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Friday 25th July 2014

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An epidemic of hate, as well as one of HIV

Violence condom from the presentation by Laurindo Garcia.

Men who have sex with men (MSM), transgender people and other vulnerable groups are facing an epidemic of hate as well as the HIV epidemic, Laurindo Garcia, the Filipino activist, told AIDS 2014

He noted that since the last International AIDS Conference two years ago, the human rights of these groups had actually gone into reverse.

Harsh new homophobic laws have been passed in Uganda and Nigeria and levels of violence directed at vulnerable groups have increased.

Access to basic HIV prevention services is denied to men who have sex with men and other vulnerable groups. This is likely to mean they will not benefit from important new prevention technologies including pre-exposure prophylaxis (PrEP) and HIV treatment as prevention.

“In 81 countries around the world, the idea of a health intervention for trans people, gay and other MSM is to beat us up or throw us in jail,” said Garcia.

He said that health professionals need to take steps to protect people from violence and ensure access for all to healthcare and treatment.

Garcia also suggested that key principles for health advocates should include choice, harm reduction and pleasure, and that there needs to be an acknowledgement of the importance of love, pleasure and desire.  

PrEP doesn’t increase risky sex, say users

Slide from the presentation by Kimberly Koester.

In-depth interviews with US gay men and other MSM enrolled in the iPrEx study show that the treatment isn’t being used as a replacement for condoms.

Interviews with 60 participants showed that PrEP was mainly used as an additional source of reassurance rather than as a replacement for other HIV risk reduction strategies, especially condoms.

Younger study participants actually increased their use of condoms after starting PrEP.

A minority of men was using PrEP as their only defence against infection with HIV. However, they tended to individuals who weren’t using condoms before they joined the study.

“I don’t know what I would have done without that pill,” said a 21-year-old man. “I would probably have HIV right now. Because I used to have sex unprotected…the pill was a blessing for me.”

Gay men’s risk reduction strategies

Slides from the presentation by Martin Holt.

An Australian study presented on Thursday showed that it is misleading to think of gay men as either consistent condom users or `condom failures`. In fact, the majority of gay men who have condomless sex employ HIV risk reduction strategies – but these are highly dependent on accurate information about HIV status for their success.

The findings come from a large community survey in Australia. Approximately one in five men reported condomless sex with a casual partner in the previous year (2942 men). 2339 men had tested HIV negative and 603 men had been diagnosed with HIV. The small number of men who had never tested for HIV were excluded from the analysis.

HIV-positive men who didn’t consistently used condoms with casual partners reported serosorting (60%), condoms (22%), strategic positioning (17%) and withdrawal (15%).

HIV-negative men were more likely to report using condoms most of the time, but serosorting was still the most widely reported tactic (44%), followed by condoms (41%), strategic positioning (24%) and withdrawal (22%).

Three-quarters of men reported using more than one strategy; the strategies most commonly combined were serosorting and condom use.

There was a very strong association between using these strategies and disclosing HIV status to sexual partners. This was the case both for HIV-positive and HIV-negative men.

Investigator Martin Holt concluded that interventions should aim to improve the consistency with which gay and bisexual men employ risk reduction strategies.

Men should be encouraged to disclose their HIV status, to make effective agreements with their regular partners about casual sex and to choose the best strategy in different scenarios.

Alternative approaches such as PrEP are likely to be appropriate for those men unable or unwilling to use existing strategies.

Recreational drug use, gay men and unprotected sex

Research involving gay men in the UK shows that unprotected anal sex is strongly associated with the number of drugs taken during a sexual encounter.

This is the first time that a relationship has been established between higher levels of recreational drug use and an increased likelihood of unprotected sex during single sexual events in a UK sample of gay men.

The research was conducted in 2011-12 and involved 2142 gay men who provided information on HIV risk behaviour and drug use for 6742 sexual encounters.

There was a 25% probability of unprotected sex when no drugs were used, this increase to 30% when a single substance was consumed, 50% with the use of three substances and 75% when five or more drugs were taken.

In general, men were less likely to have unprotected sex when they were with an anonymous partner, when they hadn’t discussed HIV status with their partner, with a partner they knew to have different HIV status and when using cruising locations or sex-on premises venues. Most unprotected sex happened in people’s homes.

A total of 321 men also provided information on 438 group sex encounters.

Their answers also showed that the higher the volume of drug use, the greater the risk of unprotected sex.

The only drug associated with “being out of control” was methamphetamine. Use of other drugs seemed to be associated with sexual pleasure. Each sexual encounter was rated on a pleasure scale of 1 to 10. The more drugs used, and the greater the number of men involved, then the higher the rating.  

