Skye McGregor

This session focused on elimination of HIV through prevention programs, focusing on how we measure elimination, progress with elimination at global, regional, and country levels, with a detailed examination of Australia, and U=U and prevention of HIV vertical transmission in the context of pregnancy and breast/chestfeeding.

Progress with elimination of AIDS as a public health threat was presented (Grulich), methods for measurement and data constraints were outlined. Global progress with 95 indicators is at 86:88:93 but PrEP coverage is substantially below needs. East and Southern Africa are on track to meet elimination targets (57% reduction), but other regions lag or are seeing substantial increases. Data from NSW Australia showed inner Sydney has achieved 88% reduction, but 31% in outer suburbs (lower proportion of adult gay men). There were different patterns of access to prevention, with lower uptake and greater impact of COVID in outer suburbs. Laufer presented a summary of evidence on vertical transmission of HIV and developments in understanding of transmission in the context of U=U and pregnancy and chest/breastfeeding. She noted that the optimal scenario was ART pre-conception and an undetectable viral load to be maintained through pregnancy. With zero risk of transmission in this context, what is the role for neonatal PEP? Analyses showed transmissions without neoPEP in context of detectable viral load only. Chest/breastfeeding guidelines around the world have started to change with U=U. People should be empowered to make decisions about chest/breastfeeding in this context, while ensuring risks were clear.

Substantial progress has been made across the world in elimination of AIDS as a public health threat (zero new HIV infections), but there are substantial inequities across the world. We cannot ignore that the world is behind targets for elimination but that it can be done when political and economic choices are made, and that true elimination still requires vaccine and cure. There still remain unanswered questions in relation to U=U and chest/breastfeeding, including what happens with mastitis, what about mixed feeding, and what is the role of cell associated DNA? But discouraging breastfeeding may contribute to inequities in health.