Are we on track to achieve the UNAIDS goals by 2030 for people with HIV in Spain?

Spain is committed to ending AIDS as a public health threat by 2030. The last update of the HIV continuum of care published in May 2023 showed that, in the period comprised between 2021 and 2022, 92.5% of the people with HIV (PWH) had been diagnosed, 96.6% of those diagnosed were on antiretroviral treatment (ART) and 90.4% of people on ART were virally suppressed.¹ Whereas these results indicate Spain has met the 90–90–90 2020 UNAIDS targets, we are still falling behind in achieving the 75% reduction in HIV incidence compared to the 2010 baseline, and additional efforts are needed to meet zero stigma and discrimination. Still, important steps are underway with over 18,000 persons at high risk of HIV on Pre-Exposure Prophylaxis for HIV (PrEP) by April 2023,² and with the identification of the elimination of HIV related stigma and discrimination as a political priority of the Spanish Presidency of the European Union the second semester of 2023.

The original article by Coll et al., achieving the UNAIDS goals by 2030 in people living with HIV: A simulation model to support the prioritization of health care interventions,³ published in this number of Enfermedades Infecciosas y Microbiología Clínica, provides very useful guidance to improve the HIV continuum of care in Spain for the next years. The authors conclude, using a simulation model, that implementing or strengthening eight interventions for HIV diagnosis, three for ART, and eight for viral suppression for the target populations during 2020–2030 would increase the continuum of care to approximately 100% diagnosed, 98% treated, and 96% virologically suppressed. It is reassuring to observe that all of these recommendations are currently included in the Strategic Plan for the Prevention and Control of HIV and other Sexually Transmitted Infections in Spain: 2021–2030.⁴ Nonetheless, whereas innovation and reinforcement of contact tracing studies in HIV and other STIs is encouraged, HIV partner notification remains an important challenge since HIV remains a heavily stigmatized condition. Few infectious diseases throughout history have had the levels of stigma and discrimination that have accompanied HIV. In Spain, although there has been substantial progress in reducing public stigma towards PWH, 10% of the Spanish population still state they do not want to have any kind of relationship with a person with HIV. As a result, the most prevalent manifestation of stigma among PWH is the anticipation of stigma, which leads to only 13% of PWH in Spain being open about their HIV status. Also, many PWH internalize the stigma, with devastating effects on their quality of life and health, but also on public health. The above data are very recent as they have been collected in the last two years under the Social Pact against Discrimination of PWH.^5,6

Still, remarkable improvements in the HIV undiagnosed fraction have been witnessed from 2017/2019 estimates and 2021/2022, as this proportion has been reduced by 42.3% in four years, that is from 13% to 7.5%.⁴ The reasons for this important decline are multifactorial but the implementation of PrEP in November 2019 is likely to be pivotal and has prompted people at risk for HIV to get tested to access PrEP.

HIV testing remains a cornerstone for ending AIDS by 2030 and is and should be, promoted relentlessly. Missed opportunities for HIV testing should be viewed as a collective failure. In representation of their respective institutions, the signatories of this editorial, call for reinforced commitments towards HIV testing to bring the undiagnosed fraction to zero. Still, in doing so, the legal framework that applies to HIV testing in Spain cannot be ignored. Informed consent for HIV testing does no longer necessitate written proof but requires the person involved to understand and agree that the test is being performed. The legal basis for this obligation is established in Law 41/2002, of November 14, articles 4 and 8, which regulate patient's autonomy, as well as the rights and obligations regarding clinical information and documentation. These cases must be addressed from the perspective of the patient's right to privacy and not from the perspective of personal data protection regulation since they are based on the information and consent of the person in the context of healthcare and not of the processing of personal data. The violation of patients’ fundamental rights could have legal implications for healthcare workers. Also, it is contrary to the current efforts towards a patient-centred model of care. A model that is needed to achieve long-term health and the sustainability of the healthcare system. The importance of promoting HIV testing to achieve the 95–95–95 objectives is clearly outlined by Coll et al, who identify eight interventions to maximize HIV diagnosis. Among them, the most valuables were focused on training health and non-health professionals, electronic alerts, and national campaigns.

Achieving the UNAIDS 2030 targets requires a commitment from all actors involved in caring for PWH, from policymakers and health workers to the community and society at large, while respecting the person's rights and addressing the stigma that still exists with this condition.