Most gay men in central Europe don’t know they have HIV

A survey of gay men from the capitals of four central European counties – Ljubljana, Prague, Bucharest and Bratislava – and two western European cities (Verona and Barcelona) has found that only a minority knew they had HIV. This is despite a majority having taken an HIV test at some point, and 32-56% having tested within the last year.

In fact, having received a negative HIV test result less than a year ago was positively correlated with undiagnosed HIV infection: 60% of men with undiagnosed HIV had taken an HIV test in the last year compared with 43% of men without HIV. Men who had HIV (diagnosed or undiagnosed) had had a higher than average number of partners in the previous six months. Condomless sex, on the other hand, was actually more common in HIV-negative men than undiagnosed HIV-positive men: 59% versus 44%. Undiagnosed HIV-positive men also had higher rates of syphilis co-infection (9%, versus 5% in diagnosed HIV-positive men and 2% of HIV-negative men) and higher rates of use of poppers, cocaine and erectile drugs.

Comment: This study’s data come from 2008-09, but the picture it paints is a worrying one. The association between frequent HIV testing and undiagnosed HIV infection – something that appears at first not to make sense – suggests that a highly at-risk subpopulation of gay men were at this time experiencing a fast spread of HIV into their milieu – and were testing for it – but that any adjustments they were making to their behaviour, such as having slightly less bareback sex, made no difference. Later evidence from central Europe has found an increasing epidemic of HIV in gay men and a 2013 survey from Poland, for instance, found that new HIV infections in gay men there have been increasing exponentially in the last decade. Furthermore, these countries still have low levels of testing: a 2011 survey by the World Bank found that just 1.7% of the population in 15 central European countries had tested for HIV in the previous year compared with 3.3% in western Europe, and 11.9% in eastern Europe, where HIV testing is a much more standard part of medical care.

More than one in three Europeans with HIV is a migrant

A study of HIV in the European Union, plus Norway and Iceland, has found that, in 2012, 35% of people with HIV were diagnosed in a country other than the one in which they were born.

The proportion of people with HIV who are migrants has decreased between 2007 and 2012. This is because the proportion of people with HIV in Europe from sub-Saharan Africa fell, from over half to under half of the migrant total. New diagnoses in African women fell by over a third. In contrast, the proportion of migrants with HIV who were gay men or other men who have sex with men (MSM) rose to over 50%. The UK and France had by far the largest number of new cases in people who were migrants, respectively 6358 and 4066 in 2012, though diagnoses in migrants have fallen since 2007.

In contrast, in the next six countries with the highest numbers of migrants diagnosed, new cases have increased in the last five years and have doubled in Italy and Greece, reflecting the new wave of trans-Mediterranean immigration. This has been accompanied by a change in people’s country of origin. There was a considerable rise in HIV-positive people from Latin America, both women and MSM, between 2007 and 2010, now ebbing partly due to austerity-related healthcare entitlement cuts in Spain. This has been replaced by a rise in HIV-positive migrants from central Europe, partly due to rising prevalence in MSM (see the story above) and also from east Asia and from north Africa and the Middle East.  

Comment: The fact that countries in the Middle East still have low HIV prevalence, yet we see a rise in HIV diagnoses in people from there, suggests that MSM in particular may well be acquiring HIV in their host country rather than their home country. Migrants in general tend to be younger than non-migrants on diagnosis (on average, in their early rather than late 30s) yet are diagnosed with lower CD4 counts. Being a migrant in itself raises the risk of HIV by 60-70% in most population groups. Yet, as a recent report by Médecins du Monde (MdM) – Doctors of the World shows, migrants and especially undocumented migrants, have very patchy entitlement to healthcare in Europe and, even in countries where they are entitled to healthcare, may not come forward for fear of being reported to immigration authorities or detained.

HIV stigma associated with condomless casual sex in Europe…

The latest in a large number of findings coming from the 180,000-strong EMIS survey finds that if participants lived in a country with high levels of stigma and legal discrimination against gay men, they were less likely to be diagnosed with HIV and had fewer sexual partners on average – but when they did have sex, were much more likely to have condomless casual sex.

EMIS – the European Men Who Have Sex with Men Internet Survey – compiled a composite index based on the legal position for MSM in a country and on social attitudes already unearthed in a European Values Survey. They compared a country’s stigmatisation level with answers men gave to questions about their HIV risk behaviour and knowledge, access to HIV services, and whether they concealed their sexuality. Men living in countries with poor legal status and high levels of stigma against gay men had poorer HIV knowledge, were less likely to have taken an HIV test, and were less likely to discuss sexuality if they did test. Men in the countries with the highest levels of stigma were 2.5 times more likely to conceal their sexuality than men in more accepting countries and this concealment in turn was associated with higher levels of risk taking and poor knowledge of and access to HIV prevention.

