European community prevention advocates prioritise testing; increased interest in treatment as prevention

A pan-European survey of opinions about HIV prevention methods has found that expanding HIV testing was universally regarded as the most important prevention, with condom provision as the second most important. The survey was conducted by NAM last year and answered by prevention experts and advocates from 21 European countries. When asked what priority should be given to various different prevention methods – while testing and condoms were still recommended as the most important priorities – treatment as prevention and pre-exposure prophylaxis (PrEP) received big increases in their priority score, while the prevention of mother-to-child-transmission, needle and syringe exchange and, especially, opiate substitution therapy were marked down in terms of popularity. However, respondents emphasised that even though they had deprioritised some things like needle exchange, they still supported them generally.

Although the score for PrEP increased, respondents were still suspicious of PrEP and wondered if its use could be justified when parts of Europe still did not have full treatment access. Although differences were slight, Portuguese- and English-speaking respondents were slightly more likely to prioritise biomedical HIV prevention methods whereas French and Spanish respondents prioritised behaviour change and psychological support. The small number of Russian respondents were more likely to prioritise needle exchange than others, reflecting the epidemic in that country. One unexpected finding was how confusing the new biomedical landscape was; even though NAM, with the help of Sigma Research, tried carefully to distinguish between treatment alone, treatment for prevention, PrEP and PEP, respondents, although understanding the different approaches, found it hard to remember which was which in practice.

Gay men who discuss HIV status with sexual partners are less likely to acquire HIV

A case-control study, examining the sexual behaviour of 105 German gay men who had recently taken an HIV test and tested positive and another 105 who had tested HIV negative, identified two key factors which distinguish the negative and positive men – consistent condom use with casual partners and discussing HIV status with them. The results lend some support to the idea of serosorting (choosing a partner who has the same HIV status), but only when HIV status is ascertained through a clear and unambiguous conversation. Men who didn’t use condoms because they assumed their partner was HIV negative had a greater risk of acquiring HIV than other men.

Only a minority of participants – including the negative men – reported consistent condom use. Not using a condom because the respondent had assumed his partner was HIV negative was reported by more HIV-positive than -negative men (25 versus 8). In contrast, not using condoms because participants had discussed HIV status was reported much less frequently by HIV-positive compared with -negative men (3 versus 16). Men who reported ‘always using condoms’ were 77% less likely to be diagnosed with HIV and men who did not use condoms because they had discussed HIV status were 82% less likely to be diagnosed with HIV – though these men were in the minority.

Comment: This study powerfully illustrates the difference between serosorting based on discussion, and what is better called ‘seroguessing’ based on assumptions about partners’ status and behaviour.

High proportion of ‘heterosexual’ men with HIV probably got it from other men

Up to a fifth of HIV infections among black African men initially classified as 'heterosexual exposure' in the UK are likely to have been acquired as a result of sex with other men, investigators report. The authors identified clusters of HIV transmissions in the UK and found that 29% of heterosexuals who had subtype B of HIV, the type most often found in gay men, were in fact in transmission clusters that only involved men who have sex with men (MSM). The authors estimate that overall 6% of HIV infections involving heterosexual men are misclassified and are actually acquired through sex with other men. But the proportion of misclassified infections involving black African heterosexual men could be as high as 21%.

The study looked at the genetic structure of subtype B virus infecting 22,500 people newly diagnosed with HIV in the UK between 1996 and 2008. Overall, 56% of heterosexual people could be placed within a transmission cluster and just over half belonged to transmission networks that only involved other heterosexuals. However, 31% belonged to clusters that involved both heterosexuals and MSM and 29% were solitary heterosexuals in transmission networks that were otherwise exclusively MSM. Heterosexual men of black African origin were the ethnic group most likely to be linked to exclusively MSM transmission networks.

Comment: Only approximately one-in-eight people with subtype B in the UK is heterosexual, and presumably the proportion of false attributions of sexuality in men with non-B subtypes would be much lower. Nonetheless, this finding is probably not that surprising to anyone aware of the stigma with which sex between men is still regarded in some minority communities in the UK. Some misattributions about the sexuality of people recently diagnosed with HIV may come from health workers too, who may be making assumptions about the sexuality of patients from Africa.

