Position Statement

ASHM calls on the Commonwealth Government and the governments of all Australian state and territories to:

(a) acknowledge that effective treatment for HIV infection has major benefits for individual people living with HIV, their partners and the Australian public;

(b) acknowledge that all people living with HIV in Australia should have ready access to effective antiretroviral therapy for HIV infection; and

(c) commit themselves to work in partnership with other governments, affected communities, people living with HIV, health care providers, researchers and the private sector, toward the goal of enabling all people living with HIV in Australia, who are willing to do so, to commence and continue effective, appropriate treatment for HIV, based on the best available scientific evidence.

HIV may be acquired through sex, exposure to infected blood, or via mother-to-child transmission during pregnancy, childbirth or breastfeeding. The high levels of viral replication and chronic activation of the immune system associated with HIV infection lead to progressive immune dysfunction and vulnerability to opportunistic infections, malignancies and autoimmune diseases. A person newly infected with HIV may experience a brief "seroconversion illness", but usually recovers spontaneously, despite ongoing viral replication, high levels of HIV detectable in blood and bodily fluids, and a steady decline in immune function. During this period, a person living with HIV may generally look and feel well, but is able to transmit HIV during condomless sex, sharing of equipment used for injecting drugs or (if female) childbearing. After several years, a person with untreated HIV infection develops more frequent illnesses related to immune dysfunction, eventually (after a median of 5 years), resulting in severe opportunistic infections and malignancies recognisable as "AIDS", with a median life expectancy of 18 months in the absence of treatment. However, combination antiretroviral therapy (cART) has revolutionised HIV treatment and prevention. Effective cART suppresses HIV replication, allowing immune recovery and decreasing risk of further HIV transmission.

People with severe HIV-related immune dysfunction and life-threatening opportunistic infections who receive cART are able to recover sufficiently to return to independent life, with improved survival and high level of subjective wellbeing. People treated early in HIV infection, before serious immune dysfunction has occurred, are able to prevent the development of AIDS and enjoy many years of good health and wellbeing, with life expectancy comparable to that of people of similar ages living without HIV. Apart from the individual benefits of avoiding illness and premature death, cART, by preventing the onset of complex, major illnesses amongst people living with HIV, prevents presentations to health services and use of health systems resources. Like other people with chronic, potentially debilitating conditions for which effective treatment is available (such as asthma and diabetes mellitus), people living with HIV who receive effective treatment are able to live independently, work and contribute to society.

cART has proven effective in preventing mother-to-child transmission and sexual transmission of HIV. Appropriate cART of women living with HIV, together with post-partum treatment of babies born to women living with HIV, has driven the risk of vertical HIV transmission from 25% down to less than 1%. Large trials of people in long-term relationships in which only one partner has HIV ("serodiscordant couples) have shown that effective cART significantly reduces the risk of HIV transmission to the seronegative partner, over and above the effect of condom use alone. Although condoms are of proven effectiveness in preventing sexual transmission of HIV, there are circumstances in which reliable condom use may not be possible: in such situations, cART provides an additional means for preventing new HIV infections.

The effectiveness of cART in suppressing HIV replication depends on a high degree of adherence to an appropriate regimen, over an extended period of time, since HIV infection is not curable with current treatments. Interruptions to therapy result in progression of immune dysfunction, risk of opportunistic infections and the development of HIV drug resistance, with subsequent need to change treatment to more complex, toxic or expensive regimens. The benefit of cART on health, wellbeing and survival also depends on the timeliness of treatment: delayed treatment allows time for HIV disease progression and increases the extent of permanent immune deficiencies, with an adverse impact on long term survival. Hence, both individual and population health benefit of cART is maximised when all people living with HIV are able to start appropriate cART as soon as possible after HIV diagnosis and continue without interruption thereafter, in accordance with current recommendation from the World Health Organisation.[i]

Most people living with HIV in Australia are able to access effective cART. For all citizens and permanent residents, as well as some temporary residents, the cost of consultations and investigations is rebated via the Medicare public health insurance scheme, whilst medications prescribed by registered Australian clinicians are available at an affordable out-of-pocket cost, with the balance of cost subsidised through the Pharmaceutical Benefits Scheme (PBS). Those ineligible for such support include short-term visitors, international students, and some temporary residents awaiting decisions regarding their applications for permanent residency (such as partners of Australian citizens/permanent residents and some people applying for asylum as refugees).

