European hospital-testing project picks up many new HIV infections
A Europe-wide project offering HIV tests to hospital patients with any of a list of symptoms associated with HIV infection has found 235 infections in 9741 patients – one in every 41 patients. In southern Europe, one in 20 patients tested had HIV.
The British HIV Association (BHIVA) conference heard that this is far in excess of the proportion of people with HIV in western Europe (one in 500) and in eastern Europe (one in 140). Most people (86%) tested as part of the project had never had an HIV test before, and half were diagnosed with CD4 counts below 200 cells/mm3.
The study, which took place between 2012 and 2014, tested both people admitted to hospital and outpatients in 42 European hospitals. It asked healthcare practitioners to test people for HIV who had at least one of a list of 14 indicator conditions. Most of these conditions were associated with an HIV infection rate of over 1%. In particular, over one in 20 patients with symptoms suggesting mononucleosis or glandular fever, a relatively common illness, had HIV. Mononucleosis, and also having a prolonged low white blood cell or platelet count, were both independently associated with HIV infection regardless of other patient characteristics.
Comment: This same study had previously found that, even among people presenting with conditions strongly associated with HIV such as anal and cervical cancer, only a minority of people received an HIV test. A separate UK study also presented at the BHIVA conference found that only 20 out of 60 guidelines for conditions associated with HIV recommend an HIV test. These results provide strong support for the suggestion that HIV tests should be included automatically if tests are also ordered for certain other conditions.
First home test approved for sale in UK
An HIV home test is now finally available in the UK, a year after a legal ban on them was lifted.
The BioSure HIV Self Test sells for UK£29.95. For the moment, the test is only available to UK residents through BioSure’s website or from the Freedoms Shop, which also sells low-cost condoms and lubricant. It tests a drop of blood extracted from a finger with a safety lancet (provided).
The test, which takes 15 minutes to produce a result, is an HIV antibody test and cannot detect recent infections, as it can take 1-3 months for HIV antibodies to become detectable. The test had to meet stringent reliability standards for approval but no test is 100% accurate. US research established that this test has a false-negative rate of 0.3% – it fails to detect one in 333 HIV infections that are actually there – and a false-positive rate of 0.1% – once in every thousand tests, it detects an HIV infection that does not actually exist. Separate trials also found that one in 31 tests produced an invalid result, usually due to people having difficulty using it correctly. This means that, for instance, if 1000 gay men living outside high-prevalence cities in the UK took a test, there would be about 917 true negative results, 50 true positive results, 32 invalid results, one false-positive result and a one in six chance of any false-negative result. If the 1000 people taking the test were typical of the UK general population, there would only be two true positive results.
Comment: A similar test will be available in France in June via a different website. As UK HIV doctor Michael Brady commented, to increase testing rates is still the single biggest thing that can be done to reduce future HIV infections and it is important that people have access to as many ways to test as possible. It remains to be seen whether there will be a big uptake of home testing, whether it picks up on a high proportion of undiagnosed infections, and whether people who home test will seek healthcare promptly.
Prioritising people at high risk will be crucial to the success of PrEP
The model, by researchers at London’s Imperial College, assumed a fixed budget of US$20 million a year. The information put into the model uses typical drug prices for the area (US$250 a year for PrEP), good and bad adherence (60% or 20% of doses taken) and moderate prioritisation (50% of people taking PrEP are at the highest risk). It finds that, under these circumstances, the cost of preventing one HIV infection with PrEP, with average levels of adherence, is about $6000 – probably cost-saving when weighed against the cost of a lifetime’s HIV infection.
The researchers then varied their inputs to see what would happen if adherence improved or worsened, if drug prices rose or fell, if the cost of delivering PrEP changed, and if all or none of the people who took PrEP were in the highest-risk group. If everyone who took PrEP was at high risk of acquiring HIV, then the cost of preventing one HIV infection would fall to $2060 and the annual number of infections prevented would triple: conversely, if it only went to the general low-risk population each infection prevented would cost over $36,000 and only a handful of infections would actually be prevented.
