HIV than is spent by local councils on HIV prevention. And while all but one of the London local councils are designated high prevalence areas, where two people in every 1000 have been diagnosed with HIV, just 81p per person was spent on HIV prevention in the capital during in 2013/2014.

Since 2001, the budget for HIV prevention designated to local authorities for HIV prevention services has been slashed from £55 million to just £10 million. With funds severely limited, those financing the programmes want to maximise their return on investment, the goal being to reach as many people as possible. But this drive towards ‘efficiency’ has effectively eliminated the likelihood of any new prevention strategies being adopted, or for checking the efficacy of those currently underway.

“Room for real innovation on the front line is slim,” says Dan Glass, an activist with ACT UP London. “HIV prevention work is so tied up with tick box exercises, delivering the minimum and ‘ticking all the boxes’ to satisfy the authority that work is being delivered. But often room for providing excellence or going above and beyond is not encouraged.”

Without any meaningful research into the potency of campaigns there’s no way of knowing exactly who is being reached. But with all current government-funded prevention programmes designed to reach as wide an audience as possible – providing that all-important ‘return on investment’ – there’s a feeling that they’re only leaving an impression on a certain kind of person.

“It’s not that these campaigns shouldn’t exist, it’s the fact that they’re the only ones that do,” says Liam Murphy, campaigns manger at GMFA. “And the sort of person they might appeal to, maybe they wouldn’t be taking those risks with their sexual health in the first place. There’s a large group of gay men that aren’t being reached. We’d target them in a different way…and talk the way they talk. If you don’t recognise yourself in the campaign it doesn’t resonate.”

Gay men and the African community are the two high-risk groups most vulnerable to these rising transmissions. But these are usually two ostensibly different demographics, and for prevention interventions to resonate effectively with them separate approaches would be needed. It’s one of major the concerns with nationwide programmes: by trying to appeal to everyone, they reach no one. Gay men in particular stand to benefit from a more nuanced approach.

“We need to see more sex. I don’t think it has to be crude or overt, but it has to be something somebody recognises in themselves,” says Murphy. “We’re trying to put the sex back into the sexual health which has been taken away. It’s not there and I feel people aren’t making the connection. You can’t shy away – people are fucking and they’re having great sex, so why is that not being brought into our HIV prevention and sexual health.”

Just as the response to shifting demographics has been slow, so too has the response to behavioural changes. The well-documented rise of chemsex is believed to be part of the reason for rising transmissions among gay men, yet the` government-funded response aimed at addressing the issue has been minimal.

“There’s been a failure to recognise and respond to emerging new scenes,” says James Johnson, also a member of ACT UP London. “Many HIV prevention organisations have been ill equipped to deal with the escalating numbers of chemsexers and the impact this is having on rising HIV rates.”

That more people than ever are getting tested is one of the big successes of campaigns like THT’s ‘It Starts With Me’. But testing alone isn’t going to halt rising transmission rates; a more nuanced approach is needed, one which incorporates these large scale programmes with refined interventions that resonate with the high risk categories, as well those who remain unmoved and unreached by current campaigns.

Current HIV prevention strategies have been hit hard by budget cuts and the drive towards efficiency.

“We need more partnership work, more community led responses, less reliance on old methods,” says Johnson. “We need less organisations relying on the fear factor to elicit donations and more use of mass media to impart simple messages about living with HIV.”

And of course, there is the ongoing NHS decision-making process as to how to distribute PrEP, potentially one of the most effective prevention techniques for curbing new transmissions.

“PrEP is not the answer to reducing HIV, it is just one tool,’ says ACT UP’s Dan Glass. “It is likely to be most useful and successful with very high-risk group. But it won’t reduce transmission numbers overnight as the one in four who remain undiagnosed continues to be the pool of HIV that is hardest to tackle.”

PrEP is unlikely to be the silver bullet that finally brings an end to HIV, but it is a very potent weapon, particularly for the gay community. And at a time when local councils in London are neglecting their responsibility to confront the problem and when transmissions are rising to levels not seen since the eighties, it’s a weapon the gay community, not only needs, but deserves. As the NHS budget comes under even more scrutiny, the fight to make PrEP as widely available as possible is on. 

“We’re arguing very strongly that it should be made available to enough gay men to make a public health difference,” says NAT’s Azad. “In the end that will be cost effective because it will reduce the amount of HIV in the community and significantly reduce over time HIV transmissions.  So at a time there’s real pressure on NHS budgets we have to make the argument very strongly that gay men’s health matters, that prep is something that absolutely has to be funded.”

Current HIV prevention strategies have been hit hard by budget cuts and the drive towards efficiency. Ill equipped to address evolving demographics and behaviours, the current provisions are now wholly inadequate. It’s short-termism, and it’s failing. If the government wants to avert an impending public health crisis then serious innovation is required, more money desperately needed. Until they recognised this, transmission rates are only going to go in one direction.