Gay men run very different risks of HIV; implications for PrEP
The researchers analysed the number of times cohort members took sexual risks over the study period (by allocating a 'risk score' to each six-month period) and found that men's risk scores tended to be consistent, and to fall into three different groups. The study found that one-in-seven men belonged to a very high-risk group, a third of whom became infected with HIV over the study period. Just under a quarter belonged to a moderate-risk group, of whom 10% became HIV positive.
The other two-thirds were at low risk of HIV, except for short periods; 3% of them acquired HIV.
Being in the one-third of the cohort that did take more risks was associated with being white, having a high income, and being younger; in addition, being in the most at-risk seventh of the group was associated with depression and taking recreational drugs.
Comment: The authors did this analysis because they wanted information that could help in better targeting of pre-exposure prophylaxis (PrEP): one of the reasons this prevention method has taken off slowly in the US, and not yet received approval elsewhere, is concern about its cost. Cost-effectiveness studies suggest that PrEP will only be economical if taken by people with the highest risk of HIV infection (see this report for one example). It is, however, of broader interest, as the first-ever study to demonstrate a relationship between specific characteristics in gay men and what the authors call “risk trajectories” – longitudinal patterns of HIV risk over time.
Big reduction in drug injecting in people who test positive for hepatitis C
Diagnosis with hepatitis C virus (HCV) is associated with a sustained reduction in injecting drug use, according to Canadian research published in the online edition of Clinical Infectious Diseases. Each additional three months of follow-up was associated with a 10% reduction in the likelihood of injecting cocaine or heroin.
“The main finding of this study is that notification of HCV test results and counseling is related to reductions in subsequent drug use behavior for PWIDs [people who inject drugs] learning that they recently contracted an HCV infection, but not for those who are uninfected”, comment the authors. “Reductions in drug use behaviors are likely to reflect a response to being informed about a recent seroconversion.”
The researchers also found that during the 30-month follow-up period of the study, the proportion of participants who reported sharing syringes fell to very low levels, regardless of HCV infection status.
The authors of an editorial that accompanies the study believe the results highlight “the importance of HCV testing as a catalyst for behavior change”.
Comment: This study isn’t able to show that a diagnosis of hepatitis C specifically led to a reduction in drug injecting, or that testing for hepatitis C led directly to less equipment-sharing. It’s more probable that testing and diagnosis were part of what happened when drug injectors were linked to a sustained programme of health care in general. As with many other studies of people who inject drugs, it does show that appropriate care can produce big changes in risk behaviour.
English study looks at male sex workers
Male sex workers were three times more likely to be diagnosed with HIV than other men attending sexual health services in England. They were also twice as likely as other men to be migrants (38 versus 19%): over a third of the male sex workers in the study were not born in the UK.
Of migrant male sex workers, 38% were from one country – Brazil. A quarter were from other western European countries, 12% from eastern Europe, and 12% from Asia.
Overall, only one in 1250 male sexual health clinic attendees identified themselves to clinic staff as a sex worker. Other UK studies, however, have estimated that only a third of male sex workers identify themselves as such to clinic staff, which would suggest that something like one-in-400 men attending sexual health services is working as a sex worker.
Perhaps surprisingly, male sex workers were slightly older than other male patients (29 versus 28 years on average) and 30% of sex workers were aged over 35. The authors highlight how these findings are contrary to “assumptions that MSWs [male sex workers] are a predominately younger group.” Male sex workers were more likely to have a sexual health screen but no more likely to take an HIV test than other men (73% did).
Less surprisingly, 57% of male sex workers identified as a man who has sex with men, compared with 15% of the general male sexual health clinic population, but the researchers comment that they were surprised that as many as 43% of male sex workers identify themselves as predominantly heterosexual.