Comment: Although this calculation is not in the model, under the same circumstances, the drugs-alone cost of treating one person for 25 years would be $6300, though the cost of drugs for both PrEP and treatment will fall in the future. PrEP would therefore save money under the relatively realistic scenario offered by the model. The researchers recommend prioritising PrEP using a risk score, as in the recent Partners PrEP Demonstration Project. They also praise the effectiveness of community-based projects such as Avahan in India in targeting possible PrEP candidates – though, as we see in the next item, these may be less successful if their original ethos is lost.
Community involvement essential for success of HIV projects, reviews find
Avahan and its smaller predecessor the Frontiers Project earned praise for achieving high levels of involvement, behaviour change and testing in men who have sex with men and female sex workers in the past. But when funding was switched from the Gates Foundation to the Indian Government, as planned, a recent report finds that sex workers became less involved as peer support workers, were less likely to use community organisations to report violence and abuse, and were less likely to contribute feedback to the project that resulted in positive initiatives.
A separate report on Avahan in Mumbai also found that too narrow a focus on condoms and testing and less on the other challenges sex workers faced in their lives, led to less involvement. In addition, it found, siting the prevention project in existing and trusted community organisations was far more effective than setting up new ones. It identified specific challenges in engaging sex workers in an urban environment, especially in engaging women who may not identify as sex workers.
Comment: The Aidsmap report adds a lot of detail to these qualitative evaluations. What these confirm is that running community-based HIV prevention programmes requires a lot of ongoing work and conscientious community involvement – they cannot be set up and left to run – and that participants have to regard them as something that improves the quality of their lives. This is a real challenge for something as big and complex as Avahan and the reports should be studied by organisations wanting to step up similar initiatives in the future.
White drug injectors in New York have less HIV than the general population
This low prevalence is due, the researchers say, to the introduction of needle and syringe exchange, which dates back to 1995: a previous study found a steady decrease in HIV prevalence in people who inject drugs between 1995 and 2008, while this latest study shows a continuing 30% decline in prevalence per year up to 2014. However, the same study also shows that HIV prevalence in black people who inject drugs remains high, at 17%, despite a somewhat lower rate of risk behaviours such as daily injecting. It is also 4% in Latino people who inject drugs. Several pieces of evidence, from rates of hepatitis infection, to the date people started injecting, suggest that the majority of people who inject drugs now living in New York actually acquired HIV before they started injecting.
Comment: This latest instalment in a long-running study suggests, as the authors say, that “HIV infection among white [people who inject drugs] has almost been eliminated” due to needle and syringe exchange. However, to eliminate HIV in black and Latino people who inject drugs, programmes are needed that offer HIV testing and treatment, pre-exposure prophylaxis and other prevention help to young people in communities where drug injection is common, but before they start injecting. It also implies that a person’s risk class at the time they are diagnosed with HIV may not actually indicate how they acquired HIV.
Truvada PrEP causes only mild bone mineral loss
A substudy of the iPrEx study of Truvada (tenofovir/emtricitabine) pre-exposure prophylaxis (PrEP) has found small but significant declines in bone mineral density in people taking PrEP versus those taking placebo. The declines occurred in both spine and hip bones.
However, decreases only happened during the first six months on Truvada, not getting any worse after that, and bone mineral density recovered after Truvada was stopped. Higher levels of tenofovir in cells correlated with greater decreases in bone mineral density. The small decreases in bone mineral density did not appear to have any clinical impact: in all iPrEx participants, the rate of bone fractures was 1.7% in people taking Truvada versus 1.4% in people taking placebo, not a statistically significant difference.
Nonetheless, the researchers recommend that people starting PrEP should receive information about ways to improve bone mineral density such as weight-bearing exercise, taking calcium and vitamin D, and avoiding alcohol and tobacco, which can reduce it.
Comment: This is a reassuring study and goes hand-in-hand with a previous study from iPrEx and one from the longer Bangkok Tenofovir Study showing that kidney malfunction in PrEP is also relatively mild and reverses after PrEP is stopped. For people starting PrEP, although longer-term side-effects are still likely to be one of the things to be taken into consideration, the short-term side-effects people experience when starting PrEP, such as nausea and headache, may in fact have more impact on adherence.