Some patients ineligible for Medicare may have access to rebates and subsidised medications through private health insurance or employer-provided health insurance. Those for whom no such support is available, must pay the full cost of consultation fees and either purchase commercially marketed medications in Australia at full price, or personally import prescribed generic medications from abroad. However, some people living with HIV in Australia not only have insufficient resources to pay the full cost of their care, but also lack both public and private health insurance. The exact number of individuals in this situation, but is not large (estimated to be several hundred people), and their situations are diverse; they resemble each other only in that the barriers they face in obtaining appropriate treatment exact a heavy toll on physical and psychological health, personal relationships and financial resources.

Treating clinicians, faced with the ethical imperative of providing appropriate treatment, must resort to time-consuming and cumbersome strategies for arranging access to medications, sometimes being forced to prescribe less effective or more toxic treatments (because these are the only ones accessible via the Personal Importation Scheme from generic drug suppliers) than would be available to other patients with similar clinical situations. Examples of such strategies include: enrolling patients in clinical trials to ensure their access to some form of treatment; compassionate access schemes subsidised by pharmaceutical companies; and managing patients through sexual health clinics or other public health services in which Medicare eligibility is not required to access treatment. Each of these strategies is vulnerable to interruptions in continuity of treatment due to government budget policies, health system restructuring and commercial pressures upon pharmaceutical companies. Moreover, they require clinicians (mainly in state-funded public hospitals and clinics) to spend considerable time in communication with representatives of pharmaceutical companies, research coordinators and others (not least their patients), which might otherwise have been spent in clinical duties with these and other patients. The most significant adverse effects of this convoluted and inefficient system, however, are the suffering, expense and occasional deaths due to disease progression and preventable illness, arising from delays and interruptions to otherwise straightforward treatment of chronic HIV infection. Delay in commencing or interruptions to treatment can also result in new onward infections, which in turn have personal impacts and in the case of Medicare and PBS eligible patients, financial impacts on Australian health spending. These considerations led the UK to amend its NHS regulations in 2012, to enable all overseas visitors to access HIV treatment without charge[ii].

Given the diversity of individual situations and the wide range of settings in which people must access care, a single, simple solution may not be available that covers all jurisdictions in Australia. However, the development of sustainable, local solutions to the problem of access to cART would be eased with the clear affirmation, by governments of the Commonwealth and all states and territories, of the principle that all people living with HIV in Australia should have access to affordable, effective, appropriate treatment. South Australia made the decision to make HIV cART available to all, this decision was based on a cost benefit analysis. It has not resulted in any adverse consequences and the number of people accessing the service remains relatively low. Interestingly many people only make use of the system for quite short periods of time because their immigration status changes or they return to their country of origin.

A recently completed study by the Australia HIV Observational Database of Temporary Residents (ATRAS) and funded by the pharmaceutical industry provided CART to 180 participants for a period of 3 years, also found that many of these patients experienced a change in their Medicare status during the study. There has been an undertaking by jurisdictions to continue to provide drug to these study participants. We urge you to extend this provision to all people in Australia in this predicament. This is done in the United Kingdom, where for example Australians can also access HIV treatment through the national health system without charge.

 

Author:               Chris Lemoh

Review               Levinia Crooks

Date to Board:   9 November 2015

 


[i] http://www.who.int/mediacentre/news/releases/2015/hiv-treat-all-recommendation/en/

[ii] https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/212952/DH-Guidance-HIV-and-NHS-Charging-fORMATED.pdf