Melbourne special – news from the 20th International AIDS Conference
This edition of HIV prevention news: Europe covers key HIV prevention news from the 20th International AIDS Conference (AIDS 2014) in Melbourne, Australia.
A tale of two cities: why is HIV incidence in gay men falling in San Francisco but not in London?
The rate of new HIV diagnoses in men, and the proportion who are diagnosed with recent infections, have both stayed unchanged since 2007 in London but in San Francisco have fallen by 37% and 67% respectively. While community surveys and figures from sexual health clinics show that 58% of men in London and 72% in San Francisco tested for HIV in the last year, the true proportion of gay men who test is thought to be very much lower than this and the actual proportions are probably more like 17% and 29% respectively.
In San Francisco, rates of gonorrhoea in gay men living with HIV are 3.5 times higher than they are in HIV-negative men, whereas in London they are the same regardless of HIV status and similar differentials apply to syphilis. This, alongside evidence showing that unprotected sex between partners of differing or unknown HIV status has fallen in San Francisco but not in London, suggests that more HIV testing may lead to a higher rate of HIV status disclosure between gay men, which enables effective serosorting.
Audience members at the presentation of this study at the conference suggested that the study should be extended to other high-prevalence cities in Europe.
Comment: As yet, this study shows some interesting associations between testing rates, rates of sexually transmitted infections, and serosorting, but it did not include other data such as the proportion of people taking antiretroviral therapy (ART) and with an undetectable viral load. Presenter Colin Brown commented that it might be much more difficult to establish a 'testing and disclosure’ culture in a larger, more geographically diffuse and more multicultural city like London. More comparative studies like this are needed, but they depend on good surveillance.
New HIV in people who use drugs in Europe is related to economic decline: can be contained with good programmes
Although HIV infection rates in people who inject drugs in Europe have generally been lower than in other world regions and have been stable in the last decade, Greece and Romania saw 10- to 20-fold increases in infections in people who inject drugs between 2010 and 2012, and it has been hypothesised that these were related to economic austerity, with cuts to harm reduction services leading to increased infections. A study from Athens University now found just such an association.
The study found that countries who had experienced increases in economic prosperity between 2003 and 2012 were 35% less likely to see increases in HIV infection in people who inject drugs and that countries in which economic inequality increased were 50% more likely to. New epidemics in people who use drugs can respond very quickly to increased resources being put into prevention, however. A new HIV screening, prevention, treatment and care package called ARISTOTLE, which included peer support and financial incentives for HIV testing, was associated with a 78% decrease in HIV incidence in Athens between August 2012 and December 2013.
This programme did not offer needle and syringe exchange and opiate substitution therapy, but researchers found that the support offered led to safer injecting and sexual practices in participants. Over the longer term, a review of the data from Ukraine found that harm reduction programmes there led to a fivefold drop in HIV diagnoses in young people between 2005 and 2012. However, HIV infection rates in the country are still high and an increasing proportion of infections are transmitted through sex between men and women, indicating the need for an additional element of prevention policy to meet the sexual health needs of people who inject drugs and their partners.
Comment: The data from both Ukraine and Greece are reassuring. The Greek data suggest that outreach, HIV testing and harm reduction have an impact on HIV incidence, even where there is inadequate coverage of needle and syringe programmes and opioid substitution therapy.
Fifty per cent efficacy in open-label PrEP study, but 100% with adequate adherence
Results from the first open-label efficacy trial of pre-exposure prophylaxis (PrEP) have essentially confirmed the findings of the original study – namely that PrEP is extremely efficacious if taken regularly but that a substantial proportion of people in the study did not take it regularly enough to avoid HIV.
In the original iPrEx study, in which participants did not know whether they were taking PrEP or a placebo, there were 44% fewer HIV infections in people allocated to PrEP. In the iPrEx OLE (Open Label Extension) study, which was reported at the International AIDS Conference in Melbourne, all participants knew if they were taking an active drug. Efficacy was 50%. No infections were seen in participants with drug levels consistent with taking PrEP at least four times a week, and only one of the 28 infections in people allocated to PrEP was in someone with drug levels indicative of their taking PrEP more than two to three times a week. Only just over a third of participants managed these levels: adherence rates fell rapidly after the start of the study and only 39% of participants classed as being at high risk of HIV at the start of the study were taking “clinically meaningful” doses three months later.