Other recent news headlines
Men taking HIV treatment have undetectable viral loads in the rectum
A small study assessing the infectiousness of HIV-positive gay men taking antiretroviral treatment has found that all study participants had an undetectable viral load in the rectum. Men who had rectal gonorrhoea or chlamydia didn’t have detectable virus either, suggesting that concerns about sexually transmitted infections raising the risk of HIV transmission may be unfounded when people are taking effective HIV treatment.
Inter-connecting health problems increase HIV risk for gay men
Intertwining health problems such as polydrug use and depression are associated with higher viral load and poorer adherence in HIV-positive men who have sex with men taking antiretroviral treatment, investigators from the United States report in the online edition of AIDS.
Many people living with HIV willing to take part in cure research
There is a strong interest among people living with HIV in studies towards an HIV cure, with many potential participants willing to consider antiretroviral treatment interruption. Respondents to a survey presented at the British HIV Association conference in Brighton generally understood that they would be unlikely to benefit personally from cure research. Priorities for a cure were to eliminate health problems and the risk of HIV transmission, rather than necessarily testing HIV negative.
Expanded vaccination and treatment could help eliminate hepatitis B worldwide
While universal infant hepatitis B virus (HBV) vaccination has already led to major advances in reducing new infections in some settings, further expansion of prevention and treatment are needed to significantly reduce HBV transmission and liver disease mortality, according to an analysis presented at the European Association for the Study of the Liver (EASL) in Vienna, Austria.
Editors' picks from other sources
ECDC recommends PrEP in Europe
from European Centre for Disease Control (ECDC)
The ECDC states:
“Evidence suggests that the use of pre-exposure prophylaxis (PrEP) for men who have sex with men (MSM) is an effective HIV prevention tool for Europe. On the basis of the new evidence, EU Members States should give consideration to integrating PrEP into their existing HIV prevention package for those most at-risk of HIV infection, starting with MSM. A key step towards roll-out of PrEP would be the review of the current regulatory approval of the medication (emtricitabine plus tenofovir disoproxil fumarate, Truvada) to allow its use as prevention treatment in the EU/EEA, as strongly advocated by the European civil society organisations.”
Fighting HIV where no-one admits it's a problem
from BBC News
For years Russia has remained remarkably silent on the challenge it faces from HIV and AIDS. Now, that silence has been broken by an epidemiologist who has been working in the field for more than two decades – and he calls the situation "a national catastrophe".
Scotland must extend PrEP, not wait for HIV vaccine
from KaleidoScot
Charities across Scotland and the UK called upon the government for access to pre-exposure prophylaxis (PrEP) as an effective means of preventing HIV infection. George Valiotis, CEO of HIV Scotland, said: “We need to see leadership from Scottish Government on making access to PrEP a reality. The steps needed to make it happen must be clarified, and action taken to speed the process up.”
PrEP prescriptions on dramatic upswing in New York State
from POZ
In less than a year, the number of New York State residents receiving Truvada (tenofovir/emtricitabine) as pre-exposure prophylaxis (PrEP) prescriptions through Medicaid has nearly tripled. According to Dan O’Connell, director of the AIDS Institute at the New York State Department of Health, from July 2013 through June 2014, 305 HIV-negative New Yorkers were taking Truvada to prevent infection with the virus. By the close of February 2015, that figure had jumped 272 percent to 832 people.
Philip Christopher Baldwin talks about living with hepatitis C in the gay community
from QX Magazine
I did not have the courage to tell people that I had hep C, worried that others would gossip about me. There were no role models in the media for co-infection with HIV and hep C, which made it harder to be open. I had fought so hard to be an out gay man, and now I was hiding something that was inextricably linked to my sexuality, to my identity and to my core sense of who I am.
First French cities apply for drug consumption rooms under new law
from Talking Drugs
Strasbourg, Bordeaux and Paris have submitted applications to implement supervised injection sites for drug users, becoming the first cities to do so under a groundbreaking law introduced last month.
Are scare tactics off the table for public health campaigns targeting HIV?
from Science Daily
Over the last 10 years, public health campaigns in New York City around smoking, obesity, and HIV underwent a dramatic shift to use fear and disgust to spur behaviour change, sometimes with the unintended consequence of stigmatising affected populations. In a new article, scholars explore the implications of this shift to fear-based campaigns in the present public health environment.