EU project maps how HIV crosses borders

Up to 30% of HIV-positive gay men diagnosed in Europe have become HIV positive outside their own country or HIV has been passed on by someone visiting from abroad, a new European study has found.    

Many heterosexual people in the study were themselves from immigrant communities. Despite this, they were less than half as likely to have been infected by someone diagnosed in another country, or by someone whose infection was connected to someone diagnosed in another country.

The SPREAD study genetically analysed HIV from samples from 4260 newly diagnosed people in 25 European countries. It found that, in 1330 cases, the virus was more than 98% genetically similar to another virus in the samples, forming a so-called ‘cluster’. For viruses to be this similar, people in the cluster must have either been infected by someone else in the cluster or by a close intermediary. There were 457 clusters, the largest containing 28 people; two-thirds of clusters were pairs.

In 17% of clusters, the people in the cluster came from more than one country; 26% of people who were in a cluster came from an international one. Thirty-one per cent of gay men came from an international cluster but only 14% of heterosexuals. People infected less than a year ago were also more likely to be in a cluster of diagnoses from more than one country.

Comment: It’s important to note that SPREAD excludes some European countries (notably the UK and France) and cannot say anything about the origin of infections unlinked to clusters. Phylogenetic testing cannot tell us who infected whom. However, it does show who is connected in a network of infection, and this study shows that a surprisingly high proportion of gay men are connected to someone diagnosed in another country. In contrast, it shows that heterosexual people from high-prevalence countries are much less likely than might be expected to be in cross-border networks; this may indicate that few immigrants diagnosed abroad pass on HIV to anyone in their new host country, or that if they do, it is overwhelmingly likely to be someone in their own community.

Global gay survey: blackmail, stigma and poverty blight lives and health

A global survey of approximately 5000 gay men and men who have sex with men (MSM) in 165 different countries has found that only a minority has easy access to HIV prevention and treatment.

The 2012 Global Men’s Health and Rights Study, co-ordinated by the Global Forum for MSM and HIV, found that the lower the income of their country, the less easy MSM found it to access condoms, lubricants and, if they had HIV, treatment. Overall, 37% of gay men said they could easily access condoms without restrictions and 25% lubes. Eighteen per cent of respondents said they had HIV. Of those, 50% had unrestricted access to HIV treatment in high-income countries, but only 14% in low-income countries (this may exclude some people who had access to condoms, treatment and lubes but with barriers such as having to pay). Access to HIV testing was lower in middle-income countries than low-income ones.

Access to HIV resources of all kinds was lower in countries with higher perceived rates of homophobia, and stigma from healthcare providers was especially associated with poor access to condoms.

Being ‘out’ as gay was a mixed blessing: belonging to a community support organisation was associated with better access to HIV resources, but being publicly gay or having experienced negative consequences of it were associated with poorer access to lubes and HIV testing.

Young men under 30 had poorer access to all categories of HIV resources than older men; young men were 50% more likely to report not knowing their HIV status. Young men on HIV treatment were much less likely to know their viral load or to have an undetectable viral load if they did know it.

The survey was supplemented in Africa by interviews with 71 men in Kenya, Nigeria and South Africa. These revealed that one of the biggest burdens they had to deal with was not so much violence as blackmail and extortion, which were a common consequence of being gay. Negative reactions from healthcare staff were also common.

Comment: The comments from the focus groups in this survey are especially worth reading. One striking finding is how blackmail, often by other gay men, is one of the most common problems MSM have to deal with in countries where homosexuality is still illegal, as it was before decriminalisation in the US and Europe. Similarly, the finding that being out as gay restricts access to prevention services may reflect that, in strongly homophobic countries, ‘passing as straight’ is still a necessary strategy to avoid bad treatment. The higher rate of HIV testing in poor countries may reflect the success of HIV testing programmes or simply that low-income countries tend to have more HIV.