Comment: There is a disconnect here between high levels of condomless sex in countries with poorer attitudes towards gay men and low levels of HIV diagnosis. This could be because low levels of testing mean that the proportion of gay men with HIV is seriously underestimated. However, it is more likely to mean that HIV prevalence in many of these countries actually is low – maybe due to lack of opportunity – but that conditions are ripe for a rapid growth in HIV in gay men once its prevalence reaches a certain level.

…and depression associated with risky sex in Britain

HIV-negative gay men with symptoms of depression were 36% more likely to report condomless sex with multiple partners, and 44% to report it with partners of unknown HIV status, according to a study of people attending UK sexual health clinics presented at the British Association for Sexual Health and HIV (BASHH) conference last month. However, men with current depression were not more likely to have sexually transmitted infections or to report group sex. A previous survey of HIV-positive people attending UK clinics had found that 27% had symptoms of depression and 19% of major depression.

In this survey, the prevalence of current depressive symptoms in HIV-negative gay male patients was 12.5% and of major depression 5.5%. This is compatible with the 13% prevalence found in gay men in a 2011 survey by Stonewall and Sigma Research, slightly higher than the 8-12% of people who suffer from depression at any one time in the UK, and significantly higher than the 7% prevalence of depression in men in general. Depression in the current survey was more common in younger people (in the general population, it tends to be more common in older people), in men with money problems, in single men, and in men without a university education. Fifty-eight per cent of those with depression had been diagnosed with a mental health problem and 52% were on treatment for it.

Comment: What’s really surprising (and depressing) about this survey is how much greater the effect of HIV status is on depression than sexuality. While it shows, as other surveys have done, that gay men tend to have higher rates of depression than other men, this, in conjunction with the previous survey, shows that having diagnosed HIV more than doubled the risk of depression and quadrupled the risk of major depression compared with other gay men. There needs to be more research into whether this is entirely due to social and psychological factors such as health anxiety and shame about HIV, or whether there is some neurological component to it. A comparison of men who are and are not on antiretroviral treatment might be a way forward.

Hepatitis C seen in HIV-negative gay men in London

Forty-four cases of infection with hepatitis C virus (HCV) were seen in HIV-negative men in London’s largest sexual health clinic at the Chelsea and Westminster Hospital between January 2010 and May 2014, according to a recent study. Hepatitis C is quite common among HIV-positive gay men: the Chelsea and Westminster saw 858 cases between 2004 and 2012. However, it has been unclear how common hepatitis C infection is in HIV-negative men. A previous study found that only 1% of gay men in London had evidence of current or cleared hepatitis C infection, compared with 8% of HIV-positive men.

Looking at the 44 cases in this study, just over a third of men diagnosed had had a negative hepatitis C test result within the previous year. One in five reported injecting drugs but with sharing needles apparently very uncommon in gay men who inject drugs (sometimes known as ‘slamming’), most infections have probably been acquired sexually. In the 44 men in the study, almost all (93%) reported condomless sex, 25% fisting, and 36% snorting drugs (also a hepatitis C risk). A third reported sex with a partner they knew had HIV and 14% with one they knew had HIV and hepatitis C. Just under a third had a concurrent sexually transmitted infection. Eighteen per cent of men said they had used post-exposure prophylaxis (PEP). Two men said they had used pre-exposure prophylaxis (PrEP). Fifty-seven per cent cleared their hepatitis C infection: a third achieved spontaneous clearance and a quarter received hepatitis C treatment, of whom all but one responded to treatment.

Comment: This study probably considerably underestimates the rate of hepatitis C infection in at-risk HIV-negative gay men, as only 15% of men attending the Chelsea and Westminster sexual health clinics are screened for hepatitis C: screening is regular in men with HIV. The study authors rightly urge that hepatitis C testing should be part of routine sexual health screening for all gay men with risk factors. The mention of PEP and PrEP also suggests that hepatitis C mono-infection could become relatively more common in gay men if they lead to fewer HIV infections in this group of men. The 25% treatment rate is also unacceptably low – a finding underlined by the study below.

Giving more gay men hepatitis C treatment could cut infections by two-thirds

More effective treatment for gay men with hepatitis C would cut the proportion of HIV-positive men in the UK who also have hepatitis C by two-thirds, from nearly 9% to 3%, within ten years, and halve the rate of new infections, a modelling study has found. However, this would involve quadrupling the proportion of men with chronic hepatitis C infection who get treatment every year from the current 5% to 20%, and doubling the proportion of newly infected men who get treatment in their first year with hepatitis C from 40% to 80%. Increasing the proportion treated in their first year would be less costly than subsequent treatment, as most (80%) would be cured with the conventional interferon-plus-ribavirin regimen, compared with only 35% with chronic infection. This model has not actually looked at cost-effectiveness yet though. The new direct-acting antiviral drugs cure 90% of people with hepatitis C, both with chronic and recent infection. In the UK, NHS England has come under fire recently for stalling on introducing newer drugs because of their considerable cost. 