European CDC cautious about PrEP

The European Centre for Disease Prevention and Control (ECDC) has issued a paper saying that it cannot make a clear Europe-wide recommendation on the use of pre-exposure prophylaxis (PrEP), and that it would require clearer data on efficacy, cost-effectiveness, side-effects, resistance and its impact on condom use before making one

This month, the World Health Organization issued a comprehensive set of prevention guidelines which continued to recommend “the correct and consistent use of condoms” as a highly effective HIV prevention strategy, but which also included the new recommendation that “Among men who have sex with men, PrEP is recommended as an additional HIV prevention choice within a comprehensive HIV prevention package”.

The ECDC has now issued a paper taking a more cautious line on PrEP. It comments that “PrEP is an antiretroviral therapy-based HIV prevention strategy which merits some mention” but while it “shows promising prospects for inclusion in the ‘HIV prevention toolbox’ in Europe […] it is difficult to provide a clear recommendation at present that would apply to the entire European Union”. This is because not enough Europe-specific research has yet been done on efficacy, side-effects, and behaviour change while using PrEP.

The ECDC is also very concerned about the cost and cost-effectiveness of PrEP, particularly in a region where access to treatment is still not fully realised.

Comment: The ECDC is right to note the lack of European research but also seems over-cautious about areas like drug resistance and side-effects, where the data so far seem to show that PrEP is pretty safe. Their main worry appears to be cost, but their brief commentary makes no mention of the fact that tenofovir will come off patent not long after the PROUD and IPERGAY results come out, which may provide an opportunity to reduce the cost of PrEP.

Signs of new needle-led HIV epidemic in Middle East and North Africa

There is “robust” evidence of HIV epidemics among people who inject drugs in at least a third of the countries in the Middle East and North Africa, according to a study. In this region, Iran, Pakistan and Egypt have the highest number of people who inject drugs, with an estimated median of 185,000, 117,000 and 89,000, respectively.

There was firm evidence of an established HIV epidemic among people who inject drugs in Iran. The first outbreak was reported in 1996 and prevalence has now reached 15%. Many of the epidemics had emerged in recent years. In Karachi, Pakistan, for instance, after several years of near zero prevalence, HIV prevalence in 2004 increased to 23% in less than 6 months, and reached 42% in 2011. Emerging concentrated epidemics are present in Pakistan, Afghanistan, Egypt and Morocco. Outbreak epidemics are present in Bahrain, Oman and Jordan.

These epidemics have the potential to expand. Prevalence of syringe/needle sharing ranges from 71% in Jordan to 97% in Oman. The median overall prevalence of sharing at the last injection was 23%. Only 12 to 25% of those who shared needles reported consistent condom use in the previous year, 18% of men reported sex with another man, 45% reported ever having sex with a sex worker and between 5 and 29% reported selling sex in the past year.

Comment: HIV in people who use drugs certainly seems to be expanding in these countries but it is important not to assume this inevitably implies an increase in sexually transmitted cases: it all depends on local custom and behaviour and so far Islamic countries have, in the main, maintained relatively low HIV prevalence, possibly partly due to high male circumcision rates. A big unknown is whether we will see expanding epidemics in men who have sex with men in these countries, as we have in eastern Asia, which would have considerable human rights implications.

High levels of adherence to study medication among women who conceived during HIV PrEP study

HIV pre-exposure prophylaxis (PrEP) appears to be an acceptable strategy for safer conception for HIV-negative women in a relationship with a partner living with HIV. Data from the Partners PrEP study showed there was a high incidence of pregnancy and that adherence to study medication was equally high among women who became pregnant and those who did not conceive. The researchers focused on 1785 couples where the female partner was HIV-negative. The pregnancy rate among these women was 10.2% a year. They evaluated blood concentrations of tenofovir in 73 women who became pregnant and 103 women who did not. The drug was detected in 71% of samples from women who conceived compared to 81% of samples from women not conceiving. This difference was not significant. There was no evidence that planning to conceive had an impact on pill taking. For the women who became pregnant, adherence rates in the three months before conception were no different to their adherence rates at other times during the study or to the levels of adherence observed in women who did not conceive.

Comment: In many couples who know they are of different HIV statuses and who wish to conceive, the partner living with HIV will already be on treatment and maintaining an undetectable viral load. However, this study provides evidence of the acceptability of PrEP for situations where the female partner is HIV negative and may need the extra surety of PrEP, or where the male partner is either not virally suppressed for one reason or another – or where his HIV status is unknown.