Comment: This is an interesting complementary study, from a similarly large participant base, to the EMIS study of gay men in Europe, which found that one-in-20 self-identified gay men had sold sex at some point, but that only one-in-200 had sold sex on 10 or more occasions. Male sex workers therefore form a relatively small proportion of men who have sex with men, but are more likely to have specific needs such as being migrants or being socially isolated from other MSM. EMIS found that selling sex was more common in some eastern European countries such as Macedonia, but was also relatively more common in Italy.
Young newly diagnosed gay men in US have high viral loads
The results may not be entirely bad news. The investigators acknowledge the high viral loads they recorded could be because young people are being diagnosed promptly: mean CD4 cell count at diagnosis was 456 cells/mm3, indicative of relatively early diagnosis. In young people in general, there was a significant association between lower CD4 cell count and higher viral load, but viral load was significantly higher in MSM than in heterosexual people: nearly a third of young MSM had a viral load over 50,000 copies/ml compared with one-in-five people who acquired HIV at birth and one-in-six who acquired HIV through heterosexual contact.
Comment: This study shows that undiagnosed young gay people in the US form a group who are on average highly infectious with HIV, but not because they are sick; on the contrary, over two-thirds of those diagnosed had a CD4 count over 350 cells/mm3, suggesting that a high proportion of infections in young MSM are being identified early. In Europe, a much lower proportion of gay men with HIV are in the under-25 age group, though the EMIS study found that the rate of new HIV diagnosis was higher in eastern Europe, where respondents were also on average younger.
Testing on hospital admission picks up many new diagnoses
Croydon University Hospital’s opt-out testing programme for medical admissions was initiated in 2011 (it is described in Tales of the late diagnosed in HIV treatment update issue 214).
Over 12,500 people were admitted to the acute medical unit between July 2011 and March 2013. A third (33%) were tested for HIV and the testing rate increased to 41% in the second half of the study.
Twenty people tested HIV positive, 14 of them men. This 0.48% diagnosis rate is roughly similar to the overall HIV prevalence rate in the London borough of Croydon.
Of those testing positive, 17 were newly diagnosed and three were people who had previously tested HIV positive but had dropped out of care: two of them were successfully re-linked to care, and efforts are continuing to contact one other patient. Eleven patients have started antiretroviral therapy. One new diagnosis was also made among contacts of those who tested HIV positive. Another male patient was in primary infection; he was married to a woman who was pregnant, and two years later, both she and her baby remain HIV negative.
Comment: One of the most important aspects of this study was that it found the policy was a remarkably cheap way of detecting new HIV infections: the total cost of 4122 tests was £20,527 or £1466 for each new HIV diagnosis. This is not the first London-based study to find that testing acute hospital admissions is a good way of detecting undiagnosed people with HIV: the HINTS study also found considerably higher prevalence in people admitted to hospital than it did in patients attending accident and emergency rooms or primary care.
Computerised counselling achieves reductions in viral load and risk behaviour
The CARE+ counselling module informed and helped participants think about topics such as adherence, HIV disclosure, safer sex, substance use and the impact of adherence on viral load.
Participants’ viral load, adherence and risk behaviour were measured one month after the end of the nine-month intervention.
Self-reported risk behaviour among counselling participants fell by 55% while it modestly increased amongst a control group. Similarly, adherence to treatment increased from 76% at baseline to 81% after the study among CARE+ users but decreased slightly in the control group. Among the 30% of patients who had a detectable viral load at the start of the study, adherence increased in CARE+ users by 13%.
These are self-reported data, but laboratory results also showed that viral loads were reduced. Among participants with a detectable viral load at baseline, there was an average 75% reduction in viral load compared with a 30% reduction in the control group, though CARE+ produced only a marginally significant improvement in viral load suppression in the group as a whole.
Comment: Behavioural intervention studies often only use self-reported outcomes, so it is impressive that this form of computerised counselling/education produced a measurable improvement in viral load in people who were not virally suppressed at baseline. It is important to note, however, that outcomes were measured only a month after the end of the programme, and it will be important to see how long its effects last.