Comment: NHS England has recently announced a nearly fivefold rise in the budget for hepatitis C treatment but is still restricting use of the new direct-acting antivirals to people with cirrhosis and advanced liver disease. This study suggests that this could be a short-sighted strategy if treating more people with acute and less-advanced chronic disease could prevent forward transmission.

Other recent news headlines

New British guidelines recommend treatment for everyone with HIV

Everyone with HIV who is prepared to take antiretroviral treatment should receive it, regardless of CD4 cell count, new draft British HIV Association (BHIVA) treatment guidelines recommend. The new draft guidelines, published for consultation last month, say that anyone living with HIV who understands the commitment of treatment and is ready to start should receive treatment. The change – from a recommendation to start treatment before the CD4 cell count falls below 350 cells/mm3 to treatment for all – follows the results of the START trial, a keenly awaited international study of when to start treatment.

Vaginal microbicide ring study releases first data on participants

An efficacy study of a new method of HIV prevention has published its first data. ASPIRE is one of two large efficacy trials of a vaginal ring microbicide that have been taking place over the last three years. ASPIRE (A Study to Prevent Infection with a Ring for Extended use) was conducted in four African countries at 15 research centres and enrolled 2629 women ages 18-45, with an average age of 26. Half the women used a vaginal ring containing the antiretroviral drug dapivirine and half a placebo ring not containing the drug. The ring is designed to be inserted and replaced monthly. Effectiveness results are expected early next year.

Hepatitis C is a health problem in Africa too

A significant proportion of people in Africa have the hepatitis C virus, according to a study in The Lancet Infectious Diseases. Overall, 3% of people in sub-Saharan Africa have hepatitis C, but the figure rises to 7% in the countries of central Africa such as the Democratic Republic of the Congo. Hepatitis C prevalence is actually lower (1%) in the countries of south-east Africa that have the highest HIV prevalence. People with HIV were twice as likely as others to have hepatitis C, with a prevalence of 6%. The few studies that have been done with people who inject drugs found much higher prevalence, such as 45% in a group of people who inject drugs in Kenya.

High lifetime costs of treating HIV show importance of investing in prevention

The lifetime cost for treating one HIV infection in the UK is almost £380,000, according to a model published in the online journal PLOS One. Switching to generic drugs once patents expired could reduce costs to just over £100,000. The investigators based their calculations on costs associated with treating a 30-year-old gay man who acquired HIV in 2013 and who lived to the age of 72 years. “In view of the high lifetime costs for HIV-positive individuals, there is large scope for preventative interventions to be cost-effective,” conclude the authors.

Washington DC sees 'remarkable' drop in number of newly reported HIV cases

from Washington Post

The number of newly diagnosed cases of HIV and the number of related deaths continued to drop in Washington DC in 2013. Deaths decreased by 44%, the most significant decline in years. The number of new diagnoses decreased from 678 to 553, with declines among black, white and Hispanic people. Although three children were born with the virus in 2012, not one was perinatally infected in 2013.

The PROUD study: a video documentary

from Vimeo

Film-maker Nicholas Feustel interviews researchers, community supporters and participants in the UK’s groundbreaking study of pre-exposure prophylaxis (PrEP).

Drugmakers warn Greek medicine supply "may be in jeopardy"

from Reuters

Drugmakers said on Monday they would continue to ship medicines to Greece in coming weeks, despite mounting unpaid bills, but warned supplies could be in jeopardy if Europe did not take emergency action. "In the worst-case scenario of 'Grexit', we believe the integrity of the medicines supply chain may be in jeopardy, which would create a risk to public health," the industry's trade association said in a letter to the European Commission.

Launch of innovative HIV prevention fund

from Public Health England press release

Public Health England is encouraging all voluntary organisations to apply for national funding to enable innovative HIV projects across England to target groups at higher risk of HIV.

Pride in London: NHS to come under pressure to provide 'miracle' HIV prevention pill

from The Independent

Campaigners from the Terrence Higgins Trust carried placards calling on the UK government to have pre-exposure prophylaxis (PrEP) made freely available on the NHS as an HIV prevention strategy for gay men at London’s Gay Pride parade on 27 June.

Drastic acceleration of HIV fight needed to stop AIDS resurgence

from Reuters

The global HIV epidemic could see a resurgence in just five years without a drastic acceleration in efforts to prevent and treat HIV, according to the United Nations and disease experts. While good progress has been made in improving access to lifesaving drugs, an analysis by UNAIDS and an expert panel commissioned by The Lancet found the rate of new HIV infections is not falling fast enough.