Back on the right(s) track? Time to take HIV prevention seriously again

The fight against HIV and AIDS symbolises progress in research, innovation, activism and human rights. Belgium holds a unique position in the global HIV response, with significant contributions from Belgian researchers, activists, and advocates. It is therefore all the more unfortunate that, for the first time in a long while, the number of new HIV diagnoses in our country is on an upward trend. This World AIDS Day calls for reflection: Where are we today, and how can we do better in the future?

Rising HIV numbers

Recently, Sciensano reported that 665 people were newly diagnosed with HIV in 2023—an average of 1.8 per day and a 13% increase compared to 2022. This increase comes despite having a wide arsenal of effective HIV prevention tools at our disposal. Clearly, merely making prevention tools available is not enough: knowledge, accessibility, and responsiveness to the needs of target populations are critical. Representatives of Sciensano and Sensoa rightly pointed out the need to invest in better awareness raising.

Moreover, condoms should be cheaper, and access to PrEP—the HIV prevention pill that, when used properly, is almost 100% effective—could be significantly improved. Yet Belgium’s situation is not unique. A similar upward trend in HIV infection rates is occurring in the Netherlands and the UK. Globally, HIV prevention is also slow, and previously set targets to eliminate HIV as a health problem by 2030 are in jeopardy.

Human rights and HIV prevention

In line with the official theme of this World AIDS Day, UNAIDS has for several years stressed the urgency of continuing to address HIV as a human rights issue. A key reason is the growing inequality in the HIV pandemic. It is no coincidence that the communities most affected by HIV are also those whose rights are increasingly suppressed. Examples include anti-LGBT policies, the criminalisation of sex work and drug use, and persistent gender inequality, all of which complicate the delivery of tailored services to key populations. Currently, at least half of these so-called key populations lack access to highly effective preventive measures such as condoms and PrEP.

In Belgium, figures from Sciensano show that inequality in HIV prevention threatens to become a growing problem here, too. For example, while persons of sub-Saharan African origin accounted for 27% of new diagnoses in 2023, yet only 3% of all people initiating PrEP were of sub-Saharan African descent. Research conducted by the Institute of Tropical Medicine in Antwerp also shows that several structural factors complicate access to PrEP for migrants—who account for a growing share of new HIV diagnoses. For example, undocumented migrants are currently not entitled to PrEP. Additionally, the organisation of care creates both geographical and financial barriers as only the twelve HIV reference centres (HRCs), all located in major cities, are authorised to initiate PrEP treatment.

Bending the curve

To reverse the trend, prevention needs to be better embedded in a structural and person-centred approach grounded in the right to health. Key steps include:

1. Better involvement of healthcare providers in the HIV response: Besides their crucial  role in HIV testing, GPs could play an additional role in providing PrEP. However, they are currently not permitted to prescribe (reimbursed) PrEP medication. Furthermore, adopting care models from chronic diseases such as diabetes, a task shift from doctors to nurses could lead to efficiency gains while maintaining quality of care. Expanding care delivery around HIV prevention can enhance outreach.

2. Removing structural barriers at the policy level: Ensuring broad access to PrEP, including for migrants and people without health insurance, is a priority. The Belgian HIV Plan—widely supported by various stakeholders, including policymakers—already highlights this, but concrete measures are still lacking.

3. Addressing the social structures behind inequality: HIV risk is influenced by various factors rooted in one’s social, sexual, and relational contexts. A better understanding of how different communities perceive HIV risk can support the development of tailored prevention strategies in dialogue with target groups.

4. Confronting stigma and discrimination: HIV stigma remains a major challenge. Research shows that unconscious biases among healthcare providers can hinder neutral assessment and promotion of effective prevention tools such as PrEP (e.g., concerns over presumed negative effects on sexual behaviour). Raising awareness and providing training for healthcare providers remain necessary.

After four decades of fighting HIV, the recent rise in new diagnoses is an avoidable reality. Belgium can rely on extensive expertise built on science, multi-sectoral cooperation, and inclusiveness. We have the knowledge and resources to definitively contain the HIV epidemic. The question is, do we have the courage to prioritise prevention and elevate it to the next level?

Jef Vanhamel is physician and researcher at the Unit of Sexual Health including HIV, at the Institute of Tropical Medicine in Antwerp.