In a separate presentation, the first European data from a PrEP study – the IPERGAY study, which is testing the efficacy of an intermittent PrEP regimen – found somewhat higher adherence: at least three-quarters of participants said they had taken PrEP the last time they had sex, drug levels indicated that 80-85% of participants had taken PrEP at least once in the week before sampling, and 50% of samples from participants’ hair, which measures consistent adherence over the longer term, contained drug levels indicative of regular PrEP.
Comment: One factor in the poor adherence in the iPrEx OLE study may have been that the vast majority of participants – 62% of whom were in Peru or Ecuador – knew they were not going to have access to PrEP after the study. Nonetheless, this result shows that while PrEP is highly efficacious, more thought needs to be put into helping users sustain adherence beyond what principal researcher Bob Grant called an initial “brief period of engagement with PrEP”. As a couple of other studies have found, young people had especially low adherence to PrEP. The figures from IPERGAY, on the other hand, are relatively reassuring: because this study is both placebo-controlled and features a rather complex before-and-after-sex PrEP regimen, there had been concerns adherence might be low.
Doing it together: couple counselling may be a vital component of HIV prevention in Africa
In Zambia, so far over 150,000 couples have received couple voluntary counselling and testing (CVCT) and in 12% of them one member of the couple is living with HIV. This study found that in couples who had received CVCT, the annual rate of infection in the HIV-negative partners declined more than fivefold, from 11% to 2%. CVCT did not necessarily involve one partner being diagnosed: in many cases, it enabled a partner who already knew they had HIV and was sometimes on antiretroviral therapy to disclose to their partner.
Researchers compared HIV incidence before and after CVCT in couples where the HIV-positive partner was already on treatment with incidence before and after CVCT when they were newly diagnosed but did not start ART. This showed that, remarkably, HIV incidence within the couple declined by 70% after CVCT but only by 30% where the HIV-positive partner started ART but had not received CVCT. If both happened, the reduction in incidence was 83%. This is very different from the 96% reduction in HIV infections seen in the pivotal HPTN052 study when the HIV-positive partner started treatment. Part of the explanation seems to be that community adherence to ART is very poor in Zambia and this is partly driven by people’s fear of their partner discovering they have HIV – so assistance to disclose helps reduce transmissions.
Comment: A remarkable result, and one that needs to be repeated, but if confirmed this should prompt a rethink about the protocols of some other treatment-as-prevention studies that have positively avoided inter-couple disclosure for fear of rejection of the HIV-positive partner and even violence. That counselling helped generally with greater trust and intimacy is shown by the fact that HIV incidence in couples where neither had HIV – i.e. infections from someone outside the relationship – went down by 70% after CVCT too, from 1.4% to 0.44% a year.
Nearly one in five gay men in eastern Europe has been arrested for being gay – only one in fifty in western Europe
The conference also heard that anti-gay laws are already having an effect on gay men’s willingness to come forward for scientific research studies. In the MSMGF survey, 82% of over 4000 self-selected gay and other men who have sex with men (MSM) were university educated – so it probably represents MSM who are more well-resourced that others in their country. One in six had HIV. In western Europe, as in North America and Australasia, only 2% had ever been arrested or convicted for same-sex behaviour. In eastern Europe, 18.1% had been, second only to sub-Saharan Africa’s 23.6%.
Having been arrested or convicted was associated with lower access to condoms, medical care, HIV testing or mental health services and in men living with HIV it was associated with 50% lower access to treatment compared with other men – though the survey was not designed to find out why. In another study, Ifeanyi Orazulike, a Nigerian researcher and advocate who is also co-chair of the MSMGF, said that the passing of the anti-gay law in Nigeria had impacted on recruitment to a study of health and behaviour in MSM there. Whereas around 60 men a month had volunteered for the study in 2013, enrolment has dropped to less than ten men a month since January. Those men who have taken part since January are more likely to report being afraid to seek health care (36%) than during interviews before the law was passed (25%).
Comment: The presenter’s comment that men had said they would rather “Die in the comfort of their beds” than risk arrest or mob justice by seeking healthcare that might ‘out’ them as MSM is eloquent testimony to the impact of anti-gay laws on public health.