Hepatitis C treatment for people taking opioid substitution therapy.

Daniel Cohen, of AbbVie, presenting at AIDS 2014. Photo by Liz Highleyman, hivandhepatitis.com.

People with chronic hepatitis C who are using methadone or buprenorphine to manage opiate addiction can be safely and effectively treated with AbbVie's 3D all-oral direct-acting antiviral regimen plus ribavirin, resulting in a 97% cure rate, according to a report this week at the 20th International AIDS Conference in Melbourne.

Hepatitis C virus (HCV) is readily transmitted through shared needles and other drug injection equipment, and people who inject drugs have high rates of HCV infection worldwide. Traditionally, however, only a small proportion of this population has received hepatitis C treatment due to concerns - both real and unfounded - about tolerability, adherence and suboptimal efficacy.

A new 12-week three-drug regimen of direct-acting antivirals plus ribavirin was tested in 38 people on stable opioid replacement therapy using either methadone or buprenorphine, with or without naloxone. All participants had genotype 1 infection. 97.4% had a sustained virologic reponse 24 weeks after completing treatment.

No participants required adjustment of methadone or buprenorphine doses during hepatitis C treatment.

No evidence of poorer memory, thought processes or concentration in people taking long-term efavirenz treatment

Andrea Antinori, from the National Institute for Infectious Disease in Rome, presenting at AIDS 2014. Photo by Liz Highleyman, hivandhepatitis.com

Efavirenz, which is widely recommended for first-line HIV treatment, has a well-known association with neuropsychiatric side-effects such as insomnia, vivid dreams, hallucinations, dizziness and poor concentration.

The association between efavirenz and neurocognitive impairment, such as problems with thinking and memory, is controversial and prior studies have yielded conflicting results.

A cross-sectional study of 859 people taking antiretroviral therapy in Italy was presented on Thursday, showing that compared to people taking other regimens, those taking efavirenz did not have poorer memory, concentration, thinking ability, fine motor skills or visual-spatial abilities.

Neurocognitive impairment was more likely with older age, HIV disease severity, injection drug use and hepatitis C coinfection.

With the expiration of its patent protection in high-income countries, less expensive generic versions of efavirenz will soon become available.

Some experts have suggested that efavirenz should no longer be considered a preferred treatment option as newer drugs are more effective and better tolerated.

But efavirenz remains a safe and effective choice for many people, and this study shows that neurocognitive problems are not a concern for those who are able to tolerate the drug.

Weight gain after starting ART may raise risk of heart disease

Amit Achhra, from the Kirby Institute in Sydney, presenting at AIDS 2014. Photo by Liz Highleyman, hivandhepatitis.com.

People with HIV with body weight in the normal range who gain a substantial amount of weight shortly after starting antiretroviral therapy (ART) may have an increased risk of cardiovascular disease and diabetes, according to findings from the D:A:D study presented this week at the 20th International AIDS Conference in Melbourne.

Several observational studies - including the large international Data Collection o­n Adverse events of Anti-HIV Drugs (D:A:D) study - have found that people with HIV have higher rates of cardiovascular disease and metabolic conditions such as diabetes.

However, the relative contributions of HIV infection itself, resulting inflammatory and metabolic changes, antiretroviral toxicities, and other factors are not yet fully understood. Many people with HIV gain weight after starting ART, and this may have a detrimental effect on health.

This analysis included 9321 people who were starting ART for the first time and who had no prior history of cardiovascular disease before treatment initiation.

The study found that a 1-unit gain in BMI was associated with an 18% increased risk of cardiovascular events in the normal weight group. However, people in the underweight, overweight and obese groups did not see a significant change in risk.

To put this in perspective, a 40-year old man weighing around 70kg (approximately 12 stone or 170 lbs) would need to gain at least 3.5kg (eight pounds) to show an increased risk of cardiovascular disease. In women with lower body weight and height, a 1-unit gain in BMI would be a correspondingly smaller amount.

A 1-unit gain in BMI was associated with about a 10% increased risk of diabetes regardless of weight.

Although these results may give cause for concern, the key takeaway message for people living with HIV is exactly the same as for the rest of the population: gaining a large amount of weight increases the risk of heart disease.

Scientific analysis from Clinical Care Options

Clinical Care Options' (CCO) is the official online provider of scientific analysis for delegates and journalists.

Over the next few weeks, their coverage will include expert audio highlights, capsule summaries of important clinical data, downloadable slidesets, and more.

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