Most HIV-positive gay men in European survey are on HIV treatment: fewer in the east
A higher proportion of men in central Europe were not taking HIV treatment, and in countries of the former Soviet Union more men had yet to start treatment than were currently on it. But this was also, in the main, because it was not recommended or they felt they did not need to start yet. This may be partly because HIV has appeared as an epidemic more recently in gay men in eastern Europe.
Very few respondents (only 2%) had started HIV treatment and then stopped, in 30% of cases primarily because of side-effects. A similar proportion said they had not started HIV treatment because they could not afford it. However, very few (only 16 men) said that HIV treatment was not available to them at all.
Comment: EMIS does not provide any evidence that gay men throughout Europe are finding it difficult to access HIV treatment or do not trust in it. However, only 7% of EMIS’s HIV-positive respondents came from the former communist countries of Europe and they were more likely to be young and well-educated; the lower levels of treatment use there may conceal problems with availability for those less likely or able to answer the EMIS survey. EMIS did not ask why people did take treatment, so we do not know what proportion of respondents were taking it with prevention in mind – see the following story.
More people in the UK are starting HIV treatment early to reduce transmission
There is increasing interest in HIV treatment as prevention among people living with HIV in the UK, with the number of people starting treatment at high CD4 cell counts doubling over a five-year period. In 2013, 49% of those starting treatment had a CD4 count of more than 350 cells/mm3 and 27% with more than 500 cells/mm3.
Some international guidelines recommend beginning HIV treatment at a CD4 cell count of 500 cells/mm3 or earlier. But the authors of the UK guidelines do not believe there is clear evidence that this will lead to improved individual health outcomes and recommend that treatment for the majority is begun with a CD4 count of around 350 cells/mm3.
Since 2012, however, UK guidelines have also recommended that doctors should discuss the evidence for the effectiveness of antiretroviral treatment as prevention with all people with HIV in their care and that – regardless of CD4 cell count – anyone who wishes to take treatment in order to protect their partners from the risk of HIV infection should be able to do so.
In 2008, 75% of 57,752 adults with diagnosed HIV were taking HIV treatment. By 2013, this had increased to 86% of 77,702 people with diagnosed HIV. Ninety per cent of people had an undetectable viral load a year after starting treatment (though only 77% of people aged under 24).
Comment: The UK has been criticised in some quarters for not raising the CD4 threshold for starting treatment, but these figures suggest that their policy of informing patients with high CD4 counts about the prevention potential of HIV treatment and letting them choose whether to start treatment is starting to work. Epidemiologists point out that the uptake of treatment is already very high and that changing guidelines to a firmer recommendation for early treatment would only have a limited impact on the total number of people receiving antiretroviral treatment.
PrEP use now could save money in the future
The paper probably underestimates the potential cost benefits of PrEP. The authors at the time of writing had access to estimates of the cost of PrEP and of HIV care but did not have access to the actual effectiveness of PrEP as seen in Ipergay, the study they use for their modelling. So they based their estimation of the cost of preventing one HIV infection on the effectiveness seen in the previous iPrEx study – 44%. In fact the effectiveness seen in Ipergay was 86% – meaning that the cost over time of preventing one HIV infection would be considerably less.
Using PrEP that had the effectiveness seen in iPrEX could still lose money if the costs of HIV treatment fall in the future, as they are likely to. If, however, the Ipergay effectiveness figures are used, then even if future HIV treatment costs fall by 5% a year PrEP could still save nearly a quarter of a million Canadian dollars (about €175,000 or £125,000) over that period.
Comment: PrEP of course, at an estimated CA$12,000 per recipient or CA$216,000 for each HIV infection prevented without taking into account future savings, will have considerable upfront costs. How long it will take to recoup these depends on what the rate of HIV infection would otherwise have been in the people who take it – a number hard to estimate. The main point of this study is that it offers a very clear and easy-to-understand model into which future cost and effectiveness figures can be inserted.