Sex workers need support for condom use with regular partners
In a study from central America, over 80% of female sex workers in most countries reported consistent condom use with clients (an exception was Belize, one of the few countries in the region that criminalises sex work, with only 60%). Condom use with clients was not improved further by behavioural support programmes. Only 30% of female sex workers used condoms consistently with regular partners, though, and a variety of different behavioural and biomedical interventions more than doubled self-reported condom use with regular partners, but did not increase HIV testing rates.
In Zimbabwe, a baseline study preparatory to a large study called SAPPH-IRe found that 60% of female sex workers used condoms with clients but that despite this, over half (56%) had HIV, only 60% knew it, and only 40% of them (24% of the total) said they were on antiretroviral therapy (ART) – though 14% of women who said they were not on ART had an undetectable viral load. Women experienced very high levels of violence, with 35% reporting attacks and 4.3% rapes, mostly from clients, in the previous year. SAPPH-IRe will randomise geographically separated groups of female sex workers to receive standardised education, counselling and testing or to also receive on-site pre-exposure prophylaxis (PrEP) and ART.
A study from India, modelling the effects of PrEP for female sex workers, found that if 40% of female sex workers took up the offer of PrEP, it could produce a 23% fall in HIV infections in female sex workers in ten years.
Comment: In most areas, the proverb “If it ain’t broke, don’t fix it” applies to programmes aimed at reducing behavioural risk with clients in female sex workers. What these studies show is that female sex workers need support not so much as sex workers – but as women who also have intimate relationships. For a study trying to tackle the huge levels of violence against women, see “Intimate-partner violence programme brings down HIV infections” below.
Other news headlines from Melbourne
Disclosure is key to gay men’s risk strategies
A national study from Australia found that most of the 21% of men who reported anal sex without a condom with casual partners nonetheless employed some kind of risk-reduction strategy, with serosorting being the most common and selective condom use also popular in HIV-negative men. The use of these strategies was highly dependent on status disclosure by partners.
Could HIV treatment mean safer sex?
A meta-analysis of every study that has ever compared sexual risk behaviour in HIV-positive people before and after they start treatment has found not a single instance where risk behaviour rose after starting treatment. Condom use in women doubled, on average, after they started treatment and went up in men by 50%. This analysis may calm fears that so-called treatment as prevention will lead to an increase in risk behaviours, though studies were mainly conducted in heterosexuals or in sub-Saharan Africa, so may not apply to other groups.
Universal home testing acceptable: treatment takes longer
A cluster-randomised study of universal home testing and local HIV treatment in South Africa has found that 88% of residents visited and offered an HIV test at home accepted one and 64% of all residents in the locality were tested. However, HIV treatment uptake among the 31% who tested HIV-positive was slower than expected, with only a half of them starting treatment within a year.
Intimate-partner violence programme brings down HIV infections
A strategy called SHARE (Safe Homes and Respect for Everyone) aimed at reducing intimate partner violence reduced HIV incidence in the total local population by 37% in men and 31% in women, although reports of intimate partner violence only went down by 20% according to women and not at all according to men.
Cash and care brings down HIV in adolescents
Financial and social support for South African adolescents such as cash allowances, free school meals or food gardens, transport vouchers and school uniforms reduced HIV risk behaviour as measured by condom use, number of partners, transactional sex, drug use, pregnancy and proportion of much older partners by 50% in boys and 45% in girls. However, risk behaviour did not decrease in young people with a parent who had died of AIDS or who was homeless.
Very high HIV incidence continues in young Thai gay men
A study of young gay men and transgender women in Bangkok has found an annual incidence of 8.8% in those aged 18-21, compared with 3.7% in over-30s. The researchers calculated that nearly half of MSM in the city who did not use condoms consistently would have HIV within five years of starting to have sex – and even one in five of those who did.
Of guidelines, targets and resources
Should we aim boldly at testing and treating a large majority of people living with HIV? UNAIDS think we could do it. The WHO on the other hand thinks that AIDS will remain unless we specifically give better support and more treatment to the ‘key affected populations’ – men who have sex with men, female sex workers, people who inject drugs, transgender people and people in prison settings. These are groups that have a higher risk of HIV everywhere and are often marginalised or persecuted.
Meanwhile activist organisation the International Treatment Preparedness Coalition (ITPC) warns that increasing economic prosperity ironically threatens to cut countries off from funding sources such as the Global Fund to Fight AIDS, Tuberculosis and Malaria that could be used to support their key affected populations.