The sharp decline in recent HIV infections among men who have sex with men points towards the effectiveness of the HIV prevention pill (PrEP). Data also show that not everyone who wanted to use PrEP had access to it in time. These findings are presented in the latest report published by the HIV Monitoring Foundation in the Netherlands (SHM), released today, leading up to World AIDS Day.

The number of new HIV diagnoses in the Netherlands continued to drop in 2021 to 427 new diagnoses. Last year, there were 250 men who have sex with men (MSM) (59%), 105 other men (25%) and 72 women (17%) diagnosed with HIV. In 2021, 13 people died from AIDS-related illnesses.

Recent HIV infections
A recent HIV infection is defined as having a negative HIV test in the 12 months prior to diagnosis, or when a blood test shows signs of an acute HIV infection.  The percentage of people who come into care with a recent HIV infection has been stable in recent years. In 2021, the percentage of recent infections among MSM fell sharply by 10 percentage points compared to  2018-2020, from 37% to 27%.

“It is likely that the decrease in the percentage of MSM with a recent HIV infection is related to the use of the HIV prevention pill, PrEP. Some people who would have previously entered care with an recent HIV infection are now adequately being protected by PrEP. If this trend continues in the coming years, the Netherlands may become one of the first countries in the world with zero new HIV infections,” explains Prof. Marc van der Valk of the HIV Monitoring Foundation. “At the same time, we still see that 57% of people come into care with an  advanced HIV infection, resulting in  an unnecessary burden of disease and avoidable mortality.”

PrEP use
In the report, 735 of the 2,500 people who entered care with HIV between 2018 and the end of May 2022 had data on whether or not they used PrEP. It appears that 660 of these people never used PrEP in the past.

Of these 660 people, 44 indicated that they wanted to use PrEP but did not have access to it, 4 were on a waiting list to use PrEP and 39 were found to have HIV at their PrEP intake visit to a healthcare professional.

“So far, we know that 48 people acquired HIV, even though they indicated that they wanted to use PrEP. The actual number may be higher because this information is only available for 44% of people newly diagnosed with HIV from 2018 onwards,” says Prof. van der Valk. “Optimizing access to PrEP care in the Netherlands, as well as optimizing care for PrEP users, could have prevented some of these new HIV diagnoses.”

Resistance
The 75 people who reported having used PrEP in the past, on average were diagnosed with HIV 100 days after their last PrEP intake and 79% had a recent HIV infection. At the time of HIV diagnosis, resistance to certain HIV medications, which could be the result of recent PrEP use, were verified in 46 of these 75 people . In 9 individuals clinically relevant resistance was found.

“Although rare, we see clinically relevant mutations in HIV  in some people with a new HIV diagnosis who have used PrEP. These mutations are probably caused by incorrect use of PrEP,” explains Prof. van der Valk. “Although these mutations do not hamper successful HIV-treatment it is important that people who use PrEP are able to use it correctly and have regular medical examinations. HIV practitioners should test for resistance in anyone with HIV who has used PrEP in the past in order to select the right treatment for these individuals.”