HIV in Spain: over 2,000 diagnoses a year despite PrEP

World AIDS Day: 2,786 HIV diagnoses in 2021 and PrEP is not bending the curve

A specialist put it bluntly: it is "not acceptable" that Spain keeps logging more than 2,000 new HIV diagnoses every year. The raw figure from the Health Ministry's latest epidemiological report shows 2,786 notifications in 2021, a rate of 5.89 per 100,000 inhabitants which, adjusted for reporting delays, is estimated at 7.41. This is not an isolated spike: the number has been stuck on an uncomfortable plateau for years.

The paradox that opens the debate is textbook stuff. Since November 2019, PrEP — pre-exposure prophylaxis — has been available in Spain, and it has been sold to us as an almost peine barrier: a 99% chance of not getting infected, we are told. If that were true at population level, the curve should be plummeting. It is not.

Why aren't HIV diagnoses falling despite PrEP?

The 2020 numbers are misleading because of elbichito. Fewer contacts, fewer diagnoses. But between 2019 — a clean year, before the pandemic — and 2021, with restrictions still in place, the drop is small. Far too small for what the pill promised. And in 2022 the regional data point the other way: the Valencian Community recorded 464 new cases compared with 393 in 2019, while syphilis (from 455 to 731), gonorrhoea (from 1,432 to 2,091) and chlamydia (from 1,711 to 2,261) all went up too.

The most frequently repeated official explanation is late diagnosis. María Velasco, president of GeSIDA (the Spanish AIDS study group), puts a figure on it: late diagnoses have risen from around 48% of new cases to almost 52%. People who do not know they carry the bicho keep transmitting it. It is a reasonable argument — and, at the same time, an elegant way of shifting the problem onto the healthcare system.

The 0.16% that props up the official narrative

The figure that really underpins the case for PrEP appears in the SCOPE study, presented at the XVI GeSIDA National Congress: HIV incidence among PrEP users in Spain barely reaches 0.16%, based on nearly 20,000 people across 12 hospitals. Individual efficacy is undeniable. Whether that individual efficacy moves the population-level needle is another matter, and the evidence available there is much thinner.

The number that would close the loop is missing: how many of the newly infected were taking the prophylaxis. It is not in the reports. Its absence fuels every suspicion, including the unfounded ones.

The UK rises, Cantabria rises, Amsterdam falls

The British mirror does not help either. In 2023, 6,402 new HIV cases were diagnosed in the UK, an increase on 2022, while 96,562 people in England started or continued PrEP — around 87% of those with an identified need, and 57% more than in 2021. More pills, more diagnoses. In Cantabria diagnoses are rising; in Amsterdam they are falling, and sharply. Nobody has produced an explanation that fits all the pieces.

From "it doesn't exist" to individual responsibility

On the fringes of the issue, the usual theories circulate: that HIV was never isolated, that the tests diagnose nothing, that antiretrovirals poison people. There is no scientific backing for any of them, and it is worth saying so without sugar-coating. What does have traction is another, more prosaic current: relaxed behaviour driven by the feeling that AIDS no longer kills. Ditch the condom — what's the point anyway.

Between those two extremes lies an uncomfortable observation shared by several participants: there are very young people, and not so young ones, who simply cannot be bothered about their own health. They are not seeking the bicho; they just don't care about anything.

The question that remains open

With PrEP now well established and the evidence of its individual efficacy intact, the system is still recording more than 2,000 diagnoses a year. If the prophylaxis works as well as its defenders claim, and the population data do not back that up, someone will have to explain what exactly is happening in that gap. Or is blaming late diagnosis and waiting for the next report enough?