Drug-resistant gonorrhoea rates plummet in US and UK

Preliminary results in the US have shown that the proportion of cases of gonorrhoea that are drug-resistant has fallen since 2011, with a sharp decline between 2012 and 2013. The fall is particularly marked in gay and other men who have sex with men (MSM), who had had the highest rates of drug-resistant gonorrhoea. The US Centers for Disease Control and Prevention (CDC) attribute the fall in gonorrhoea resistance to two revisions of treatment guidelines in 2010 and 2012 that recommended more aggressive therapy and that excluded an antibiotic the gonorrhoea bacterium was rapidly becoming resistant to.

Between 2006 and 2010 in the US, the proportion of gonorrhoea resistant to the then-standard drug cefixime increased from less than 0.1% to 1.4%. After the second guideline revision in August 2012 that recommended the use of ceftriaxone, a drug of the same class, instead of cefixime, along with a second antibiotic from a different class, the proportion of cases that were resistant to cefixime declined from 1.4% in 2011 to 0.4% in 2013. In gay men it declined from 4.0% in 2010 to 0.6% in 2013.

Before the 2010 treatment revision, only 35% of clinics were treating gonorrhoea as recommended while 53% were prescribing antibiotics in excess of the CDC recommendations, which is one cause of resistance. After the institution of the second set of guidelines in August 2012, 82% were prescribing in accordance with the guidelines.

Meanwhile in the UK, a blog in the British Medical Journal notes that UK-defined cefixime resistance declined from 3% in 2011 to 1.6% in 2012 and from 17% to 7% in gay men.

Comment: This is very welcome news, especially given recent concerns about the rises in sexually transmitted infections in gay men in Europe. However, both the CDC and the BMJ remind readers that the gonorrhoea organism has ended up developing resistance to every class of antibiotic used against it. “The potential that gonorrhoea could become untreatable remains real,” the CDC comments, urging both new treatment options and improved prevention efforts.

Other recent news headlines

HIV prevention needs to support gay men to discuss HIV status and risk, especially in relationships

Gay men in Scotland rarely talk explicitly about HIV status with their sexual partners, but make sexual decisions based on their beliefs about their own HIV status and that of their partners, say the authors of a recently published needs assessment. This is a particular issue within long-term relationships, especially those in which men have sex with casual partners as well.

Potential for worsening of HIV epidemic among people who inject drugs in Europe

A team of investigators looking at HIV prevalence and rates of risk behaviours among people who inject drugs across Europe has found that HIV prevalence was significantly higher in eastern Europe compared to western Europe (38 vs 30%). There were significant differences in rates of reported sexual risk behaviours between participants in eastern and western Europe. Unprotected sex was reported by 58% of the HIV-negative participants living in western Europe compared to 82% of participants in eastern Europe. People who had HIV reported lower rates of unprotected sex but were more likely to report injecting-related risk, including being 17% more likely to sharing syringes.

Health interventions in online cruising environments more acceptable when they take a 'passive' approach

A survey of men who have sex with men in Scotland has found that sexual health promotion is acceptable in online cruising environments such as Gaydar and Grindr, but that a significant minority of men object to health workers initiating contact with them while using these websites and apps. On sexual networking websites such as Gaydar, Recon or Squirt, 85.7% said it was acceptable for workers to have a profile or identity and to wait to be approached by users. Slightly fewer (74.5%) supported this approach on smartphone apps such as Grindr. There was less support for a more ‘active’ approach, in which health workers approach participants and solicit engagement. On websites this was supported by 54.6% of respondents; on apps it was acceptable to 40.5%.  “Orthodox public health systems may have trouble engaging with the transgressive sites favoured by some gay men with HIV,” the authors comment.

HIV infection due to unsafe medical injections may have fallen by almost 90% worldwide in decade after 2000

The number of HIV infections in low- and middle-income countries acquired due to unsafe medical injections fell by 87% between 2000 and 2010, investigators report. The authors describe this as “a remarkable public health achievement”. The number of new hepatitis B and hepatitis C infections attributable to unsafe medical injections also fell by 83 and 91%, respectively.

PrEP users say it provides an ‘extra layer of protection’ and ‘peace of mind’

American gay men who have chosen to take pre-exposure prophylaxis (PrEP) are aware of their own risk of being exposed to HIV and see PrEP as providing 'an extra layer of protection' on top of their efforts to use condoms, some or all of the time. The use of PrEP can help reduce anxiety and provide greater ‘peace of mind’, men reported in in-depth interviews. The study also sheds light on the motivations of men who stopped taking PrEP or who chose not to take it at all. Most frequently this was because their sexual relationships or behaviour had changed, but concern about potential side-effects also deterred a number of men.