Opioid substitution treatment increases adherence to HIV therapy
Opioid substitution treatment (OST) increases the chances of people who inject drugs achieving good adherence to HIV treatment by 68%. Canadian researchers monitored 1852 people living with HIV, who were injecting drugs and who were eligible for HIV treatment, for an average of 5.5 years. They wanted to see if there was a causal relationship between OST and adherence to HIV treatment – at least 95% adherence assessed by pharmacy refill. After controlling for potential confounders, OST increased the odds of HIV treatment adherence by two-thirds, a finding that remained robust in a sensitivity analyses.
One in five people were on OST when they started or became eligible for HIV treatment and 39% had accessed it in the past. By the end of follow-up, 50% of the study population had accessed OST. Participants in the study spent over half (56%) the time they were receiving OST on HIV treatment. If out of OST, participants were receiving HIV treatment for only 36% of the time.
Comment: This adds to the evidence base for the health and prevention benefits of opioid substitution therapy – something that may help to put pressure on countries that refuse to even consider it, like Russia. To quote the researchers: “This study demonstrates the substantial benefits of OST in linking HIV-positive opioid-dependent individuals into antiretroviral therapy in a universal healthcare setting.”
Most US HIV infections transmitted by people who know they have HIV but aren’t in care
Sixty per cent of the HIV in the USA is transmitted by people who know they have HIV but are not in care, a recently published study shows. Another 30% is transmitted by people who are living with undiagnosed HIV, the researchers found.
The study found that viral suppression (having an undetectable viral load) equated to a 94% reduction in the likelihood of transmission compared to people who were undiagnosed. However, it found that even in people who were not taking antiretroviral therapy (ART), simply being retained in medical care was associated with a 60% reduction in the likelihood of transmitting HIV.
Another study found that about one in four to one in five people with HIV in medical care in the US had a viral load above 1500 copies/ml, indicating they could potentially infect another person.
People’s risk behaviour fell dramatically once they started HIV treatment – contradicting the assumption that people on successful HIV treatment might increase their risk behaviour because they felt safer or were healthier. The reverse appeared to be the case: 16% of people on HIV treatment and 10.5% of those with an undetectable viral load reported unprotected sex with HIV-negative or unknown-status partners in the last year, compared to 51% of those who knew they had HIV but were not in care and 62% of people who were undiagnosed.
Comment: This study shows how every step of the HIV treatment cascade contributes to reducing the number of infections transmitted by people with HIV, not just achieving viral undetectability – though that in itself cut infectiousness in this model by 78%. In the case of the US the big problem, as this model so starkly highlights, is getting people with HIV – who are likely to be disproportionately poor, black and unemployed, all of which limits access to health insurance and the ability to contribute even small co-pays – into regular medical care.
Good mental health associated with excellent adherence in people taking HIV treatment for prevention
Good mental health was the only significant factor associated with optimal adherence in people taking HIV treatment for the prevention of sexual transmission of HIV, investigators from the HPTN 052 study report. In 2011, this study showed that if HIV therapy was given to the HIV-positive partner in a couple, it reduced the risk of HIV transmission to an HIV-negative partner by 96%. Study participants were provided with regular adherence and safer sex counselling. Adherence was assessed using pill count and patient self-report at each study visit. Participants were also asked about their levels of social support and possible reasons for missing doses of their medication.
Eighty-two per cent of participants took all or nearly all their doses and several factors were associated with good adherence but the only factor that was an independent predictor of excellent adherence was good mental health. Adherence needed to be excellent, because the only significant predictor of viral suppression was an adherence level of at least 95%.
In another study from Kenya, it was found that 36% of patients experienced treatment failure of their first-line HIV therapy and another 36% (13% of all patients) also experienced treatment failure of their second-line HIV therapy, leaving them with few options in this resource-limited setting. These rates are considerably higher than failure rates in richer countries. Use of inappropriate regimens and lack of adherence support were associated with failure to control viral load.
Comment: The HPTN 052 sub-study is one of a succession to show that poor mental health is the single most significant predictor of poor adherence to HIV treatment. It is a valuable reminder that HIV treatment will not reach its potential to bring down the rate of HIV infection without maintaining social and psychological support for people living with HIV. The second study, however, also fits a strong association between poor adherence and the kind of cheap but out-of-date and toxic regimens HPTN 052 did not use. In particular, continued use of the drug stavudine (d4T) was associated with a 41% treatment failure rate. Even in this study, however, people actively engaged in community peer support programmes had a mean viral load nearly 20 times lower than people who hadn't received peer support.