Many Dutch men with HIV take viral load into account in condom decisions

A community survey of HIV-positive gay men in the Netherlands has found that, of the 68% who said they had had unprotected anal sex since their diagnosis, nearly two-thirds (63%) said they had considered their viral load as a factor when deciding whether or not to use a condom. This represents 41% of all the men asked, including those who did not have unprotected anal sex.

The survey was conducted among gay men with HIV who form part of a community consultation panel in the Netherlands. In total, 177 men who had an undetectable viral load completed the survey and are included in the analysis.

The survey split the men’s answers into whether a respondent’s most recent partner was a casual or regular partner and whether he was known to have HIV or not.

Respondents took viral load into account with both HIV-positive and (potentially) HIV-negative partners in making the decision on whether or not to have unprotected sex. With HIV-positive partners, they were more likely to do so if they were with a regular partner.

With partners who also had HIV, viral load was likely to be openly discussed as part of a general discussion on whether or not to use condoms. Conversely, with negative or unknown partners, few people disclosed status and even fewer talked about their viral load openly; instead it was part of an internal process of risk calculation the men went through.

Comment: This study doesn’t explore what “taking viral load into consideration” actually means. Because its respondents were part of a community panel, they may be more informed about viral suppression and risk than the average person with HIV, so results may not be generalisable. It confirms, as so many studies have done, that HIV-positive men find it very difficult to disclose to new partners and go through a unilateral ‘risk assessment’ exercise when making decisions about sex with partners of unknown status. In terms of the law, this might not be enough to exonerate them legally in legal systems where HIV disclosure to partners is mandatory, though it might be a valid plea against exposure where it is not.

Getting viral load as low as possible may pay prevention dividends

A low-level but detectable viral load in the blood of gay men taking antiretroviral therapy (ART) is strongly predictive of low but detectable levels of HIV also being found in the semen, a Californian study has found.

More than one-in-three gay men on ART with viral loads between 50 and 500 copies/ml in their blood also had detectable virus in their semen, at a mean level of 126 copies/ml.

In contrast only one-in-17 men with blood viral loads below 50 copies/ml had detectable seminal HIV.

Another factor independently associated with detectable HIV in the semen was active infection with two viruses of the herpes family: cytomegalovirus (CMV) and Epstein Barr virus (EBV). Men with high levels of these viruses in their semen were respectively 4.5 and six times more likely to also have detectable HIV in their semen. CMV and EBV are very common and normally asymptomatic.

There was no relationship between detectable HIV in the semen and duration or type of ART or self-reported adherence (which was high in this group). Perhaps surprisingly, there was also no relationship to bacterial STIs such as gonorrhoea or chlamydia, although these were relatively uncommon in this group.

Comment: We don’t know how infectious someone with a seminal viral load of 126 copies/ml really is – probably not very. However, this study does suggest that blood plasma viral load when someone is taking ART is a good surrogate for seminal viral load, and getting it as low as possible will improve the efficacy of ART as prevention as well as treatment. There is little research into treating chronic CMV or EBV infection, though giving drugs against the related genital herpes virus (HSV2) has so far not resulted in reducing HIV transmission between serodiscordant couples.

Steroid injectors: an under-studied HIV risk group

A study presented at the British HIV Association conference last month has uncovered a previously almost completely unresearched group of people at risk of HIV and hepatitis B and C – male bodybuilders who inject steroids or growth hormone to build muscle.

The study recruited 395 men and found that six (1.5%) were HIV positive – ten times the prevalence of HIV in the general UK population. In addition, 5.5% had hepatitis C infection and 8.8% had evidence of past or current infection with hepatitis B.

This group has only ever been the subject of three studies ever before, Dr Vivian Hope of Public Health England told the conference. In the one previous study conducted in the UK, no one was found with HIV.

The men were recruited via needle and syringe exchanges so may not be typical of the steroid-injecting population. Their average age was 28 and they were almost all (97%) heterosexual. Twenty per cent had had at least five female sexual partners in the last year and 8% had had at least ten; only one in five always used a condom. Five per cent had ever injected a psychoactive drug such as heroin, methamphetamine or cocaine.