NAM/AVAC webinar – HIV prevention research update: what to watch in 2014
The first of NAM and AVAC’s joint webinars (telephone teach-ins with accompanying slides) will take place on Thursday 30 January at 14:00 GMT, 15:00 central European time.
This time, we look forward to likely prevention news in 2014.
Speakers include:
- Gabrielle Breugelmans, European and Developing Country Clinical Trials Partnership
- Tina Bruun, PARTNER study
- Giulio Maria Corbelli, European AIDS Treatment Group.
AVAC’s Rebekah Webb will moderate the session.
To register, please go to https://cc.readytalk.com/r/4vjyo4vedwjy&eom
Other recent news headlines
Large US study shows which HIV tests are most accurate
A US study has confirmed that ‘fourth-generation’ tests that combined testing for HIV antibodies with a test for the HIV protein p24 are more sensitive in general and in particular can detect more than half, and up to 87%, of very recent infections where the best antibody-only tests detects about a third. The study also found that the saliva tests used in some rapid and at-home tests missed 13% of all infections. Fourth-generation tests are standard in Europe but were only approved in 2010 in the US.
Penile HPV increases HIV risk in men regardless of circumcision
A sub-study of a circumcision trial in Kisumu, Kenya has found that men who had penile infections with human papillomavirus (HPV) were 72% more likely to acquire HIV, and 92% more likely if they had one of the cancer-causing types. Risk increased for each HPV infection, and men infected with three or more HPV sub-types had over three times the risk of infection. The HIV risk was no lower in circumcised men. This finding shows HPV increases the risk of HIV in heterosexual as well as gay men.
Widespread support for PrEP among US doctors
Three-quarters of infectious disease specialists in the United States and Canada are supportive of HIV pre-exposure prophylaxis (PrEP), but only 9% have prescribed it, results of a survey show. The most commonly cited reservation about PrEP was its cost.
Malawi: contact-tracing people with STIs finds people with HIV
A programme in which people newly diagnosed with HIV or other sexually transmitted infections (STIs) were asked to recruit contacts for testing found a much higher proportion of people with undiagnosed HIV than testing in the general population in Malawi, where one-in-nine people has HIV. Eighteen people from the control group had to be screened to find one new HIV infection, but in people diagnosed with HIV this was only one in eight, and in people diagnosed with another STI, only one in ten.
Editors' picks from other sources
HIV epidemic plagues Russia as government rejects prevention methods
from Bloomberg Businessweek
Hidden from the outside world and abetted by policies that critics say promote infections rather than curbing them, the HIV scourge plaguing Russia is one that even the poorest countries have begun to subdue.
The World Health Organization’s error on HIV self-infection in Greece adds insult to injury for HIV positive Greeks
from United Solidarity International
The idea that people would deliberately get a serious infection in order to stave off poverty is imaginary. What drove the spike in HIV infections in Greece in the past three years was not individuals living on the street but individuals dictating policy at the top.
Non-antiretroviral microbicide quest looks to expand prevention toolbox
from Science Speaks
An agreement between the United States Agency for International Development and the Population Council for the development of a non-antiretroviral-based compound to block HIV and sexually transmitted infections could yield a low-risk product for women in low-resource settings in as few as a dozen years, if a promising new compound performs as hoped. That is a big if – the field of microbicide research has seen a rollercoaster of raised expectations and dashed hopes over the last decades.
PrEP cost-effective in discordant, regular MSM partnerships
from Healio
Although targeting HIV-negative men in a discordant, same-sex regular partnership for pre-exposure prophylaxis appears to be cost-effective, it would not have a large population-level impact, according to the results of an Australian study.
England's HIV services face complex new environment
from The Lancet
HIV prevention and care, and sexual health services, are facing substantial reorganisation in England, with big implications for care.
Ireland: HIV infections among gay men at record high
from Pink
News
According to Ireland’s Health Protection Surveillance Centre (HPSC), the number of new cases has been “rising steeply” since 2008 and reached record levels in 2012.