Other recent news headlines
Women in PrEP trial feared being excluded if they reported low adherence
Post-study interviews and computer questionnaires, conducted with former participants in a trial of pre-exposure prophylaxis (PrEP) that reported zero effectiveness, show that participants concealed their low adherence to the study pills because, despite reassurances from researchers, they feared they would be asked to leave the study, which they greatly valued for the medical care it offered.
Chinese study sheds light on how well treatment may work as prevention in the real world
A study from the Henan province of China shows that antiretroviral therapy (ART) may not be as effective at suppressing HIV and preventing onward transmission in real-world settings as it is in the best clinical practice. The study found that ART given to the partner with HIV within monogamous heterosexual couples with different HIV status only reduced the number of HIV infections passed on between them by about 50% over the course of a study period – though its effectiveness did increase over time and by the end of the study stood at 67%.
HCV sexual transmission linked to anal sex, drug use, lower CD4 count
In addition to the usual risk factors for hepatitis C virus (HCV) sexual transmission seen in most previous studies – such as anal sex and having other sexually transmitted infections – researchers in the Netherlands also saw an association with nasal and injection drug use and lower CD4 cell count. This analysis differs from most prior studies in that it saw a significant effect of injection drug use – although the total number of people who reported injecting drugs was quite small, so it is hard to draw definitive conclusions – and did not see an association with having more sexual partners or participating in group sex.
Editors' picks from other sources
Czech human rights advocates up in arms over proposal to make HIV testing compulsory for high-risk groups
from Radio Prague
The Czech Health Ministry is pushing a proposed amendment to the law on public health which would make HIV testing compulsory for some people in high-risk groups. While the ministry argues that this is to curb the spread of the disease and ensure early treatment, human rights advocates say it would mean a serious breach of human rights.
Serbia is losing harm reduction
from Eurasian Harm Reduction Network
The situation with harm reduction in Serbia is getting increasingly alarming after withdrawal of the Global Fund. Three organisations doing harm reduction programmes in Serbia for more than a decade are struggling to maintain services.
Broadly neutralizing antibody suppresses HIV in clinical trial
from Treatment Action Group
There is now intense interest in learning whether the blossoming array of broadly neutralizing antibodies (bNAbs) can be put to therapeutic and preventive use. A paper published in Nature describes encouraging results from a phase I trial involving the bNAb 3BNC117. Reflecting the level of interest in the topic, the paper has attracted extensive press coverage.
Still refusing to date HIV+ guys? Here’s why you could be putting your health at risk
from Gaystar News
Matthew Hodson, of UK-based gay men’s health charity, GMFA, explains why arguments for not having sex with gay men who are HIV positive make little sense – and could actually pose a danger for those who are HIV negative.
We should have a better condom by now. Here’s why we don’t
from Slate
In 1993, Danny Resnic was having anal sex during a casual hookup in Miami Beach when his partner’s latex condom broke. After several weeks of worrying about the broken condom, Resnic got tested for HIV. The test came back positive. “I couldn’t believe it,” Resnic says, “because I was really vigilant. I lost all my friends during the AIDS crisis, and I used condoms religiously. And then when one broke, I thought, ‘How could that happen?’ Resnic became obsessed with answering that question: he set out to build a better condom.
Providers have mixed feelings about prescribing HIV prevention
from Group Health Research Institute
A US national survey has found providers’ perspectives lag behind PrEP guidelines. The survey was the first to be conducted since the US Public Health Service released detailed PrEP guidelines in May 2014. In the web-based survey, fewer than half of 324 practitioners, most of them HIV specialists, reported being “very likely” to prescribe PrEP to their patients who are high-risk heterosexuals or people who use intravenous drugs. For some other prime candidates – HIV-negative men whose male partners have the virus – 79% of providers reported being very likely to prescribe the regimen.