Should all gay and bisexual men take PrEP?

from Huffington Post

While it's historic for the World Health Organization to make a recommendation about PrEP, there's nothing shocking here... it's similar to what the CDC summarised about its new PrEP guidelines in May. The new federal guidelines recommend that PrEP be considered for people who are HIV-negative and at substantial risk for HIV.

While comprehensive, these recommendations hardly apply to all gay men, or heterosexuals for that matter. More than the sensationalism of the's headlines, what frustrates me is how they distract from the importance of WHO's recommendations related to what it calls "Critical Enablers”. These are often described in epidemiology as structural drivers of the epidemic. For example, WHO calls for the decriminalization of same-sex activity, sex work, and non-conforming gender identities, the implementation of anti-discrimination laws that eliminate stigma, discrimination and violence, and safe, accessible, and culturally competent health care services for populations most affected by HIV.

Russia's HIV epidemic starts in its prisons

from The Moscow Times

Russia is home to the world's most explosive HIV epidemic, with an estimated 1.2 million infections accounting for 55% of the total number in Europe.

While the epidemic is concentrated among people who inject drugs – primarily opioids – there is growing evidence that it is spreading to the general population. Despite this, the government exacerbates the problem by creating a climate of fear, repression and stigmatisation for drug users, while simultaneously denying them access to effective treatment programmes. Since 1997, a federal law has banned the single most effective treatment for opioid dependence: opioid substitution therapy with methadone or buprenorphine, approved by the World Health Organization.

HIV incidence among gay and bisexual men in British Columbia shows no meaningful decrease

from The Toronto Globe and Mail

The number of new HIV diagnoses in British Columbia has steadily declined in the past decade – but not for gay and bisexual men, who have shown no meaningful decreases and accounted for nearly two-thirds of new cases in 2012, according to a new report.

The report notes a complex interaction of societal and structural drivers has resulted in gay and bisexual men carrying a disproportionate burden of HIV in British Columbia. These include individual factors such as sexual behaviour and HIV testing, as well as outside factors such as stigma, marginalisation, poor social supports and other systemic challenges to HIV prevention.

Sex without fear

 from New York Magazine

Gabriel, a 32-year-old real-estate broker, never wanted to go through the experience of having to get a course of post-exposure prophylaxis (PEP) again. So he got a prescription from his doctor for Truvada. Truvada is a ten-year-old HIV-treatment pill that, in 2012, quietly became the first drug to be approved in the US for a new use: to prevent HIV infection. The drug has the potential to dramatically alter the sexual behaviour – and psychology – of a generation. When taken every day, it’s been shown in a major study to be up to 99% effective. Several months after starting the drug, Gabriel says it’s allowed him to be bolder and more unapologetic in his desires, to have the kind of joyfully promiscuous, liberated sex that men enjoyed with one another in the decade or so after the Stonewall riots brought gay life out from the shadows and before the AIDS crisis shrouded it in new, darker ones.

Researchers relate arrests with HIV risk environment

from Science Daily

A study, conducted by researchers from Boston University Schools of Medicine and Public Health, in collaboration with St. Petersburg Pavlov State University, sought to discover the effect police arrests had on the health outcomes of a cohort of people living with HIV with lifetime of injection drug use. Those who were arrested by police were more likely to share needles – increasing HIV transmission – and to overdose. Their research also found no indication that police arrests reduce drug use.

All public health marketing to be in partnership with brands

from Marketing Week

Unveiling its marketing strategy for the current financial year, Public Health England says it will never launch a marketing campaign unless in partnership with an external organisation.

The failure of the ABC approach to HIV prevention

from Communications Initiative

For close to 25 years, the standard HIV prevention strategy was the ABC sexual behaviour change strategy: Abstain, Be faithful, and use Condoms. Today, this ‘old’ strategy has all but faded into the background, with only condoms remaining on the tick-list of ‘to do’s’. The evidence was clear: New infections continued to rise steadily year after year, regardless of ABC. The 2012 South African Department of Health Antenatal Study confirms this.

What’s your long-term risk of transmitting HIV?

from Poz

How mathematical models can help us better understand both the long-term probability of HIV transmission and the benefit of combining risk-reduction strategies.