Nine per cent reported ever sharing a needle, syringe or vial (steroid hormones come ready-mixed in vials and are injected into muscles rather than intravenously).

Three of the six HIV infections were in the 13 men who had sex with men involved in the study, and they had probably acquired it sexually.

Comment: As the presenter said at the time, these results need to be interpreted with caution as male steroid users may have other risks that raise their risk of HIV above the general population. However, it is of some concern that HIV has been found in this group when a study 20 years ago found none. At the very least, it indicates that doctors and health advisers may need to be aware of steroid injection as an HIV and hepatitis risk factor in men without any other apparent risk factors. Given that, despite quite high levels of sexual activity, only one in six had gone for a sexual health check-up in the last year, these are exactly the type of people that may ‘slip through the net’ and be diagnosed with HIV very late.

European HIV prevention webinars – an HIV cure

As part of its European HIV prevention work, NAM is collaborating with AVAC to provide a series of webinars (conference calls with accompanying slides) to train and inform prevention advocates and anyone interested in the newest developments in HIV prevention technology.

The fifth webinar is entitled:

Cure research: The facts and figures

Recently several stories have appeared in national newspapers and magazines over-optimistically predicting that HIV may be curable soon. It is timely therefore that the fifth webinar in our series will look at recent developments in the area of cure research.

Time and date: 2pm UK time (BST), Tuesday 11 June (3pm CEST)

To register for the webinar and get phone numbers and joining instructions click this link:

https://cc.readytalk.com/cc/s/registrations/new?cid=voleabg088e9

As usual, the presentations will be followed by a question and answer session with our expert speakers. Questions can be submitted in advance to info@avac.org. The webinar will be 90 minutes long and chaired by Rebekah Webb of AVAC.

Other recent news headlines

Consistent decline in partner numbers in US gay men in last decade, but no change in condom use

Data from two national sex surveys in the United States show that gay and bisexual men (men who have sex with men, or MSM) reported significantly fewer sexual partners in the previous year in a survey conducted between 2006 and 2010 than they did in one conducted in 2002. This decline was consistent across most ethnicities and age groups, but was particularly marked, and statistically significant, in men aged under 24. In contrast, the proportion who reported having condomless anal sex at least once in the previous year did not change between surveys.

Researchers stop the only current HIV vaccine efficacy trial

In a blow to HIV vaccine development, the US National Institute of Allergy and Infectious Diseases (NIAID) announced on 25 April  that it was discontinuing the HVTN 505 HIV vaccine trial. This trial started in July 2009 and involved 2504 volunteers. Since the successful conclusion of the RV144 vaccine trial in September 2009, HVTN 505 has been the only ongoing HIV vaccine trial large enough to be a true test of vaccine efficacy. The trial’s data and safety monitoring board (DSMB) found that the vaccine regimen was neither preventing HIV infection nor reducing viral load among vaccine recipients who acquired HIV. There were actually more HIV infections in volunteers receiving vaccine than placebo, but this difference was not statistically significant and could be due to chance.

High prevalence of oral HPV infection in Dutch gay men

Oral infection with human papillomavirus (HPV) is common among gay men, Dutch investigators report. Prevalence was especially high among HIV-positive gay men, who were also more likely to be infected with the strains of HPV associated with a high risk of cancers of the head and neck. In a study of 767 gay men, 40% of samples taken from them had oral HPV infections. Prevalence differed by HIV status and was significantly higher among the men with HIV (57 vs 27%).

PrEP doesn't lead to increases in risky sex among gay men

Taking HIV pre-exposure prophylaxis (PrEP) did not lead to increased levels of sexual risk behaviour among gay men taking part in the second study of PrEP ever completed, a 400-member safety trial that took place in San Francisco, Atlanta and Boston between 2005 and 2007. The average number of sexual partners in the previous three months fell from 7.25 to 5.7 during the trial and the number of partners of HIV-positive or unknown status from 4.2 to 3.3. In this trial, half the participants received PrEP immediately and half nine months later; the falls in partner numbers were similar in the immediate- and delayed-PrEP arms.